I just finished my month-long hospice rotation at the Connecticut Hospice in Branford, which both gave more and took more than I anticipated. Perhaps because after a slew of clinical rotations, I've lost a bit of the expectant newness that used to come before each new venture, and so there wasn't much anticipation to begin with. I didn't think much about what hospice would be like before I started. Having had a strong experience that led me to being interested in the rotation in the first place, I think I unconsciously felt that I'd reached a certain level of intensity that would prevent me from being taken by surprise here, even as I approached this rotation as an opportunity for broadening experience, concrete and emotional. I'm glad to have been wrong.
I haven't felt this motivated to write about a medical school experience for a long time, but before doing it in a structured and comprehensive form, it feels nice to sit in bed and ramble about all the things that made it filling, and hard.
On my last day, an APRN asked me what was the most memorable event during the rotation. It would be hard, and probably not accurate, to choose one event or interaction or experience. Instead it was more generalities absorbed that most affected me. I told her that I'd take with me the calmness of the place, the simplicity of the medicine, and the kindness of the people.
Connecticut had the most snow in January on record since years and years ago. We had two two-feet snowstorms, a couple ice storms, and record below freezing temperatures. While I was used to this in Boston where the winter is more harsh than here, I'd never had to deal with the visceral challenges of snow and ice. For the first time in my life, I had to shovel my car out of the snow, had to try to drive it through the narrowly plowed driveway, had to shovel myself out of the driveway that wasn't plowed widely enough, had to shovel piles of snow off the entrance to the street where the tires would just spin in place, had to chip away at inches of ice off every window and off the roof of the car, had to see why getting ice off the roof is important as a I saw sheets of ice slip off cars on the highway, had to steer my car as it slid on unsalted iced roads, had to walk strategically to avoid puddles of slush and piles of iced snow. It was uncomfortable, and tiring to have to work so hard and think so hard about how to simply get somewhere.
There were also incredible vignettes of how pretty harshness can be, in the snowflakes that would freeze on my car windows to create a printed pattern I'd have to scrape away, in the ice that dressed bare tree branches making the forests on my drive looks like crops of glistening gray hair, and in the sheen of clean soft snow hardened on top like creme brulee, by the ice. There were incredible views from the windows, of big flakes falling against warm yellows and cold grays. There were the first falls, untouched, and the old snows, dirtied.
After the trek through all of that, I arrive at a workplace with windows in tandem, bookshelves, and fireplaces. Laid on the beds are crocheted blankets and patchwork quilts. Hand-painted signs of patient's names are hung in their respective spaces. Guitars strum, and every other day there are sweets from families or employees. It seemed to me I was lucky to have done this rotation during the onslaught of winter, to have to confront bitter elements with reason to escape to this cove. It's not often that you think of a workplace as soothing, especially not hospitals.
It's true that this atmosphere is partly due to the way that the rough edges of medicine are worn away a bit by the different goals and mindset of hospice. There is more thought to necessity, and the removal of what's not. In that sense, things feel simpler. There are no fancy tests to order; people often get sicker and instead of embarking on a diagnostic quest for etiology, we acknowledge the worsening condition and continue. There's still a lot of room for creativity in catering to individual needs. My attending pushed us to consider the best options for care, to not get stuck in status quo. But grounding all of that movement is a framework of simple stability. Not to say that dying is simple, but in the face its possible complexities, people's wants and needs become basic and streamlined to the core, without the excess that can often distort. After awhile the pharmacological treatments become routine, leaving more room to focus on non-pharmacological care, and hospice focuses on that much more than other areas of medicine. Its wholistic perception of people is reflected in its interdisciplinary approach to care; doctors aren't at the center, are instead an arm, of the scheme. There is constant, continual communication with the nurses, social workers, pastors, and family. And while there are many factors to consider, the way in which all these people work together to focus on each person's care, gives a simple sense of value.
I imagine that the comforts and simplicity help the staff as much as the patients, because as calming and welcoming a place it is, it is a hard place to be. Because of that, I think it attracts and seeks certain qualities in the people who work there, making for an incredible community. I've never met such a cluster of genuinely warm, kind, and strong people. The nurses, who are the heart of hospice care, made the biggest impression on me, but the kindness is palpable in every person encountered, from the person at the front desk to the person manning the cafeteria.
In the morning, the nurses and physicians round together, going over the care for each patient. The nurses are the ones giving report, which has never been the case for any other rounds I've seen. They make me remember why I want to be good at whatever it is that I do. They take care in the most whole way possible: delicate where people are fragile, tough and honest when needed. They advocate for their patients, they know their stuff, and they all have voice. It's this combination of warmth and strength that I admire most in women who give care, and every day it reinforced goals to work for.
On my last day I told a slightly demented patient of mine that it had been really nice to take care of her. She replied, "It was really nice to take care of you too." Even as her response was a rote one, I appreciate the truth in that. I think that at their worst these patients and their loved ones have given me more than I could give at my best. Each person copes differently, experiences different pains and discomforts. It would be misguided to say that all of them gave the same thing, but as a whole, it was valuable to witness their capacity to give when so much is being taken from them. There is a woman whose body has been distorted and disfigured by tumors, and as she struggles with grace and patience, she makes me think of how deep our reserves run, how much we can face without being torn. There is a man who has accepted that it will be difficult for him to breathe until he no longer has to, and his first thought in conversation is to answer all the questions he knows you'll ask before you ask them, without pause and without rest, with the creases in his face working with effort to give you all he can. There is a man actively dying before the eyes of his wife, who comforts me with stories of him before he was sick--redheaded, singing silly songs in the morning.
In conversation about this, it was pointed out that perhaps it is something about this stage in life, and not something intrinsic to these specific people, that make us that way. It doesn't matter to me too much from where the source stems. To see people in pain, so close to something unknown, be gracious and generous and sensitive gives me faith in the endurance of these qualities and makes me try harder for the patience to endure. And it's not to say that these people weren't struggling, weren't falling back in some ways, but that there seems to be a pull to hang onto the good when things are slipping away.
I can't say that I endured the past month of this rotation with the same kind of grace that I observed in my patients and their families. The rotation was hard for me. I was surprised by how quickly people transitioned from alert to unresponsive, how I could never get used to someone changing so much over hours or days from the way I first met them even for the ones I rationally knew had come to hospice to die. I missed the people they were as they were still breathing, and I wondered how it was for people who had been their lives. While the pace was unhurried and I was never overworked, and I loved most days there, at the end of them I felt tired.
And I was mean when tired, and the emotional stress of seeing and taking in this weighty process manifested in a lot of physical breakdown. Getting sick, breaking out with a cold sore, a couple allergic reactions, and developing various muscle strains, I was told that I was pushing myself too hard, that I needed to listen to my body. I think it is true that we should take care of ourselves, but I also find value in digging for the resilience that lies in vulnerability, and believe that this first means knowing what makes us weak. I didn't plan this of course, and it could be argued that I'm rationalizing the discomforts of the experience. But somehow, an intuitive, inexplicable part of me feels that there is good reason the weather was so harsh, the people so fragile.
Showing posts with label medical school. Show all posts
Showing posts with label medical school. Show all posts
Saturday, February 5, 2011
Tuesday, January 18, 2011
hospice (beginning)
I'm a week into my rotation at Connecticut Hospice, the first hospice established in the States. It's located in Branford, about twenty minutes north of New Haven, and overlooks the Long Island Sound. The water is a wide expanse, with a wide expanse of ground from the building to the water, and every room has this view. Currently the ground is piled upon with snow, and unlike the snow of city and of routine living, this snow has remained white since its fall one week ago. There's little to disturb it other than the few who walk out from the building to the black fence outlining the beginnings of the water, and these steps add not color but a faceless depth. The sun rising and setting seeps into crevices of the water and clouds, in increments of half seconds, such that you get a sense of change without any motion.
With that backdrop, we have morning rounds, where the nurses (the heart of hospice) report on their patients and their daily plans are discussed. With that backdrop, we visit the patients and write notes on those visits. With that backdrop, we watch people die.
I hesitate with that line, hesitate to dramatize, but when thinking of the actual fact of things, that's just what it is. And some of it is as heavy as it sounds, and some of it floats away without much notice. As not just newbies seeing things for the first time, but as students whose role is to absorb as much as possible, the experience as a whole is quite a bit to take in.
In this short time, I've been struck by a number of things. For example, of how scared I was to see someone physically transition from life to death. Not out of empathy for the person who had not much life before that transition than after, but out of an instinctual aversion to seeing it happen and an awkward, sad sense of trivializing something by being there for the last breath of a person I didn't know.
I've been struck too by resilience, by how people give more at their most difficult times than I can at my best. At a time when I imagine people might feel compelled to turn inwards, they are instead touchingly sensitive to others. They continue on as the people they were--they want to take care of the families they've raised, they are insecure about how others perceive them in hospital beds,
And I've been struck by the variety of burdens, in quality and quantity. There's a lot to consider, besides the sufficient issue of absence. There's a man whose wife donated her kidney to him, there's an unresponsive woman whose 14 year old son reads her stories she'd read him, there's a man whose son and wife don't know how to speak to each other about the same thing, there's a 98 year old woman who says she feels full of emptiness like a room where sound echoes on and on, there's a woman whose understanding of her husband's pain is a more meaningful transition than his from life to death, there's an artist whose wife never let him draw her portrait until now and he draws a black and white picture of her face with her eyes closed. There is a 46 year old man who without telling his wife bought a sports car, who then crashed it while speeding, who then dies after months of his family tracking the movements of his left eye.
And I've been struck by the humor, and conventional routes to warmth paved in a place one might imagine as cold. I wrote my first prescription for a daily beer, frailty quickly turns into feist when a woman wants her nails polished and thinks you're the one who promised them to her, and you find that innocence doesn't need to be young, that the sweetness of wanderings renews itself with dementia. And it's things like all of these that bring awareness from knowing logic to feeling realness, like the sense that maybe death is an emptiness but one that's full.
With that backdrop, we have morning rounds, where the nurses (the heart of hospice) report on their patients and their daily plans are discussed. With that backdrop, we visit the patients and write notes on those visits. With that backdrop, we watch people die.
I hesitate with that line, hesitate to dramatize, but when thinking of the actual fact of things, that's just what it is. And some of it is as heavy as it sounds, and some of it floats away without much notice. As not just newbies seeing things for the first time, but as students whose role is to absorb as much as possible, the experience as a whole is quite a bit to take in.
In this short time, I've been struck by a number of things. For example, of how scared I was to see someone physically transition from life to death. Not out of empathy for the person who had not much life before that transition than after, but out of an instinctual aversion to seeing it happen and an awkward, sad sense of trivializing something by being there for the last breath of a person I didn't know.
I've been struck too by resilience, by how people give more at their most difficult times than I can at my best. At a time when I imagine people might feel compelled to turn inwards, they are instead touchingly sensitive to others. They continue on as the people they were--they want to take care of the families they've raised, they are insecure about how others perceive them in hospital beds,
And I've been struck by the variety of burdens, in quality and quantity. There's a lot to consider, besides the sufficient issue of absence. There's a man whose wife donated her kidney to him, there's an unresponsive woman whose 14 year old son reads her stories she'd read him, there's a man whose son and wife don't know how to speak to each other about the same thing, there's a 98 year old woman who says she feels full of emptiness like a room where sound echoes on and on, there's a woman whose understanding of her husband's pain is a more meaningful transition than his from life to death, there's an artist whose wife never let him draw her portrait until now and he draws a black and white picture of her face with her eyes closed. There is a 46 year old man who without telling his wife bought a sports car, who then crashed it while speeding, who then dies after months of his family tracking the movements of his left eye.
And I've been struck by the humor, and conventional routes to warmth paved in a place one might imagine as cold. I wrote my first prescription for a daily beer, frailty quickly turns into feist when a woman wants her nails polished and thinks you're the one who promised them to her, and you find that innocence doesn't need to be young, that the sweetness of wanderings renews itself with dementia. And it's things like all of these that bring awareness from knowing logic to feeling realness, like the sense that maybe death is an emptiness but one that's full.
Thursday, September 16, 2010
what i'm doing
I've finished my month of subinternship and am in the midst of a month in between rotations. I'll be starting a primary care rotation in October, but in the meantime, when people ask what I'm doing, I usually say, nothing. Which is both true and not true. It's true that I'm not assigned a particular rotation, don't have a routine schedule, and don't have any concrete tasks to accomplish each day or even by the end of the month that anyone is going to check on. And it's true that I've prioritized getting enough sleep, food, exercise, and time with people above all else, which can generally qualify as what's commonly regarded as nothing, as it's not work. But it's not true that I don't have goals to work towards during this time. This block of time was blocked off for research and writing, both endeavors with less concrete goals than this past month.
The last month of being in the hospital was absolutely worth the time and work (of which there was an incredible amount), and I loved it more than I thought I would (in the beginning I was mostly terrified). The structure, mindset, and general atmosphere are very different than my current state, though. Being in the hospital is about treating acute problems, accomplishing tasks: figuring out a diagnosis, ordering the right medicine, filing out the right paperwork, presenting numbers. You work patients up for their problems, you try your best to make them better, and then you discharge them from the hospital. In the gaps and in the broader scheme there are all the other things that make a good doctor, that are more abstract and less straightforward, but the day to day is about getting stuff done.
Which isn't the case with research and writing, both of which I've been working on this past week, without much visible to show for it.
In terms of research, I developed a project that is more about knowing patients than attaining data, which is a difficult thing to 1) do and 2) measure. The general gist is that I want to speak to terminally ill patients who have transitioned from care with goals of cure, to care with goals of quality of life. In the hospital we're good at acute care and quantifiable results, but not as good with transitions that happen over time and aren't easily communicated. I think it's important to know what factors play into patients being ready for this transition, so that we know when and how to talk to them about it, so that care is focused on minimizing suffering, not so much maximizing breathing time.
The first patient I interviewed is dying from lung cancer and had been admitted to the hospice unit of the VA. He was very open to speaking with me but was breathing so heavily, with few gaps between large gasps, that he couldn't talk for longer than a few minutes. When I came back the next day, it was only worse. So nothing came about from those efforts, in terms of my project. But it reminded me of what it's like to see someone actively dying, and of what I want to learn in this process.
My second interview was an actual interview, with a lovely 88 year old woman with lymphoma. She had very developed thoughts about her life and death, and was very comfortable talking about them, so the outcome was completely different from my previous attempt. Another thing I wanted to explore was personal writing, and to have patients journal about their experiences at the end of life, because that can be so different than what someone is able to share in a conversation with a doctor. So at the end of the interview I asked the woman if she'd be interested in participating in something like that. She said that she can't really write due to arthritis, but she had been working awhile ago on a story about her childhood. She brought out several pages of yellow lined paper, and asked if I wanted to read it. We talked about typing it up and having me help her finish it.
So I took the pages home to read and transcribe. Several of them are numbered the same number, such that the order was hard to determine, and as I read through them I realized that's because she had written several different beginnings. Throughout there are some anecdotes told in slightly different ways, so that in typing up the story, I had to maneuver some passages, putting the similar ones side by side, so that she could decide which parts of the same story she wanted to keep, discard, combine. During some particularly difficult parts to decipher, where reading continuously didn't seem to give a sensible narrative, I saw that she'd written in every other line, and in the lines in between added other parts of the story. All of this required some rearranging as I read and typed, and I liked indulging in both the neurotic need to organize and the creative desire to piece things together. The story has nothing to do with my research, but it does have to do with what a lot of people seem to want, a desire to record certain memories, something that resonates a lot with me personally.
I really appreciate the flexibility of this time, that allows things to happen that don't fit a mold of efficiency or list of things to do, where I'm led not by steadfast goals but by natural happenings and my natural responses to them.
And this woman's story comes to me during a time when I've been working on a story about my childhood too. The writing part of this time off is even more vague than the research. I have a list of things I want to write about, which is a little overwhelming, and even when I focus on one, I'm not quite sure what I want to say or how to say it. All I'm sure of is that I feel compelled to write about them, but having the time to do it means being faced with why, and that has resulted in major writer's block. I could spend an entire day on something without much to show for it, and the lack of proportion can be disorienting. But I'm endeared to writing in the way that it's not science and things don't logically lead to other things, and it is amazing to wake up each day with the freedom and privilege to just try, with no expectations, to feel that that's enough, for now.
And so instead of explaining to every person who asks, I say I'm doing nothing. It gets somewhat tiresome, because we're not used to nothing being okay. I'm not traveling anywhere, so it's not like a vacation. The few times I've tried to go more deeply into it, I usually just confuse the person and I'd rather have them think I'm doing nothing of significance instead of misunderstanding something of personal significance. Besides, everyone takes nothing in their own way, and I think we could all use more of it.
The last month of being in the hospital was absolutely worth the time and work (of which there was an incredible amount), and I loved it more than I thought I would (in the beginning I was mostly terrified). The structure, mindset, and general atmosphere are very different than my current state, though. Being in the hospital is about treating acute problems, accomplishing tasks: figuring out a diagnosis, ordering the right medicine, filing out the right paperwork, presenting numbers. You work patients up for their problems, you try your best to make them better, and then you discharge them from the hospital. In the gaps and in the broader scheme there are all the other things that make a good doctor, that are more abstract and less straightforward, but the day to day is about getting stuff done.
Which isn't the case with research and writing, both of which I've been working on this past week, without much visible to show for it.
In terms of research, I developed a project that is more about knowing patients than attaining data, which is a difficult thing to 1) do and 2) measure. The general gist is that I want to speak to terminally ill patients who have transitioned from care with goals of cure, to care with goals of quality of life. In the hospital we're good at acute care and quantifiable results, but not as good with transitions that happen over time and aren't easily communicated. I think it's important to know what factors play into patients being ready for this transition, so that we know when and how to talk to them about it, so that care is focused on minimizing suffering, not so much maximizing breathing time.
The first patient I interviewed is dying from lung cancer and had been admitted to the hospice unit of the VA. He was very open to speaking with me but was breathing so heavily, with few gaps between large gasps, that he couldn't talk for longer than a few minutes. When I came back the next day, it was only worse. So nothing came about from those efforts, in terms of my project. But it reminded me of what it's like to see someone actively dying, and of what I want to learn in this process.
My second interview was an actual interview, with a lovely 88 year old woman with lymphoma. She had very developed thoughts about her life and death, and was very comfortable talking about them, so the outcome was completely different from my previous attempt. Another thing I wanted to explore was personal writing, and to have patients journal about their experiences at the end of life, because that can be so different than what someone is able to share in a conversation with a doctor. So at the end of the interview I asked the woman if she'd be interested in participating in something like that. She said that she can't really write due to arthritis, but she had been working awhile ago on a story about her childhood. She brought out several pages of yellow lined paper, and asked if I wanted to read it. We talked about typing it up and having me help her finish it.
So I took the pages home to read and transcribe. Several of them are numbered the same number, such that the order was hard to determine, and as I read through them I realized that's because she had written several different beginnings. Throughout there are some anecdotes told in slightly different ways, so that in typing up the story, I had to maneuver some passages, putting the similar ones side by side, so that she could decide which parts of the same story she wanted to keep, discard, combine. During some particularly difficult parts to decipher, where reading continuously didn't seem to give a sensible narrative, I saw that she'd written in every other line, and in the lines in between added other parts of the story. All of this required some rearranging as I read and typed, and I liked indulging in both the neurotic need to organize and the creative desire to piece things together. The story has nothing to do with my research, but it does have to do with what a lot of people seem to want, a desire to record certain memories, something that resonates a lot with me personally.
I really appreciate the flexibility of this time, that allows things to happen that don't fit a mold of efficiency or list of things to do, where I'm led not by steadfast goals but by natural happenings and my natural responses to them.
And this woman's story comes to me during a time when I've been working on a story about my childhood too. The writing part of this time off is even more vague than the research. I have a list of things I want to write about, which is a little overwhelming, and even when I focus on one, I'm not quite sure what I want to say or how to say it. All I'm sure of is that I feel compelled to write about them, but having the time to do it means being faced with why, and that has resulted in major writer's block. I could spend an entire day on something without much to show for it, and the lack of proportion can be disorienting. But I'm endeared to writing in the way that it's not science and things don't logically lead to other things, and it is amazing to wake up each day with the freedom and privilege to just try, with no expectations, to feel that that's enough, for now.
And so instead of explaining to every person who asks, I say I'm doing nothing. It gets somewhat tiresome, because we're not used to nothing being okay. I'm not traveling anywhere, so it's not like a vacation. The few times I've tried to go more deeply into it, I usually just confuse the person and I'd rather have them think I'm doing nothing of significance instead of misunderstanding something of personal significance. Besides, everyone takes nothing in their own way, and I think we could all use more of it.
Tuesday, August 17, 2010
subintern
I've just returned from my first day as a medicine subintern. It was about as overwhelming and exhausting as the hype goes, but the core of it was intensely gratifying. And that's not rationalization of the semi-blind choices I've made and difficult path I've chosen, and it's not making the best of things. It's something I feel in my tired chest (why is it that fatigue localizes there, as though our beats and breaths really do consume us). Why else would I be staying up to write this, in a partly delirious state, after having slept less than two hours in the past thirty-two hours? There's so much to say.
A subintern functions much like an intern, which is the first year you legitimately call yourself doctor, except nothing about it feels legitimate. This means that every four nights, you are on-call at the hospital. This means that you work a 30-hour shift. During this time, you see patients who come to the hospital, try to figure out what they have, and try to treat them. You also take care of the patients who are already in the hospital, who are getting better, worse, or staying the same. It's an incredible jump in responsibility, and work hours, from being a student to subintern. I was terrified, and after the first day, still am.
My first day of being a subintern also happened to be my first day on call. So not only did we have to learn the ropes of this new role with parameters wider than my mind could wrap around, but we had to do it for 30 hours straight. Naturally I had a lot of fears about all this. Fears of incompetence, of willpower giving way to fatigue, of being lost in what's supposed to be our space. All of these fears came true. I must say that I did a horrible job on my first day and call. I didn't get morning labs scheduled on time, I didn't think of multiple tests needed for my patients, I made several unnecessary calls and missed other necessary ones, I didn't know how to find new patients in the emergency department, my admission notes were short not for conciseness but for lack of comprehensiveness, my morning oral summaries of the patients were choppy, I didn't gather enough information from past records, I didn't perform complete physical exams on my patients. On and on and on.
It's natural to feel a little frustrated with failure, but what I found myself thinking more than shit, I'm doing such a bad job was, I really WANT to do a good job. For the first time in awhile, I felt want in the purest form. I didn't want it out of frustration from doing badly or because we're always being evaluated, but because I realized 1) just how damn difficult it is to be a good doctor, and 2) how worth it is to be a good doctor. I was lucky to be working with doctors who are good in such complete sense--smart and efficient with the science, smart and kind with the people. People acknowledge that both of these areas take training and effort, but personally, it goes far beyond what I imagined. On the science end, there is an incredible amount of information to gather and most importantly, analyze, apply and synergize. There's the story of symptoms, the methods of the physical exam, the interpretation of numbers, the understanding of images, and how all these complexities interact. And for many patients at once, juggling the components of one patient and then juggling multiple patients--it's dizzying. There is so much to know, and the knowledge isn't empty. Lab values and squiggly lines might appear dry, but when you consider how they are created representations of raw happenings in your body, it's pretty amazing. The indirect ways we've designed to figure ourselves out--I respect them, and I want to know that language in the same way I value language in its conventional definition, as a means of communicating ourselves and something bigger than ourselves. It's never quite the thing itself, but is our approach to it, and a whole other thing on its own. Of course, much (sometimes the majority) of it can be logistics and errands, which I can foresee becoming old fast. But it also appeals to my nerdy, neurotic self and also to a human part of wanting to build when immersed in an environment where people are not rarely falling apart. In both science and logistics I don't pick up things that quickly, and so I know I'll be lost for quite some time, but that's not a source of bitterness--I'm glad to be pursuing something that doesn't come easily.
And I'm glad that the challenge isn't simply for the sake of challenge. Besides the natural appeal of science and systems, there are the patients, and there is the learning of how to be with patients. People think that this isn't as hard as learning all the other stuff; I used to think that way too. But I've learned that while being nice is easy, connecting takes as much of your mind and effort as knowing the science. More often than not I'm not very good at it. I get mixed up with my words and with my silence, I'm bewildered as how to translate my intentions, I find myself painfully aware of my simple experience. The workings of another person can be as foreign as the mechanism of an antibiotic, and I know it's a corny parallel, but the truth is, I often feel myself encountering the same boundaries and confusion with a person as with a drug. But just like with the science, the feelings of stumbling make me feel how much I want this, how much I want to be good at this because I believe in its worth as a goal. I've seen other doctors show such grace at it, and I want that.
It's one of the things I love most about medicine, the way it forces you to interact with people you would never, ever know otherwise. Even as the VA gets the reputation of catering to old men with similar shadings of gruff salted life, each of them carries biting character. The lack of teeth, the sweetness of ninety years of age, the inhibition of schizophrenia, the depression of age, the depression of a hard life, the response to talk about pain, the blue blue eyes, the contortions of wrinkles going this way and that, the leg no longer there, the missing fingers, the natural questions, the natural anxiety. There is such pleasure in coaxing out qualities, of trying hard to see what you can and respect what you can't. And there are fleeting moments where you stop discriminating, when the harsh becomes as welcome as the welcoming, because it's another thing to absorb, another way to hold quality. Of course you'll get mad and annoyed when someone makes things difficult for you; when you're tired and responsible, you aren't looking for this extra baggage and I know I'll never be immune to impatience. But still, isn't baggage the reason we do all this in the first place.
A subintern functions much like an intern, which is the first year you legitimately call yourself doctor, except nothing about it feels legitimate. This means that every four nights, you are on-call at the hospital. This means that you work a 30-hour shift. During this time, you see patients who come to the hospital, try to figure out what they have, and try to treat them. You also take care of the patients who are already in the hospital, who are getting better, worse, or staying the same. It's an incredible jump in responsibility, and work hours, from being a student to subintern. I was terrified, and after the first day, still am.
My first day of being a subintern also happened to be my first day on call. So not only did we have to learn the ropes of this new role with parameters wider than my mind could wrap around, but we had to do it for 30 hours straight. Naturally I had a lot of fears about all this. Fears of incompetence, of willpower giving way to fatigue, of being lost in what's supposed to be our space. All of these fears came true. I must say that I did a horrible job on my first day and call. I didn't get morning labs scheduled on time, I didn't think of multiple tests needed for my patients, I made several unnecessary calls and missed other necessary ones, I didn't know how to find new patients in the emergency department, my admission notes were short not for conciseness but for lack of comprehensiveness, my morning oral summaries of the patients were choppy, I didn't gather enough information from past records, I didn't perform complete physical exams on my patients. On and on and on.
It's natural to feel a little frustrated with failure, but what I found myself thinking more than shit, I'm doing such a bad job was, I really WANT to do a good job. For the first time in awhile, I felt want in the purest form. I didn't want it out of frustration from doing badly or because we're always being evaluated, but because I realized 1) just how damn difficult it is to be a good doctor, and 2) how worth it is to be a good doctor. I was lucky to be working with doctors who are good in such complete sense--smart and efficient with the science, smart and kind with the people. People acknowledge that both of these areas take training and effort, but personally, it goes far beyond what I imagined. On the science end, there is an incredible amount of information to gather and most importantly, analyze, apply and synergize. There's the story of symptoms, the methods of the physical exam, the interpretation of numbers, the understanding of images, and how all these complexities interact. And for many patients at once, juggling the components of one patient and then juggling multiple patients--it's dizzying. There is so much to know, and the knowledge isn't empty. Lab values and squiggly lines might appear dry, but when you consider how they are created representations of raw happenings in your body, it's pretty amazing. The indirect ways we've designed to figure ourselves out--I respect them, and I want to know that language in the same way I value language in its conventional definition, as a means of communicating ourselves and something bigger than ourselves. It's never quite the thing itself, but is our approach to it, and a whole other thing on its own. Of course, much (sometimes the majority) of it can be logistics and errands, which I can foresee becoming old fast. But it also appeals to my nerdy, neurotic self and also to a human part of wanting to build when immersed in an environment where people are not rarely falling apart. In both science and logistics I don't pick up things that quickly, and so I know I'll be lost for quite some time, but that's not a source of bitterness--I'm glad to be pursuing something that doesn't come easily.
And I'm glad that the challenge isn't simply for the sake of challenge. Besides the natural appeal of science and systems, there are the patients, and there is the learning of how to be with patients. People think that this isn't as hard as learning all the other stuff; I used to think that way too. But I've learned that while being nice is easy, connecting takes as much of your mind and effort as knowing the science. More often than not I'm not very good at it. I get mixed up with my words and with my silence, I'm bewildered as how to translate my intentions, I find myself painfully aware of my simple experience. The workings of another person can be as foreign as the mechanism of an antibiotic, and I know it's a corny parallel, but the truth is, I often feel myself encountering the same boundaries and confusion with a person as with a drug. But just like with the science, the feelings of stumbling make me feel how much I want this, how much I want to be good at this because I believe in its worth as a goal. I've seen other doctors show such grace at it, and I want that.
It's one of the things I love most about medicine, the way it forces you to interact with people you would never, ever know otherwise. Even as the VA gets the reputation of catering to old men with similar shadings of gruff salted life, each of them carries biting character. The lack of teeth, the sweetness of ninety years of age, the inhibition of schizophrenia, the depression of age, the depression of a hard life, the response to talk about pain, the blue blue eyes, the contortions of wrinkles going this way and that, the leg no longer there, the missing fingers, the natural questions, the natural anxiety. There is such pleasure in coaxing out qualities, of trying hard to see what you can and respect what you can't. And there are fleeting moments where you stop discriminating, when the harsh becomes as welcome as the welcoming, because it's another thing to absorb, another way to hold quality. Of course you'll get mad and annoyed when someone makes things difficult for you; when you're tired and responsible, you aren't looking for this extra baggage and I know I'll never be immune to impatience. But still, isn't baggage the reason we do all this in the first place.
Saturday, April 24, 2010
childbirth
For the past three years we've spent most of our education considering things that harm, threaten or take life. Now on my ob-gyn rotation, for the first time in med school and really in my life, I've given serious thought to the birth of life. This brings to mind something I heard somewhere (okay, from Dawson's Creek) about how people think of life as the opposite of death, but really birth is the opposite of death and life has no opposite. I still think the latter part of this is true, but I feel now that the former is not quite so straightforward. Setting birth and death apart from life assumes that they're isolated events. But as medicine has showed me that dying is a process, ob-gyn has taught me the same for birth.
The process happens in so many different ways in so many different venues, and even the same kind of labor and delivery holds unique crevices. That the joys of fostering life can be so nuanced makes me think that Tolstoy's all-happy-families-are-the-same philosophy isn't true. I haven't minded observing deliveries several times over. Each baby is different by nature of being new. Besides that inherent change, every woman experiences this process in her own way, absorbs and gives in her own form. Even the same silence, or the same cries, can't be described quite similarly. It's the eyes and the lips and the hands clenched or open that I find drawn to, that I want to use to etch the outlines of those sounds that might sound the same but travel to the ear and register in mind in singular paths.
Then there are all the other places where life is considered and formed. At the fertility clinic, I watched a sixteen year old deal with premature ovarian failure and I watched a forty year old couple contemplate their options for having a child. Having failed in vitro fertilization three times, they would like to try again, and after that? Adoption, egg donation? I clearly remember the first time egg donation ever crossed my mind as any sort of thought, sitting at the freshman dining hall and glancing at a school newspaper advertisement for egg donations from tall women with high SAT scores. I don't think I've given it any sort of thought since then, until fertility clinic, where I realized that childbirth includes all that precedes it, the carrying and laboring. And this is why women choose to place within themselves someone unconnected to them, to take this process into their own hands and foster the connection with strength and desire and commitment. Later in the antenatal testing unit, where women receive ultrasounds during pregnancy, I watched twins float within a 45 year old woman, a phenomenon made possible by egg donation. In class we watch a video about home birth, and debate its use. Regardless of anything else, home birth pays attention to the labor of childbirth, and I find this respect for the process so important. Like most things, it's not something that happens to you; it's something you go through. I can't honestly say it seems easy or pleasant to bear all that pain, but I do believe feeling fully allows for a heightened awareness of experience and why settle for less of something so substantial?
Ob-gyn brings to the forefront much of what I've enjoyed in medicine, the broad range of experience and emotion, and the role of healthcare providers to connect to patients dealing with personal, sensitive, important issues. With each component of this field as a whole and of individual patients, it challenges us to confront things as continual processes with steps, thoughts, and consequences, immediate and far in time. I've really enjoyed seeing babies born, which is a given, but I'm thankful for the surprise of how the value of this moment comes so much from the before and after.
The process happens in so many different ways in so many different venues, and even the same kind of labor and delivery holds unique crevices. That the joys of fostering life can be so nuanced makes me think that Tolstoy's all-happy-families-are-the-same philosophy isn't true. I haven't minded observing deliveries several times over. Each baby is different by nature of being new. Besides that inherent change, every woman experiences this process in her own way, absorbs and gives in her own form. Even the same silence, or the same cries, can't be described quite similarly. It's the eyes and the lips and the hands clenched or open that I find drawn to, that I want to use to etch the outlines of those sounds that might sound the same but travel to the ear and register in mind in singular paths.
Then there are all the other places where life is considered and formed. At the fertility clinic, I watched a sixteen year old deal with premature ovarian failure and I watched a forty year old couple contemplate their options for having a child. Having failed in vitro fertilization three times, they would like to try again, and after that? Adoption, egg donation? I clearly remember the first time egg donation ever crossed my mind as any sort of thought, sitting at the freshman dining hall and glancing at a school newspaper advertisement for egg donations from tall women with high SAT scores. I don't think I've given it any sort of thought since then, until fertility clinic, where I realized that childbirth includes all that precedes it, the carrying and laboring. And this is why women choose to place within themselves someone unconnected to them, to take this process into their own hands and foster the connection with strength and desire and commitment. Later in the antenatal testing unit, where women receive ultrasounds during pregnancy, I watched twins float within a 45 year old woman, a phenomenon made possible by egg donation. In class we watch a video about home birth, and debate its use. Regardless of anything else, home birth pays attention to the labor of childbirth, and I find this respect for the process so important. Like most things, it's not something that happens to you; it's something you go through. I can't honestly say it seems easy or pleasant to bear all that pain, but I do believe feeling fully allows for a heightened awareness of experience and why settle for less of something so substantial?
Ob-gyn brings to the forefront much of what I've enjoyed in medicine, the broad range of experience and emotion, and the role of healthcare providers to connect to patients dealing with personal, sensitive, important issues. With each component of this field as a whole and of individual patients, it challenges us to confront things as continual processes with steps, thoughts, and consequences, immediate and far in time. I've really enjoyed seeing babies born, which is a given, but I'm thankful for the surprise of how the value of this moment comes so much from the before and after.
Monday, April 12, 2010
experience
I wanted to do medicine for a strong desire for something vague--experience. I spent a good chunk of my life reading stories, thinking about stories, cooped up inside of myself. I wanted to see things, do things, understand things, as a means to reach outwards. I wasn't sure of the actual texture and contours of these endeavors, but I knew that I wanted texture and contours. And the main reason I love med school is that it has been just that. It's let me in on so much experience.
There's so much variety. We rotate through so many different areas of medicine that we constantly see people dealing with different aspects of life. A sudden heart attack, the realities of the deficits of a stroke, a long struggle with cancer, a steady adjustment to a chronic disease, recovering from the pains of a surgery, having parts of your body rearranged, having parts of your body removed, giving birth, terminating a pregnancy, battling mind with mind, losing movement, losing thought, recovering movement, recovering thought--so much can happen to a person, and each experience tells you so much about people and what's around people and what's in between people and what's independent of people.
A friend of mine recently mentioned an aversion for how a crowd of people tend to respond to things in the same way, stripping people of their individual qualities and interactions with things around them. Once you've chosen your path in medicine, it's easy to do this to people, by nature of seeing similar things over and over. But even within the same experience, there's depth and nuance. I saw four women give birth today and each one was different. Each person feels things differently; expresses in their own way; lives what happens to them as only they are fit to do.
In one day there were these experiences, for me to absorb and give back in some form. Today was a long day and I have to write quickly so nothing will be entirely accurate or remotely elegant, but at the least it's fresh. One of my top ten things is seeing people do things for the first time. Two women gave birth for the first time. Many sets of eyes saw the outside for the first time. I delivered my first baby, a six pound girl with curly black hair. I tried my hardest to hold it like a football but I probably forgot how because my memory sometimes fades in the presence of wonder. When pushed to do more, one woman immersed in pain continued to give more and more. Her friend of twenty plus years hung onto her leg and told her the baby was getting closer and closer ("you're lying!"). The father of one baby held tentatively to the mother's foot, unattached or unsure. A head popped from the abdomen (perhaps blossoming is more ethereal but popping is what it was); in another, the foot came first. These ones were purply gray, wrinkly, gross and so damn gorgeous it hurt you through your double gloved hands. He said his little girl was suffering from ET skin, so apt. There is a female camaraderie where certain things can be said in the open and cause laughter and comfort, as women just met share something momentary and lasting. There is a lot of endurance but only because there is a lot of pain, and it reminds you that you're here not for a blip but for the spectrum.
There's so much variety. We rotate through so many different areas of medicine that we constantly see people dealing with different aspects of life. A sudden heart attack, the realities of the deficits of a stroke, a long struggle with cancer, a steady adjustment to a chronic disease, recovering from the pains of a surgery, having parts of your body rearranged, having parts of your body removed, giving birth, terminating a pregnancy, battling mind with mind, losing movement, losing thought, recovering movement, recovering thought--so much can happen to a person, and each experience tells you so much about people and what's around people and what's in between people and what's independent of people.
A friend of mine recently mentioned an aversion for how a crowd of people tend to respond to things in the same way, stripping people of their individual qualities and interactions with things around them. Once you've chosen your path in medicine, it's easy to do this to people, by nature of seeing similar things over and over. But even within the same experience, there's depth and nuance. I saw four women give birth today and each one was different. Each person feels things differently; expresses in their own way; lives what happens to them as only they are fit to do.
In one day there were these experiences, for me to absorb and give back in some form. Today was a long day and I have to write quickly so nothing will be entirely accurate or remotely elegant, but at the least it's fresh. One of my top ten things is seeing people do things for the first time. Two women gave birth for the first time. Many sets of eyes saw the outside for the first time. I delivered my first baby, a six pound girl with curly black hair. I tried my hardest to hold it like a football but I probably forgot how because my memory sometimes fades in the presence of wonder. When pushed to do more, one woman immersed in pain continued to give more and more. Her friend of twenty plus years hung onto her leg and told her the baby was getting closer and closer ("you're lying!"). The father of one baby held tentatively to the mother's foot, unattached or unsure. A head popped from the abdomen (perhaps blossoming is more ethereal but popping is what it was); in another, the foot came first. These ones were purply gray, wrinkly, gross and so damn gorgeous it hurt you through your double gloved hands. He said his little girl was suffering from ET skin, so apt. There is a female camaraderie where certain things can be said in the open and cause laughter and comfort, as women just met share something momentary and lasting. There is a lot of endurance but only because there is a lot of pain, and it reminds you that you're here not for a blip but for the spectrum.
Wednesday, February 24, 2010
alone
Leaning against my car, I didn’t see any water. Void of any geographical sense, I wasn’t sure where the Long Island Sound was situated but I wasn’t really looking for it either. Though the space between, between where I was and where the bank of trees ahead lay, steeped down and gave a feeling of being higher up, the parking lot was likely not elevated enough to afford a view. It was cold, not bitingly so, just so to match the gray that comes too early in the day during months like December. The sky held a dull solid gray, the trees blended a hazy one.
It’d been a short and unfamiliar drive from New Haven to the Connecticut Hospice, and now that I’d entered and left the entrance of the building, it was easier to stay. The stray leaves clinging to deceptively precarious branches didn’t keep the trees from being bare, but made them feel heavy, and I tried to focus on the lean trunks. I tried not to choke on my heaving breaths. And to stop the flow of salt and water from my eyes to the air around, air that you could tell was dry by the way it soaked up the moisture layering my skin.
He’d been transferred from the hospital to hospice the day before. He hadn’t been happy about it, had responded with “horrible” when asked how he was doing, the last two syllables swallowed by the effort of the first. Often his breathing was too labored for fluency, and sometimes words took a long time, occupying a space that I didn’t realize was open until his voice closed them. Even though his voice sounded the same whether he was comfortable or uncomfortable, it moved more than anything else about him. It was never accented by the rest of his face; his lips didn’t migrate from the straight road they naturally formed, the taut white of his forehead never disrupted even while his lungs crumpled into rough coughs.
He lived in a bed next to the door in a room of three, and when we waved from the hallway he called out hello if he saw us. The wet brown of his eyes drew a full film from one corner to the other and felt protective of something, but they kept him from seeing his food well enough to eat. He didn’t want to eat anyway, and he directed his gaze towards the sound of the television, even when the hospital headphones slipped off his ears and forward onto his chest like a necklace. It made me think that hospital gowns don’t lend themselves to accessories.
He had been a patient on our list of patients to see every morning for almost a week before I really met him, when the physician taking care of him allowed another medical student and me to sit in on a conversation she had with him about his health. Earlier that day she had talked of him as a patient she knew would stick with her; “he’s sweet; you can tell life’s been unfair to him.” I’d felt somewhat guilty for not noticing, as once I sat down on his bed it was palpable through the blankets.
The doctor touched his shoulder, which was usually enough to rouse him if his eyes were closed (at this time they weren’t), and told him she wanted to talk to him about things.
She gently explained the state of his major organs and how in trying to support one, we hurt another. When things reach a balancing act where balance would be unstable, when piling or removing things from either end keeps hurting, we turn our attention to the fulcrum. Again nothing in his face moved, but he said he wasn’t ready. He’d have to talk to his wife. She didn’t visit because they didn’t have a car, and a taxi would be too costly for their resources. She didn’t like seeing him so sick, anyway. But Thanksgiving was coming up, and his nephews and nieces had cars that could carry his family, and turkey with cranberry sauce in plastic containers, to the hospital then.
I was also in the hospital on Thanksgiving, when his room went from three patients whose beds were separated by cloth curtains maneuvered by nurses and doctors, to a flock of relatives standing in their puffy winter coats that they didn’t remove once inside. His wife’s shape matched her voice on the phone but she looked much older than him, with the gray in her hair prominent since she’d let it go long while his hair was still brown, and the wrinkles I sometimes imagined to be hiding in his forehead openly lined her eyes. A teenager with glasses and thick strands of hair across his forehead, a nephew I presumed, brought him a walkman. The headphones that came with it weren’t any more stable around his head than the others, but he took them with him to hospice; we had to disentangle them from the other pair to make sure he had the right ones.
I said hello to the group forming a sort of semi-circle at the foot of his bed as though participating in an icebreaker, and saw the cranberry sauce. It is strange to meet people whose lives give a disproportionate amount of substance to yours when compared to vice versa. I wasn’t in the room when the doctors talked to them about the future. But I saw them leave the room and walk down the hallway in a choppy stream, some visibly upset and others subtly so.
His wife nodded as I passed and said that she would like him to be comfortable. I nodded back, and went into his room out of an invisible inertia, without thought to if I had anything to offer and if so what form that would take. And so I started as we did every morning.
“How are you doing?”
“Oh, half and half.”
“I saw your family in the hallway. It must’ve been nice to have them here.” I looked at his bedside table to see if he’d eaten, but I couldn’t really tell. It was only then that I heard what he’d said, which was something he would say often in the following days. When evaluating his physical state, the doctors taking care of him spoke of him as having good days and bad days. It is true that on some days his face looked cleaner and his lungs sounded clearer, and other days the crackles that our stethoscopes could hear would rattle his chest so that he looked limp and for some reason during those times, the crust that develops from standstill remained in his eyes instead of being washed with blinks. “Half and half?”
He nodded, which for him meant bringing his chin down to his chest. By the time he’d bring it back up, you may have forgotten the first motion.
“Did you talk to your family about things?”
“We’re looking for a place. There’s one near my house so my wife can walk there and see me.”
Surprised that the logistics of things had already been discussed, I nodded.
Back in the room with the computers where we typed records of how our patients were doing today versus yesterday, they tried guessing what would take him, eventually: his kidneys, said one; his lungs, said another. How does that work, when his cancer had started in his throat? He never asked, but I wondered and despite the daily updates on his physical state I never knew.
Later through a process of which I wasn’t aware but trusted, it was decided that he go to Connecticut Hospice in Branford, not to the place he mentioned in his town. We told him it would probably be better when he was settled into a place, in a room with more privacy. He asked whether he would be in his own room, and was told that it was likely to be shared but that the rooms were vast. Although he seemed to want his own room, he wasn’t eager to leave the company of the people passing his open door in the hallway, though he never stated either sentiment directly. “It’s nice to just see faces,” he said in what felt more like a confirmation than a confession.
On one Friday, after having seen him on our morning rounds every day he’d been in the hospital, I said I’d miss him over the weekend.
“Well, then you should work on the weekend.”
I paused. “I’ll come by to see you.”
There was no pause, and no movement of his eyes from their station. “That’s very nice, but you won’t.”
Our interactions were not scarce, but brief. We ran out of things to say. I didn’t find out much about his life before here, or his life at that time outside of that bed. The natural course of asking how he was would be to discuss the present and near future, and I didn’t know how to bring the past in relief. On days when he wanted to be in limbo or something more than that, he’d talk about the new cancer center and what his doctors had told them. On the days it was explicit, mostly he said he didn’t want to die. Asking why would have felt too easily misunderstood, but now feels too easily absent.
So the day he left for hospice was one of the half and half days; to his doctors it was a bad one. In the hours before the transport from hospice arrived, he was having trouble breathing, and when they arrived he was receiving a breathing treatment to help open the vessels in his lungs. The man and woman in uniform who had come for him stood by the window and told us to take our time; they were “in no rush.” When he finished breathing into the mask, they brought a thin stretcher alongside the hospital bed.
“We’re going to move you from there into this so we can drive you there, okay?”
“How far is it?”
“The ride will be over before you know it. Barely twelve minutes.” The woman’s conversation was proficient, and I became acutely aware that this was my first time seeing all this happen. Her hair was tight where her braid started to form and then throughout. Nothing about her gave way, but still she was kind in a way difficult to pinpoint with tone or act. Maybe it was this softness without known source that made me turn away when they put the rails down on his hospital bed.
But I watched as they gathered the sheet below him and swiftly transferred him to the stretcher. Narrow as he was, the stretcher still just accommodated him. The man and woman layered him with blankets that had the texture of towels.
“There will be a brief period, less than a minute, where you’ll be outside as we move you into the van. It’ll be cold, but we’re putting these blankets on you, and it’ll be very quick.”
His belly was large, but he was seamlessly consumed by a swarm of blankets. Once covered, his arms and legs disappeared. His small face lacked sharp edges and fell into underlying pillow without difficulty. There were hints of him against the sheet: the deep brown of his hair splayed in tufts, the red in his cheeks dissolving thinly out and down to his jaw and seeping into the pillowcase, the wet in his eyes making all else feel dull. This was all I could see of him; everything else was white on the black stretcher.
“We’re going to strap you in now, okay?”
He brought his chin down to his chest, and coughed, “Okay.”
The woman pulled on a black belt with a heavy buckle, stretched it to as far as her arm extended, and handed the other end across his body to the man, who pulled down and tightened it. This spanned his torso. They started another across his lower body but as the transfer of buckle was taking place, one caught the other’s eye and they paused. “It’s probably not necessary.”
I’d never seen him walk while in the hospital, though I knew he went to and from the bathroom on his own, but it wasn’t until now that it seemed that he couldn’t move, with or without the one buckle. He was breathing less heavily now and unlike when he was sitting up in bed with his gown in full view, as he lay there I couldn’t see his chest struggling.
“I hope you’ll come see me.” We’ve been advised never to promise anything, and despite instincts, we force ourselves to rephrase things into “I’ll try.” It was a Tuesday, and I told him I’d try my best to come see him, though it might not be until Thursday or so. I watched them wheel him through the door and down the hallway, no further though I could have rounded the corner to the elevators with them.
I’d never been to Connecticut Hospice but had heard it was beautiful, overlooking the water. I looked up its information on the internet on Wednesday morning. I called their number for his room number, and was given it, though they said I wouldn’t need it. The person at the front desk would help me once I got there.
It was late afternoon when I got there. Though the streets were a little confusing, I’d found the way fairly easily with my friend’s GPS. The parking lot was large and three fourths full. As I walked to the main entrance, I felt glad the transition had been made, and looked forward to seeing him in a brighter place, one designed for comfort. The front desk was where they said it would be, and I found myself thankful for the ease of things. The woman manning it wore a thick sweater upon which her light curls rested. When I gave her his name, she carefully scanned a list in front of her. As the seconds crawled, I regretted forgetting the room number I’d called for in the morning.
She picked up the phone to call for his room, and as I waited I watched others pass through the front desk and down a corridor past large glass windows, without stopping. She spoke softly, but I heard her say his name. Then, “oh,” to the phone and to me, “Are you a family member?”
“No. I’m a med student. We took care of him at the hospital.”
“Oh,” to me, and to the phone, “She took care of him at the hospital.”
I watched her nod several times at the phone, continuing to speak softly, and hang up. “Someone’s coming.”
“Thank you.” I waited and watched more people pass, without waiting.
Someone whose face and shape I don’t remember came. “Hello, are you a family member?”
“No. I’m a med student. We took care of him at the hospital.”
“Oh.” She nodded. I gave a small smile. She told me she was very sorry; he’d passed away that afternoon.
“Oh. That was fast.” So fast. Twelve minutes to get from the hospital to there. What happened in between? I’d called that morning. He’d had a room number. One with a letter, so he was sharing space. But it was more space. Blinking to buy time, I paused before it came to me to ask, “Was his family there?”
“No. We called his wife. She didn’t want to come.”
I nodded. “Thank you.” I wanted to give her more than that thank you, or to fully give the thank you, and paused. But it was too brief, and the sentiment too blurry. I turned slowly, maybe to match the stride of what had come before. But once out the door, the passing air that grazed my skin on its way to elsewhere held in it the shortness of my time inside, taking it for itself and carrying it away. Maybe because of that I stayed outside.
He hadn’t asked to be moved to a building with a view, or for much of anything other than our presence. It wasn’t much to give, and it wasn’t hard to want to give it, but in the end it was the most elusive. When asked about how he wanted to proceed, he’d defer to what we thought, saying we knew best. There were a lot of us: the respiratory team watching over his lungs, the oncology team monitoring his cancer, the renal team reminding us that his kidneys were failing, and the geriatric team checking every morning for a bad or good day. Each of them explained things, and asked questions to cater to his needs, trying to provide care in the niches they’d formed in training and in experience. Because the weight of confrontation and decision was too much for him, and because this weight had become a part of their anatomy, they let him give it to them, in the hopes that they could give something to him.
I thought this too, thought that though it felt viscerally out of place to attach him to that stretcher and move him, it would take him to a place that would be better, eventually. What happened in that transition to this place, that took from him the time required to make it better? We’d left him alone before.
Never having seen him in a new place, standing with the hospice in close distance I only saw him as he looked when I first knew him. After not too long I left for home, with the water still out of view behind the low level of trees.
It’d been a short and unfamiliar drive from New Haven to the Connecticut Hospice, and now that I’d entered and left the entrance of the building, it was easier to stay. The stray leaves clinging to deceptively precarious branches didn’t keep the trees from being bare, but made them feel heavy, and I tried to focus on the lean trunks. I tried not to choke on my heaving breaths. And to stop the flow of salt and water from my eyes to the air around, air that you could tell was dry by the way it soaked up the moisture layering my skin.
He’d been transferred from the hospital to hospice the day before. He hadn’t been happy about it, had responded with “horrible” when asked how he was doing, the last two syllables swallowed by the effort of the first. Often his breathing was too labored for fluency, and sometimes words took a long time, occupying a space that I didn’t realize was open until his voice closed them. Even though his voice sounded the same whether he was comfortable or uncomfortable, it moved more than anything else about him. It was never accented by the rest of his face; his lips didn’t migrate from the straight road they naturally formed, the taut white of his forehead never disrupted even while his lungs crumpled into rough coughs.
He lived in a bed next to the door in a room of three, and when we waved from the hallway he called out hello if he saw us. The wet brown of his eyes drew a full film from one corner to the other and felt protective of something, but they kept him from seeing his food well enough to eat. He didn’t want to eat anyway, and he directed his gaze towards the sound of the television, even when the hospital headphones slipped off his ears and forward onto his chest like a necklace. It made me think that hospital gowns don’t lend themselves to accessories.
He had been a patient on our list of patients to see every morning for almost a week before I really met him, when the physician taking care of him allowed another medical student and me to sit in on a conversation she had with him about his health. Earlier that day she had talked of him as a patient she knew would stick with her; “he’s sweet; you can tell life’s been unfair to him.” I’d felt somewhat guilty for not noticing, as once I sat down on his bed it was palpable through the blankets.
The doctor touched his shoulder, which was usually enough to rouse him if his eyes were closed (at this time they weren’t), and told him she wanted to talk to him about things.
She gently explained the state of his major organs and how in trying to support one, we hurt another. When things reach a balancing act where balance would be unstable, when piling or removing things from either end keeps hurting, we turn our attention to the fulcrum. Again nothing in his face moved, but he said he wasn’t ready. He’d have to talk to his wife. She didn’t visit because they didn’t have a car, and a taxi would be too costly for their resources. She didn’t like seeing him so sick, anyway. But Thanksgiving was coming up, and his nephews and nieces had cars that could carry his family, and turkey with cranberry sauce in plastic containers, to the hospital then.
I was also in the hospital on Thanksgiving, when his room went from three patients whose beds were separated by cloth curtains maneuvered by nurses and doctors, to a flock of relatives standing in their puffy winter coats that they didn’t remove once inside. His wife’s shape matched her voice on the phone but she looked much older than him, with the gray in her hair prominent since she’d let it go long while his hair was still brown, and the wrinkles I sometimes imagined to be hiding in his forehead openly lined her eyes. A teenager with glasses and thick strands of hair across his forehead, a nephew I presumed, brought him a walkman. The headphones that came with it weren’t any more stable around his head than the others, but he took them with him to hospice; we had to disentangle them from the other pair to make sure he had the right ones.
I said hello to the group forming a sort of semi-circle at the foot of his bed as though participating in an icebreaker, and saw the cranberry sauce. It is strange to meet people whose lives give a disproportionate amount of substance to yours when compared to vice versa. I wasn’t in the room when the doctors talked to them about the future. But I saw them leave the room and walk down the hallway in a choppy stream, some visibly upset and others subtly so.
His wife nodded as I passed and said that she would like him to be comfortable. I nodded back, and went into his room out of an invisible inertia, without thought to if I had anything to offer and if so what form that would take. And so I started as we did every morning.
“How are you doing?”
“Oh, half and half.”
“I saw your family in the hallway. It must’ve been nice to have them here.” I looked at his bedside table to see if he’d eaten, but I couldn’t really tell. It was only then that I heard what he’d said, which was something he would say often in the following days. When evaluating his physical state, the doctors taking care of him spoke of him as having good days and bad days. It is true that on some days his face looked cleaner and his lungs sounded clearer, and other days the crackles that our stethoscopes could hear would rattle his chest so that he looked limp and for some reason during those times, the crust that develops from standstill remained in his eyes instead of being washed with blinks. “Half and half?”
He nodded, which for him meant bringing his chin down to his chest. By the time he’d bring it back up, you may have forgotten the first motion.
“Did you talk to your family about things?”
“We’re looking for a place. There’s one near my house so my wife can walk there and see me.”
Surprised that the logistics of things had already been discussed, I nodded.
Back in the room with the computers where we typed records of how our patients were doing today versus yesterday, they tried guessing what would take him, eventually: his kidneys, said one; his lungs, said another. How does that work, when his cancer had started in his throat? He never asked, but I wondered and despite the daily updates on his physical state I never knew.
Later through a process of which I wasn’t aware but trusted, it was decided that he go to Connecticut Hospice in Branford, not to the place he mentioned in his town. We told him it would probably be better when he was settled into a place, in a room with more privacy. He asked whether he would be in his own room, and was told that it was likely to be shared but that the rooms were vast. Although he seemed to want his own room, he wasn’t eager to leave the company of the people passing his open door in the hallway, though he never stated either sentiment directly. “It’s nice to just see faces,” he said in what felt more like a confirmation than a confession.
On one Friday, after having seen him on our morning rounds every day he’d been in the hospital, I said I’d miss him over the weekend.
“Well, then you should work on the weekend.”
I paused. “I’ll come by to see you.”
There was no pause, and no movement of his eyes from their station. “That’s very nice, but you won’t.”
Our interactions were not scarce, but brief. We ran out of things to say. I didn’t find out much about his life before here, or his life at that time outside of that bed. The natural course of asking how he was would be to discuss the present and near future, and I didn’t know how to bring the past in relief. On days when he wanted to be in limbo or something more than that, he’d talk about the new cancer center and what his doctors had told them. On the days it was explicit, mostly he said he didn’t want to die. Asking why would have felt too easily misunderstood, but now feels too easily absent.
So the day he left for hospice was one of the half and half days; to his doctors it was a bad one. In the hours before the transport from hospice arrived, he was having trouble breathing, and when they arrived he was receiving a breathing treatment to help open the vessels in his lungs. The man and woman in uniform who had come for him stood by the window and told us to take our time; they were “in no rush.” When he finished breathing into the mask, they brought a thin stretcher alongside the hospital bed.
“We’re going to move you from there into this so we can drive you there, okay?”
“How far is it?”
“The ride will be over before you know it. Barely twelve minutes.” The woman’s conversation was proficient, and I became acutely aware that this was my first time seeing all this happen. Her hair was tight where her braid started to form and then throughout. Nothing about her gave way, but still she was kind in a way difficult to pinpoint with tone or act. Maybe it was this softness without known source that made me turn away when they put the rails down on his hospital bed.
But I watched as they gathered the sheet below him and swiftly transferred him to the stretcher. Narrow as he was, the stretcher still just accommodated him. The man and woman layered him with blankets that had the texture of towels.
“There will be a brief period, less than a minute, where you’ll be outside as we move you into the van. It’ll be cold, but we’re putting these blankets on you, and it’ll be very quick.”
His belly was large, but he was seamlessly consumed by a swarm of blankets. Once covered, his arms and legs disappeared. His small face lacked sharp edges and fell into underlying pillow without difficulty. There were hints of him against the sheet: the deep brown of his hair splayed in tufts, the red in his cheeks dissolving thinly out and down to his jaw and seeping into the pillowcase, the wet in his eyes making all else feel dull. This was all I could see of him; everything else was white on the black stretcher.
“We’re going to strap you in now, okay?”
He brought his chin down to his chest, and coughed, “Okay.”
The woman pulled on a black belt with a heavy buckle, stretched it to as far as her arm extended, and handed the other end across his body to the man, who pulled down and tightened it. This spanned his torso. They started another across his lower body but as the transfer of buckle was taking place, one caught the other’s eye and they paused. “It’s probably not necessary.”
I’d never seen him walk while in the hospital, though I knew he went to and from the bathroom on his own, but it wasn’t until now that it seemed that he couldn’t move, with or without the one buckle. He was breathing less heavily now and unlike when he was sitting up in bed with his gown in full view, as he lay there I couldn’t see his chest struggling.
“I hope you’ll come see me.” We’ve been advised never to promise anything, and despite instincts, we force ourselves to rephrase things into “I’ll try.” It was a Tuesday, and I told him I’d try my best to come see him, though it might not be until Thursday or so. I watched them wheel him through the door and down the hallway, no further though I could have rounded the corner to the elevators with them.
I’d never been to Connecticut Hospice but had heard it was beautiful, overlooking the water. I looked up its information on the internet on Wednesday morning. I called their number for his room number, and was given it, though they said I wouldn’t need it. The person at the front desk would help me once I got there.
It was late afternoon when I got there. Though the streets were a little confusing, I’d found the way fairly easily with my friend’s GPS. The parking lot was large and three fourths full. As I walked to the main entrance, I felt glad the transition had been made, and looked forward to seeing him in a brighter place, one designed for comfort. The front desk was where they said it would be, and I found myself thankful for the ease of things. The woman manning it wore a thick sweater upon which her light curls rested. When I gave her his name, she carefully scanned a list in front of her. As the seconds crawled, I regretted forgetting the room number I’d called for in the morning.
She picked up the phone to call for his room, and as I waited I watched others pass through the front desk and down a corridor past large glass windows, without stopping. She spoke softly, but I heard her say his name. Then, “oh,” to the phone and to me, “Are you a family member?”
“No. I’m a med student. We took care of him at the hospital.”
“Oh,” to me, and to the phone, “She took care of him at the hospital.”
I watched her nod several times at the phone, continuing to speak softly, and hang up. “Someone’s coming.”
“Thank you.” I waited and watched more people pass, without waiting.
Someone whose face and shape I don’t remember came. “Hello, are you a family member?”
“No. I’m a med student. We took care of him at the hospital.”
“Oh.” She nodded. I gave a small smile. She told me she was very sorry; he’d passed away that afternoon.
“Oh. That was fast.” So fast. Twelve minutes to get from the hospital to there. What happened in between? I’d called that morning. He’d had a room number. One with a letter, so he was sharing space. But it was more space. Blinking to buy time, I paused before it came to me to ask, “Was his family there?”
“No. We called his wife. She didn’t want to come.”
I nodded. “Thank you.” I wanted to give her more than that thank you, or to fully give the thank you, and paused. But it was too brief, and the sentiment too blurry. I turned slowly, maybe to match the stride of what had come before. But once out the door, the passing air that grazed my skin on its way to elsewhere held in it the shortness of my time inside, taking it for itself and carrying it away. Maybe because of that I stayed outside.
He hadn’t asked to be moved to a building with a view, or for much of anything other than our presence. It wasn’t much to give, and it wasn’t hard to want to give it, but in the end it was the most elusive. When asked about how he wanted to proceed, he’d defer to what we thought, saying we knew best. There were a lot of us: the respiratory team watching over his lungs, the oncology team monitoring his cancer, the renal team reminding us that his kidneys were failing, and the geriatric team checking every morning for a bad or good day. Each of them explained things, and asked questions to cater to his needs, trying to provide care in the niches they’d formed in training and in experience. Because the weight of confrontation and decision was too much for him, and because this weight had become a part of their anatomy, they let him give it to them, in the hopes that they could give something to him.
I thought this too, thought that though it felt viscerally out of place to attach him to that stretcher and move him, it would take him to a place that would be better, eventually. What happened in that transition to this place, that took from him the time required to make it better? We’d left him alone before.
Never having seen him in a new place, standing with the hospice in close distance I only saw him as he looked when I first knew him. After not too long I left for home, with the water still out of view behind the low level of trees.
Saturday, February 13, 2010
bypass
They tell us to look for patterns in medicine, in the way diseases work and in the way we treat them. One of our favorite things to do is to bypass. When a vessel supplying blood to the heart becomes blocked, we use other vessels to go around the blockage. Same idea with a block in the vessels supplying the small intestine. And when you don't want food going to the stomach, you bypass it by cutting off a point where two points of the stomach connect and reconnect the stomach to the small intestine instead. It all works pretty well, perhaps not quite as well as the anatomy with which we're born, but after the wear and tear of time and experience we cope the best we can.
Currently on my one month gastrointestinal surgery rotation, and have seen several gastric bypasses for morbidly obese patients. They were good surgeries to see; the abdominal anatomy is compact and clear. When the stomach is cut, you find the pancreas behind it. As you move horizontally to maneuver things, you find the liver and spleen flanking the stomach. And you follow the small intestine down to find the best place to cut, and to reconnect, saying hello to the large intestine amidst the surroundings along the way. Seeing things in real color (the spleen really is purple, and the pancreas off-white), and three dimensions makes for a pretty view.
Sitting in the back during a informational meeting for gastric bpyass patients also afforded an interesting view. Insurance typically covers this procedure once a person's BMI is greater than 40 (ideal being 20) and most of the patients I've seen run beyond 50. They suffer from an interaction between their physiology and their environment that makes it nearly impossible for non-surgical interventions to help. Interestingly, their internal anatomy is not so different from others. At one point, the surgeon giving the talk said all of our stomachs are the same size, "including that of my med student sitting in the back there." To my relief no one turned around to look at me, but I was grateful to be present. A secretary who'd had a bypass herself talked about the experience, the looking forward before she'd had it and the looking backward now that she had, while emphasizing that the process was never over. The surgeon went into detail about what the procedure entailed and what it demanded of its patients. People listened and asked questions.
Medicine so randomly throws you into the stories of people you might otherwise never consider, and being literally dwarfed in a corner of this room made me feel it pretty strongly. Seeing one bypass after another in the operating room fools us into thinking the stitches signify an end and numbs us to the change that's happening or will happen. But hearing an acknowledgment of the anticipation leading to this surgery and hearing the patients be told the long course of care that must happen after the surgery reminds us of context. There's a lot--a lot of work, thought, feelings--encased in a two hour procedure that for those in the operating room starts with an incision and ends with a suture. Up until then surgeries for us as students have been so open-shut, and part of why I feel out of place during the week is because I have nowhere to put what we see on a daily basis. Settling their organs and skin back into place still leaves a sense of intrusion that isn't fully reversed. From the room full of people hoping to become more by becoming less, I'm more able to place what I see back into the people themselves, and this isn't something we can afford to bypass.
Currently on my one month gastrointestinal surgery rotation, and have seen several gastric bypasses for morbidly obese patients. They were good surgeries to see; the abdominal anatomy is compact and clear. When the stomach is cut, you find the pancreas behind it. As you move horizontally to maneuver things, you find the liver and spleen flanking the stomach. And you follow the small intestine down to find the best place to cut, and to reconnect, saying hello to the large intestine amidst the surroundings along the way. Seeing things in real color (the spleen really is purple, and the pancreas off-white), and three dimensions makes for a pretty view.
Sitting in the back during a informational meeting for gastric bpyass patients also afforded an interesting view. Insurance typically covers this procedure once a person's BMI is greater than 40 (ideal being 20) and most of the patients I've seen run beyond 50. They suffer from an interaction between their physiology and their environment that makes it nearly impossible for non-surgical interventions to help. Interestingly, their internal anatomy is not so different from others. At one point, the surgeon giving the talk said all of our stomachs are the same size, "including that of my med student sitting in the back there." To my relief no one turned around to look at me, but I was grateful to be present. A secretary who'd had a bypass herself talked about the experience, the looking forward before she'd had it and the looking backward now that she had, while emphasizing that the process was never over. The surgeon went into detail about what the procedure entailed and what it demanded of its patients. People listened and asked questions.
Medicine so randomly throws you into the stories of people you might otherwise never consider, and being literally dwarfed in a corner of this room made me feel it pretty strongly. Seeing one bypass after another in the operating room fools us into thinking the stitches signify an end and numbs us to the change that's happening or will happen. But hearing an acknowledgment of the anticipation leading to this surgery and hearing the patients be told the long course of care that must happen after the surgery reminds us of context. There's a lot--a lot of work, thought, feelings--encased in a two hour procedure that for those in the operating room starts with an incision and ends with a suture. Up until then surgeries for us as students have been so open-shut, and part of why I feel out of place during the week is because I have nowhere to put what we see on a daily basis. Settling their organs and skin back into place still leaves a sense of intrusion that isn't fully reversed. From the room full of people hoping to become more by becoming less, I'm more able to place what I see back into the people themselves, and this isn't something we can afford to bypass.
Wednesday, January 27, 2010
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.
"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.
Tuesday, September 8, 2009
angry
At the United States border, driving from Montreal Canada, a friendly man with a Southern drawl asks us where we lived, where we were coming from, what we did, and what we were doing. When I tell him we're students in Connecticut, he asks what we were studying. "Medicine." A slight grimace, and "...Why?" We break into real laughter, not of the oh-you're-funny sort, but of the oh-you're-right kind. "We've been wondering that the whole drive here."
I'm generally not that negative about the harder, less ideal aspects of medicine, mostly because 1) I keep hoping that we'll fight against them, and 2) even when that fails, I feel lucky to meet such variety of people, to witness and understand subtle individual qualities, to get strands of stories even as most are still wound tight. But this doesn't mean that I don't see the shortfalls of what we've seen of medicine, though I do worry that my modes of adapting to or coping with them will lead to passivity and unawareness.
Anyway, I get disconcerted and quietly mad throughout the days. Most days I see it and think about it and tuck it away, for storage and memory and recall and change. This keeps me sane, and optimistic even as I try to stay open to how that optimism may pan out (ie, it may not). Some days it's much harder; while the mad remains quiet, it's noticeably present to me and it gets to the point where hope gives way to worry and slight depression about why things are this way. A friend of mine who saw with me some of the saddest parts of medicine I've seen, asked me the other week to explain my distinction between sadness and depression. There's probably a lot to it that I feel and haven't yet expressed, but the best I could do at the time was that--I find sadness in loss that is natural, whereas unnatural loss brings depression. Disease and death is sad; injustice and undue unkindness or undue absence of kindness (more common than the former), depresses me. This hole amidst a profession of caretaking can really get to us sometimes.
At times like this I look around for the ground that we're supposed to stand in; at this point in our venture I don't mind if it's grass sunken from continuous downpour, if it's uneven pebbles that uncomfortably dig, even fresh tar that traps. But then there are those moments I look and there. is. nothing. We reach and reach, and we're left drifting in some two-dimensional space where the ground of taking care has been replaced with simple blank.
What to make of this, at the end of a day when I don't want to be helplessly angry? As with other modes of sustaining positivity, I'm not completely sure but hope that--in this fury we'll throw wide heavy blocks at this wall with no floor.
I'm generally not that negative about the harder, less ideal aspects of medicine, mostly because 1) I keep hoping that we'll fight against them, and 2) even when that fails, I feel lucky to meet such variety of people, to witness and understand subtle individual qualities, to get strands of stories even as most are still wound tight. But this doesn't mean that I don't see the shortfalls of what we've seen of medicine, though I do worry that my modes of adapting to or coping with them will lead to passivity and unawareness.
Anyway, I get disconcerted and quietly mad throughout the days. Most days I see it and think about it and tuck it away, for storage and memory and recall and change. This keeps me sane, and optimistic even as I try to stay open to how that optimism may pan out (ie, it may not). Some days it's much harder; while the mad remains quiet, it's noticeably present to me and it gets to the point where hope gives way to worry and slight depression about why things are this way. A friend of mine who saw with me some of the saddest parts of medicine I've seen, asked me the other week to explain my distinction between sadness and depression. There's probably a lot to it that I feel and haven't yet expressed, but the best I could do at the time was that--I find sadness in loss that is natural, whereas unnatural loss brings depression. Disease and death is sad; injustice and undue unkindness or undue absence of kindness (more common than the former), depresses me. This hole amidst a profession of caretaking can really get to us sometimes.
At times like this I look around for the ground that we're supposed to stand in; at this point in our venture I don't mind if it's grass sunken from continuous downpour, if it's uneven pebbles that uncomfortably dig, even fresh tar that traps. But then there are those moments I look and there. is. nothing. We reach and reach, and we're left drifting in some two-dimensional space where the ground of taking care has been replaced with simple blank.
What to make of this, at the end of a day when I don't want to be helplessly angry? As with other modes of sustaining positivity, I'm not completely sure but hope that--in this fury we'll throw wide heavy blocks at this wall with no floor.
Monday, July 20, 2009
in review
Pediatrics was my introduction to life in the hospital, and while it gave me time to cook and exercise and spend time with my friends over dinner and at the beach, finding balance still meant too tired at night to flesh out the day. So as inadequately as usual, some snippets of a wonderful four weeks working with school age children (spanning ages five to eighteen, though the highest I personally got was thirteen).
*Getting personal with swine flu: It was splashed anywhere our eyes and ears fell upon, and overexposure created distance. It's true that it's not much different from your annual winter flu, but it gave me a chance to see its effects during a summer rotation, out of its usual season. "Asthma exacerbation secondary to swine flu" sometimes made up a quarter of the hospital admissions while I was there, and it was my first patient. Heard real "crackles" in the lung for the first time (sounds like undoing velcro). Flu is inconvenience for most; for asthmatics it means being confined to a hospital room where people come in and out armed with a gown and gloves and strapped with a respirator mask, a mouth mask, and a face mask.
*Listening slowly: A patient with chronic pain, in the hospital for an acute episode, was my foray into this world of subjective disease and healing. I learned that one way to measure a pain is whether a person is "easily distractable," and learned that distraction is a two-way street. My sickle cell patient read aloud deliberately and slowly. So slowly that I lost track of sentences and just heard words. She decided she didn't like two books after a few pages; she did finally like Nancy Drew.
*Witnessing what's worthy: I never found a way to the feverish little one, who was seen by so many different doctors and nurses and random people like me. Politely answered my questions, politely refused offers of games, always said he was feeling good, in between and during fits of cough and sputum. But he lit up for his older sister, my age. His sister who stayed nights with him and left at six in the morning to commute to her job a couple hours away, after having left a detailed note about where she left his Taco Bell leftovers and full of thanks for taking care of him. Who was so happy to see him improve, happy maybe more ingenuously than anyone I've seen. When I told him he was lucky to have such a sister, he looked at her, smiled a slow crinkle of lips, and said I know. How many kids know, how many grown-ups really know.
*Finding the elusiveness of observation: So many of the kids we saw had been through so much, for so little body grown and so little time lived. Being impressed by their toughness became quickly ingrained, such that moments of outright vulnerability surprised me, and reminded me to let things show themselves and to consider them as they did. Hearing a little girl say she was scared, pulling her hand away from the IV, hearing her dad talk about not wanting to put her through another sedation, stood in my mind beside the images of her walking steady and holding her head firm, despite physical oppositions--I was pulled back to what was there, reminded to be open and not escape into all else that had formed.
*Gathering more and more respect: I admired one resident's natural cheerfulness through sleepless nights and ease of humor, another's tough efficiency and caring demeanor with the kids over whom he towered, and the attentiveness of everyone on our team to everyone else, past the patients to everyone in the hospital regardless of role or involvement. I was more than awed by the expertise of the nurses, their quickness and ease of movement. Sometimes I want to be them, with so much concrete need in their hands, more presence to their kids.
*Memorizing contours from senses: We've absorbed so much from sight and experience, almost without effort, that I wonder why I've tried so hard all my life to pound all that's outside inside. I think I felt this most with my last patient, who sometimes slept with his glasses on, and whose facial features would register at odd moments. Long after the day was over I found myself worrying about how he'd grow up and whether he'd gain the comfort of a secure home, the self-confidence of good health taken for granted, and the weight to develop into a person that could physically stand among others. He smiled inadvertently and in surprise when I beat him in Connect Four, with a diagonal line he hadn't noticed. When I remember that, I worry also that his teeth might always be in the wrong place.
*Seeing people return: I've seen more than a handful of patients return: with the same thing, with the same thing but worse, with a different thing, for nothing at all. It is strange to feel some sense of accomplishment with sending a patient home, then to feel a sort of regression when they return, because it's the same person. There's a disconnect between the linear or even cyclical image we have of a person's life, and thereby our relation to it, and the connect-the-dots relationship we actually have with them. I was disconcerted by some of the discontinuity, some of the chronic non-health problems.
*Seeing people disappear: We talked about how we thought she would still be there when we finished our month of inpatient pediatrics. Each day hearing of her tiny progress, only to find out the next that she'd deceived. She wasn't healed when she left. Watching her leave that one day, one day earlier than had been scheduled earlier that week, many days earlier than in my mind--face and nails made-up and leaving me a sense of glittery blue even as I'm unsure that's what she was really wearing--I felt I understood so little.
A., who likes to sit next to waterfalls, talks often of being humbled by feeling his smallness among big things and his incapacity to know anything in this vastness, and recently listed a slew of good places to perceive this: in the hospital, in a warzone, in love. I hope that the next time I forget, I'll try to think on how the immensity of small things and small people made me feel small too.
*Getting personal with swine flu: It was splashed anywhere our eyes and ears fell upon, and overexposure created distance. It's true that it's not much different from your annual winter flu, but it gave me a chance to see its effects during a summer rotation, out of its usual season. "Asthma exacerbation secondary to swine flu" sometimes made up a quarter of the hospital admissions while I was there, and it was my first patient. Heard real "crackles" in the lung for the first time (sounds like undoing velcro). Flu is inconvenience for most; for asthmatics it means being confined to a hospital room where people come in and out armed with a gown and gloves and strapped with a respirator mask, a mouth mask, and a face mask.
*Listening slowly: A patient with chronic pain, in the hospital for an acute episode, was my foray into this world of subjective disease and healing. I learned that one way to measure a pain is whether a person is "easily distractable," and learned that distraction is a two-way street. My sickle cell patient read aloud deliberately and slowly. So slowly that I lost track of sentences and just heard words. She decided she didn't like two books after a few pages; she did finally like Nancy Drew.
*Witnessing what's worthy: I never found a way to the feverish little one, who was seen by so many different doctors and nurses and random people like me. Politely answered my questions, politely refused offers of games, always said he was feeling good, in between and during fits of cough and sputum. But he lit up for his older sister, my age. His sister who stayed nights with him and left at six in the morning to commute to her job a couple hours away, after having left a detailed note about where she left his Taco Bell leftovers and full of thanks for taking care of him. Who was so happy to see him improve, happy maybe more ingenuously than anyone I've seen. When I told him he was lucky to have such a sister, he looked at her, smiled a slow crinkle of lips, and said I know. How many kids know, how many grown-ups really know.
*Finding the elusiveness of observation: So many of the kids we saw had been through so much, for so little body grown and so little time lived. Being impressed by their toughness became quickly ingrained, such that moments of outright vulnerability surprised me, and reminded me to let things show themselves and to consider them as they did. Hearing a little girl say she was scared, pulling her hand away from the IV, hearing her dad talk about not wanting to put her through another sedation, stood in my mind beside the images of her walking steady and holding her head firm, despite physical oppositions--I was pulled back to what was there, reminded to be open and not escape into all else that had formed.
*Gathering more and more respect: I admired one resident's natural cheerfulness through sleepless nights and ease of humor, another's tough efficiency and caring demeanor with the kids over whom he towered, and the attentiveness of everyone on our team to everyone else, past the patients to everyone in the hospital regardless of role or involvement. I was more than awed by the expertise of the nurses, their quickness and ease of movement. Sometimes I want to be them, with so much concrete need in their hands, more presence to their kids.
*Memorizing contours from senses: We've absorbed so much from sight and experience, almost without effort, that I wonder why I've tried so hard all my life to pound all that's outside inside. I think I felt this most with my last patient, who sometimes slept with his glasses on, and whose facial features would register at odd moments. Long after the day was over I found myself worrying about how he'd grow up and whether he'd gain the comfort of a secure home, the self-confidence of good health taken for granted, and the weight to develop into a person that could physically stand among others. He smiled inadvertently and in surprise when I beat him in Connect Four, with a diagonal line he hadn't noticed. When I remember that, I worry also that his teeth might always be in the wrong place.
*Seeing people return: I've seen more than a handful of patients return: with the same thing, with the same thing but worse, with a different thing, for nothing at all. It is strange to feel some sense of accomplishment with sending a patient home, then to feel a sort of regression when they return, because it's the same person. There's a disconnect between the linear or even cyclical image we have of a person's life, and thereby our relation to it, and the connect-the-dots relationship we actually have with them. I was disconcerted by some of the discontinuity, some of the chronic non-health problems.
*Seeing people disappear: We talked about how we thought she would still be there when we finished our month of inpatient pediatrics. Each day hearing of her tiny progress, only to find out the next that she'd deceived. She wasn't healed when she left. Watching her leave that one day, one day earlier than had been scheduled earlier that week, many days earlier than in my mind--face and nails made-up and leaving me a sense of glittery blue even as I'm unsure that's what she was really wearing--I felt I understood so little.
A., who likes to sit next to waterfalls, talks often of being humbled by feeling his smallness among big things and his incapacity to know anything in this vastness, and recently listed a slew of good places to perceive this: in the hospital, in a warzone, in love. I hope that the next time I forget, I'll try to think on how the immensity of small things and small people made me feel small too.
Friday, July 3, 2009
little ones
It's been sprinkling or pouring with a spurt of sun after stretches of gray since I've been back in Connecticut. The weekend before orientation we went to the beach at Lighthouse Point and shielded ourselves from water splinters underneath a large warm blanket Ali carries in his car, along with a portable bench of sorts and lawn chairs. We smiled at A. and B. sitting past the shore in the ocean, their chairs in wet sand, few inches deep in salt water. Then we went on the swings; I’d never swung on a beach before, and just like flying a kite in the sea in Puerto Rico, these whimsies are made magic by the blue or bluish gray of the beach. Swinging back, you’re immersed in a jar of lighweight sand, grains you separate like the beaded curtains you find in hippie homes, and swinging forward, you burst through the sand, crash lightly through glass to see water seamlessly meeting sky. We were also laughing hard.
Moving from this to my pediatrics rotation required less destitching and sewing up than I anticipated. Two weeks into working on the schoolage-adolescent team (5-18 year olds), I feel ablur. I know as little as I suspected, and the pace is fast and learning wide. My stethoscope heard its first wheeze and crackles. A little one shields her hand and says, I’m too afraid. Video games make his face light up one day, less so as the days pass. I press the fingernails of a ten year old who has been through too much, to see if they blanch in the right amount of time, but they’re painted red and I can’t see underneath. A girl, whose words spill forth from her mouth like water, sees Ali bid farewell and drive away on his scooter and proclaims “Niiiiiiiiiiice” with vehement approval and tells me she’s going to get him and me both Hannah Montana shoes. We taste different medicines, some of them tolerable, many gross but started to blend together as I had one after another, and the last left a long long aftertaste of rotten eggs that made us gag. We also had our lungs uncomfortably scrambled by vibrating vests and pseudomassagers, which are used to disrupt the mucus in patients with cystic fibrosis and bronchiectasis. The boy in a red wagon calls for help from his room, and I sit him on his chair and place his new red shoes on his feet. It’s hard to understand what he says, but he doesn’t give up until you give some sign that you get it, taking the shoe and mimicking several times before I know to tie the laces twice. He points outside, wraps his arms around his chest and shivers, and shakes his head until I ask, you want to know if it’s cold outside? He’s overcome with glee when I tell him it’s warm, and when I look at a picture of a truck he’s colored and notes that it looks like his wagon, he pats my back excitedly, and somewhere in the subsequent pride that I feel for figuring it out, I realize again I’m as much kid in all this as the one who colors.
When I come home, some days I cook dinner with J. and most days we talk a little about our days and those are good moments. Last night was the first I didn’t have to sleep early, and A. and B. cooked a delicious, delicious dinner of a tuna noodle salad, cornish hen, red cabbage and rice textured with potato. Most of their meals can’t be duplicated, because they make it up as they go and add innumerable amounts of spices and sauces they can’t recall afterwards. We ate on their balcony in the cool summer night, then closed the sliding door when it got cold and listened to them make music the same way they make food, while the girls listened and laughed. He strummed Michael’s Song from the Godfather, and sang acappella the Italian one from Part III, sung by Michael’s opera-singing son. When J. asked him to sing about fruits, he sang, some girls are like bananas, others like strawberries, I want to make a smoothie. He sang a silly tune about mom, sister and wife that earned him a hug. B. controlled mood and speed with the guitar and chimed in, carrying the last words of A’s phrases, like “louder,” with impressive timing. I love music and these people. The room was dim, it was raining sleet black outside (we caught a flash of lightning), and I fell asleep.
Today we were outdoors again, driving beneath a canopy of green trees to rest beneath the waterfall at West Rock, climbing what was called a cave and what was more like some rocks with crevices that went in one way and went out another, and grabbing a view of the city before rain splattered down. We shared red bean & jelly popsicles, nectarines, and strawberry jam and nutella sandwiches in the car, and smelled over and over some honeysuckle that Ali found.
At night, I did another thing I've never done on the beach: watch fireworks. West Haven is a small town, and the beach is a popular place to celebrate July 4. We parked a good ten-minute walk away from the beach and walked through the residential area to get to the sand, and summer was palpable. The streets were packed with families, and the beach densely peppered with the same. People were selling cotton candy, people were carrying lawn chairs and towels. We arrived just as the fireworks began, and we could see them shoot from their source up to their destination; we were close and they felt huge. At some points there would be a steady stream shooting a short distance up while others sporadically went higher, and at the end they were insanely bright like snaps of lightning. The sounds were louder too, than I've heard in the past, and some had distinct sounds, just as their colors and trajectories and lifetimes are distinct. A small group of small girls frolicked with glow in the dark sticks, singing "land of the free, for you and for me," attempting cartwheels and screaming "fireworks!" while generally paying no attention to the lights underneath which they were dancing. Afterwards we walked to the shore's edge, and Allison mentioned it reminded her of Puerto Rico, the last time she saw the water at night. That time the bay lit up as your brushed your hand through the water or dipped your oar into it, from the light of microorganisms. The first time I moved through water at night.
As we stood people continued to set off fireworks, in all corners, such that standing in one spot you felt the sparks in every direction and couldn't see them all at once. Families set them off in the sand and water, and the ocean picked up the colors and melted them. We walked away as the fireworks kept going, and drove home with the windows down to keep the cool summer air.
One thing I've yet to do at the beach is swim. I do as I do in the hospital--I wade, I move with the waves, I jump the waves, I sink into the waters and gaze up and down, but I don't know how to swim. I'm scared to learn, but I want to and have to, and when I do it, I trust that the ocean will again make the sensations of what's commonplace as strong and sharp as those that little ones feel.
Moving from this to my pediatrics rotation required less destitching and sewing up than I anticipated. Two weeks into working on the schoolage-adolescent team (5-18 year olds), I feel ablur. I know as little as I suspected, and the pace is fast and learning wide. My stethoscope heard its first wheeze and crackles. A little one shields her hand and says, I’m too afraid. Video games make his face light up one day, less so as the days pass. I press the fingernails of a ten year old who has been through too much, to see if they blanch in the right amount of time, but they’re painted red and I can’t see underneath. A girl, whose words spill forth from her mouth like water, sees Ali bid farewell and drive away on his scooter and proclaims “Niiiiiiiiiiice” with vehement approval and tells me she’s going to get him and me both Hannah Montana shoes. We taste different medicines, some of them tolerable, many gross but started to blend together as I had one after another, and the last left a long long aftertaste of rotten eggs that made us gag. We also had our lungs uncomfortably scrambled by vibrating vests and pseudomassagers, which are used to disrupt the mucus in patients with cystic fibrosis and bronchiectasis. The boy in a red wagon calls for help from his room, and I sit him on his chair and place his new red shoes on his feet. It’s hard to understand what he says, but he doesn’t give up until you give some sign that you get it, taking the shoe and mimicking several times before I know to tie the laces twice. He points outside, wraps his arms around his chest and shivers, and shakes his head until I ask, you want to know if it’s cold outside? He’s overcome with glee when I tell him it’s warm, and when I look at a picture of a truck he’s colored and notes that it looks like his wagon, he pats my back excitedly, and somewhere in the subsequent pride that I feel for figuring it out, I realize again I’m as much kid in all this as the one who colors.
When I come home, some days I cook dinner with J. and most days we talk a little about our days and those are good moments. Last night was the first I didn’t have to sleep early, and A. and B. cooked a delicious, delicious dinner of a tuna noodle salad, cornish hen, red cabbage and rice textured with potato. Most of their meals can’t be duplicated, because they make it up as they go and add innumerable amounts of spices and sauces they can’t recall afterwards. We ate on their balcony in the cool summer night, then closed the sliding door when it got cold and listened to them make music the same way they make food, while the girls listened and laughed. He strummed Michael’s Song from the Godfather, and sang acappella the Italian one from Part III, sung by Michael’s opera-singing son. When J. asked him to sing about fruits, he sang, some girls are like bananas, others like strawberries, I want to make a smoothie. He sang a silly tune about mom, sister and wife that earned him a hug. B. controlled mood and speed with the guitar and chimed in, carrying the last words of A’s phrases, like “louder,” with impressive timing. I love music and these people. The room was dim, it was raining sleet black outside (we caught a flash of lightning), and I fell asleep.
Today we were outdoors again, driving beneath a canopy of green trees to rest beneath the waterfall at West Rock, climbing what was called a cave and what was more like some rocks with crevices that went in one way and went out another, and grabbing a view of the city before rain splattered down. We shared red bean & jelly popsicles, nectarines, and strawberry jam and nutella sandwiches in the car, and smelled over and over some honeysuckle that Ali found.
At night, I did another thing I've never done on the beach: watch fireworks. West Haven is a small town, and the beach is a popular place to celebrate July 4. We parked a good ten-minute walk away from the beach and walked through the residential area to get to the sand, and summer was palpable. The streets were packed with families, and the beach densely peppered with the same. People were selling cotton candy, people were carrying lawn chairs and towels. We arrived just as the fireworks began, and we could see them shoot from their source up to their destination; we were close and they felt huge. At some points there would be a steady stream shooting a short distance up while others sporadically went higher, and at the end they were insanely bright like snaps of lightning. The sounds were louder too, than I've heard in the past, and some had distinct sounds, just as their colors and trajectories and lifetimes are distinct. A small group of small girls frolicked with glow in the dark sticks, singing "land of the free, for you and for me," attempting cartwheels and screaming "fireworks!" while generally paying no attention to the lights underneath which they were dancing. Afterwards we walked to the shore's edge, and Allison mentioned it reminded her of Puerto Rico, the last time she saw the water at night. That time the bay lit up as your brushed your hand through the water or dipped your oar into it, from the light of microorganisms. The first time I moved through water at night.
As we stood people continued to set off fireworks, in all corners, such that standing in one spot you felt the sparks in every direction and couldn't see them all at once. Families set them off in the sand and water, and the ocean picked up the colors and melted them. We walked away as the fireworks kept going, and drove home with the windows down to keep the cool summer air.
One thing I've yet to do at the beach is swim. I do as I do in the hospital--I wade, I move with the waves, I jump the waves, I sink into the waters and gaze up and down, but I don't know how to swim. I'm scared to learn, but I want to and have to, and when I do it, I trust that the ocean will again make the sensations of what's commonplace as strong and sharp as those that little ones feel.
Friday, June 19, 2009
second beginning
On Monday we start on the wards, and it's what we've been anticipating excitedly and in immense fear for quite some time. But unexpectedly, a lot of things began with Survival Fair two weeks ago. I know we complain about having to wake up early for lectures, long days of workshops, and some very dry sessions on legality, privacy, sexual harassment, and so on. It is a pain, but I've also learned a lot, medically and personally and while there's a lot I'd change about it and I could use another week to wind down, it's helped me.
We haven't had as much down time as I'd thought and wanted, especially this past week with afternoons full of advanced cardiovascular life support, phlebotomy, and a clinical skills session. We've learned the steps beyond CPR in resuscitating people, which include shocking them (or not shocking, depending on what's wrong with their heart) and a handful of drugs. We learned to draw blood for cultures, how to put in an IV, how to insert a catheter. Among these procedures, some of the hardest things are little steps that require a lot of attention. For example, sterility is a huge concern, and it's kind of interesting to think about how we are trying to avoid everything that surrounds us, like slipping in between slits of rain drops. There is a certain way to put on sterile gloves, to ensure that nothing gets "dirty," and you have to be constantly aware of your hands and body and what lies in a "sterile field" and what doesn't. It's pretty cool conceptually, to think of how we negotiate our environment, but it's also exhausting and prime ground for mistakes. So I enjoy the explanations, fumble around with my own imitations of what I saw, and come home crammed and tired.
In the midst of this, I am grateful to Yale for pounding into us the personal aspects of medicine, all the issues that we're going to face as people. Even as some of the topics can first come across as superfluous or obvious, like gender discrimination and power dynamics, much of it has been helpful in thinking about how to interact with people. More specifically, how to interact such as to bring greatest benefit to patients, stick to your principles, not cause drama, and avoid frustration. This is hard.
I've heard many things that connected to me, that I know will be hard to keep in mind; I can barely recall them now after a week of so many things. A lot of it helped me with some of the feelings I had from the last entry, and made me think about what to do in conflicts to benefit people most. I also learned to think about how circumstances influence my own feelings, and to remember that most things happen out of neglect rather than bad intentions, which includes a lot of my own negative responses. Another thing emphasized is the detachment of certain behaviors and feelings from individuals; for us to seek systemic reasons for why a person might do something we perceive as unkind or unjustified. Today was particularly powerful...oops, no pun intended. Our last day of orientation was called Power Day, and it was dedicated to thinking about potential abuses of power in the health profession. We read two stories where physician-writers narrated their own experiences of taking advantage of patients' vulnerability in order to enact what they felt was best care. The day started with a fabulous keynote speaker, a woman who had been my section leader for Public Health, who talked about the power dynamics of race and ethnicity.
She was amazing in several respects. Firstly, I think the majority of the audience loved her and it's hard to sustain the attention of any group of people and make yourself relatable to a diverse number. Secondly, she read us a couple journal entries she kept back in med school, which of course inspired me to write as much as possible. The entries themselves narrated powerful (again) experiences that were unique in how they explored the medical hierarchy, the divides between people in general, and language (even though this wasn't really mentioned). The first story dealt with a doctor's use of literature to degrade a med student (the speaker), and unraveled at a slowly building pace that made it seem natural that such a thing could happen not even fully understood by the student. It ended with a sentiment that it was nice to think about literature, a part of her brain that'd been suppressed in medicine, but that in the end literature had hurt her medical learning and herself. It's a longer story that can't be done justice by summary, only by her voice, but I appreciated this thought and remind myself that stories in my head are one thing and stories in front of me are another. The second entry the speaker shared with us dealt with a med student gracefully, creatively, and humbly standing up to a doctor who failed to address a patient's language barrier. In both stories, she noted a couple things that have been, in different lights, emphasized these past weeks: these powers and responsibilities we have and will come to have carry much weight, for both a lot of good and a lot of bad. In her first story, thoughtfulness and kindness from an unexpected source saved the speaker from her superior's racism, and in the second, strength and ingenuity came from the lowest rung on the totem pole. Of course there were "adversaries" in these stories, but she, like others, have encouraged us not to see them as such, to give more room for gray. Related to this, we're encouraged to see where the problems lie within the system, not the individual. For example, why was this allowed to occur in the first place, why wasn't the speaker comfortable reaching out to anyone about it, why didn't anyone else notice anything or if they did, why did they do nothing? In the other story, the med student took it upon himself to change the system that led up to miscommunication between doctors and patients, via a simple suggestion to place simple signs on doors of patients who couldn't speak English, to refer healthcare providers to interpreter services. This systemic approach was also brought up in a session on leadership and group dynamics, wherein we talked about distinguishing when individual behavior is indeed individual and when it is a reflection of group thought.
This is not to escape personal interactions, because that's where any systemic change occurs and that's also where we live. Even before starting on the wards, and way back since starting first year, I've been amazed at how many issues we discuss because medicine deals with countless aspects of life and not necessarily just in the patient encounter, how hard a lot of this can be and what rare challenges we experience and witness others experience, and how lucky we are to continually question and start.
We haven't had as much down time as I'd thought and wanted, especially this past week with afternoons full of advanced cardiovascular life support, phlebotomy, and a clinical skills session. We've learned the steps beyond CPR in resuscitating people, which include shocking them (or not shocking, depending on what's wrong with their heart) and a handful of drugs. We learned to draw blood for cultures, how to put in an IV, how to insert a catheter. Among these procedures, some of the hardest things are little steps that require a lot of attention. For example, sterility is a huge concern, and it's kind of interesting to think about how we are trying to avoid everything that surrounds us, like slipping in between slits of rain drops. There is a certain way to put on sterile gloves, to ensure that nothing gets "dirty," and you have to be constantly aware of your hands and body and what lies in a "sterile field" and what doesn't. It's pretty cool conceptually, to think of how we negotiate our environment, but it's also exhausting and prime ground for mistakes. So I enjoy the explanations, fumble around with my own imitations of what I saw, and come home crammed and tired.
In the midst of this, I am grateful to Yale for pounding into us the personal aspects of medicine, all the issues that we're going to face as people. Even as some of the topics can first come across as superfluous or obvious, like gender discrimination and power dynamics, much of it has been helpful in thinking about how to interact with people. More specifically, how to interact such as to bring greatest benefit to patients, stick to your principles, not cause drama, and avoid frustration. This is hard.
I've heard many things that connected to me, that I know will be hard to keep in mind; I can barely recall them now after a week of so many things. A lot of it helped me with some of the feelings I had from the last entry, and made me think about what to do in conflicts to benefit people most. I also learned to think about how circumstances influence my own feelings, and to remember that most things happen out of neglect rather than bad intentions, which includes a lot of my own negative responses. Another thing emphasized is the detachment of certain behaviors and feelings from individuals; for us to seek systemic reasons for why a person might do something we perceive as unkind or unjustified. Today was particularly powerful...oops, no pun intended. Our last day of orientation was called Power Day, and it was dedicated to thinking about potential abuses of power in the health profession. We read two stories where physician-writers narrated their own experiences of taking advantage of patients' vulnerability in order to enact what they felt was best care. The day started with a fabulous keynote speaker, a woman who had been my section leader for Public Health, who talked about the power dynamics of race and ethnicity.
She was amazing in several respects. Firstly, I think the majority of the audience loved her and it's hard to sustain the attention of any group of people and make yourself relatable to a diverse number. Secondly, she read us a couple journal entries she kept back in med school, which of course inspired me to write as much as possible. The entries themselves narrated powerful (again) experiences that were unique in how they explored the medical hierarchy, the divides between people in general, and language (even though this wasn't really mentioned). The first story dealt with a doctor's use of literature to degrade a med student (the speaker), and unraveled at a slowly building pace that made it seem natural that such a thing could happen not even fully understood by the student. It ended with a sentiment that it was nice to think about literature, a part of her brain that'd been suppressed in medicine, but that in the end literature had hurt her medical learning and herself. It's a longer story that can't be done justice by summary, only by her voice, but I appreciated this thought and remind myself that stories in my head are one thing and stories in front of me are another. The second entry the speaker shared with us dealt with a med student gracefully, creatively, and humbly standing up to a doctor who failed to address a patient's language barrier. In both stories, she noted a couple things that have been, in different lights, emphasized these past weeks: these powers and responsibilities we have and will come to have carry much weight, for both a lot of good and a lot of bad. In her first story, thoughtfulness and kindness from an unexpected source saved the speaker from her superior's racism, and in the second, strength and ingenuity came from the lowest rung on the totem pole. Of course there were "adversaries" in these stories, but she, like others, have encouraged us not to see them as such, to give more room for gray. Related to this, we're encouraged to see where the problems lie within the system, not the individual. For example, why was this allowed to occur in the first place, why wasn't the speaker comfortable reaching out to anyone about it, why didn't anyone else notice anything or if they did, why did they do nothing? In the other story, the med student took it upon himself to change the system that led up to miscommunication between doctors and patients, via a simple suggestion to place simple signs on doors of patients who couldn't speak English, to refer healthcare providers to interpreter services. This systemic approach was also brought up in a session on leadership and group dynamics, wherein we talked about distinguishing when individual behavior is indeed individual and when it is a reflection of group thought.
This is not to escape personal interactions, because that's where any systemic change occurs and that's also where we live. Even before starting on the wards, and way back since starting first year, I've been amazed at how many issues we discuss because medicine deals with countless aspects of life and not necessarily just in the patient encounter, how hard a lot of this can be and what rare challenges we experience and witness others experience, and how lucky we are to continually question and start.
Monday, June 15, 2009
no, really this time
So after I wrote that entry yesterday about appreciating our experience and privilege in the face of embarrassment, frustration, and indignation, I faced all of these today to the furthest extent as yet in med school (this threshold, I know, will continue to be pushed each day on the wards). And it was harder in practice to tell myself what I'd been thinking for the past week: that these incidents are challenges that push us to focus on why we're here, that roughness is rough but not crippling, and that our learning is on us. There were a couple things in particular I saw today that I didn't like and bothered me for quite some time afterwards, but after talking to a few friends I remember goals I've accumulated over the past week of Survival Fair. Don't dwell or complain (not in the moment and not too long after the moment either; everyone should give justice to their feelings, but in my case I need to recognize and move on, or it becomes consuming and unproductive). Use the energy to improve, instead, even if in the rare case the problem lay outside of myself. Let what I see change me in ways I would want, and come home as a person I still like. I didn't expect to need to remind myself so much before I even stepped inside the hospital, but better here than there. This year will be tough, and good.
Sunday, June 14, 2009
surviving
I like to do my laundry and clean my room before I leave it on vacation (or in this case, Boards-study) so that its openness and togetherness welcomes me upon return. This time around, because my subletter hasn't completely moved out yet, my room is less able to fulfill its role, the cluttered surrounds mirror what this period of time has been.
Before we assume our roles as third years in the hospital (the wards), we have two weeks of "Survival Fair." We didn't know what it meant either, other than that it's an orientation designed to prevent us from being stupid on the wards. It turns out that the first week is mostly a warning: we will be stupid. We will be told so, made to feel so, and we are legitimately so.
I've never been so scared, so excited, or so scared and excited at once, to be beginning something. Part of this stems from the mystery that enshrouds medicine. Survival Fair consists of lectures, workshops and hands-on sessions that prepares us for 1) stress (details on what will stress us, how to cope) and 2) practical skills (putting in an IV, advanced CPR, learning the hospital computer system). I feel like a big number three is missing, the one that tells us what we'll actually be doing, what our responsibilities are. I know that this is hard, varies not just from department to department but from doctor to doctor. I also know that just as with our first two years of book learning, these next years are about figuring out for ourselves what we need to know and do. Still, somehow knowing we're about to descend into a black hole (in both positive and negative terms; I mean, it sounds bleak but it's kind of cool) without any remote idea of what makes it black is disconcerting. Though I guess that element is part of it.
As much as I don't like it, I admit it is probably good to coat this anticipation with a guard against the negative aspects of medicine. It seems we've been told over and over that we will be criticized, a lot; that people will be mean to us, a lot. It's been good advice to not take it personally because people are at their worst when stressed and sleep deprived, but among our class the natural response has been: why must this be true? I know that for myself I'm more easily irritated and more quickly take it out on people around me when stressed, and rather than falling back on that, I should avoid that crutch. I suppose that the warning to grow lizard skin is for the inevitable fallbacks.
But the nurse who taught us how to scrub in for surgeries left us with the advice to be nice. It goes without saying you should be nice to your patients, but she told us to be nice to everyone, to our doctors and medical teams and to each other. It also kind of goes without saying that you should be nice to your doctors, but I got the feeling she meant, nice in thought and not just in action-for-show. She herself was not about nice-for-show; she was rough when things were rough and kind when kindness was sincere.
Rough is necessary in surgery. I'm looking forward to being involved in them, but it's natural to feel more apprehensive. We had a two-hour session about how to prepare for one. Scrub your arms and hands for five minutes: 10 strokes on each side of your fingers, five across the webs in between, circular motions across both surfaces of your hands, turn the scrubber to the other side and continue the circles as you rotate your arm back to front, two inches above your elbows. We learned how to put on gloves (if you look this up on the internet, you'll find there is a five-step procedure for putting on gloves), how to put on a gown (this entails holding onto a tag at an exact spot and spinning around; I've already forgotten whether it's clockwise or counter). I learned that my glove size is the same as my shoe size. Then stand for upwards of 7-8 hours, half of which might consist of leaning over a patient holding an instrument in place and in place means in place, and remaining aware of what every inch of you is touching (lean on a patient out of fatigue and he may wake up with a hematoma). This indeed means holding your bladder for the duration of the operation. No scratching your face. If you sneeze, that will stay in your face mask until you're out. They've warned us back to back that we will be yelled at, blamed for everything we do wrong and for things not our fault. All while being asked questions to name what's before you, things that are less clear when real than when etched in a deliberate textbook.
In a timely turn of events I just read the Diving Bell and the Butterfly, the book whose words streamed from the blinking of a completely paralyzed man. He talks a little about his medical caretakers, and a lot about his world, the one which in our highest aims we seek to reach.
I haven't decided yet whether the negativity is a necessary tool or an unfortunate byproduct, or where it falls on the space between, but I do think that Survival Fair and third year in general is about pushing us to find ways to fight against it, and in the process, remembering or finding anew or finding for the first time what this is for. It's not for us, or at least not the majority of it. I don't intend to forget myself, though I know that may happen often. I want badly to take care of myself: write, drink milk, run twice a week, respond to emails, talk to people, eat fruits and vegetables. I'm trying my best to keep it simple and possible (I decided against making any resolution about cooking, even just once a month). We already know that there may be months when this list will be tough, but I know how much better I will feel to have things to control and give myself.
On the other end of that, like the operating room nurse told us, this isn't just about us. For the person whose literal cluttered insides are vulnerable and open, and not in the openness of a clean room but of an honest one, we go through what we do and we work to do the most we can. It shouldn't wear you away completely, but perhaps there is reason to wear a little. It wouldn't be realistic to bestow purpose to all negative; some crappy things are just crappy. But I think what drives us is the belief and hope that to see things as they are, messy or clean, is worth it.
Before we assume our roles as third years in the hospital (the wards), we have two weeks of "Survival Fair." We didn't know what it meant either, other than that it's an orientation designed to prevent us from being stupid on the wards. It turns out that the first week is mostly a warning: we will be stupid. We will be told so, made to feel so, and we are legitimately so.
I've never been so scared, so excited, or so scared and excited at once, to be beginning something. Part of this stems from the mystery that enshrouds medicine. Survival Fair consists of lectures, workshops and hands-on sessions that prepares us for 1) stress (details on what will stress us, how to cope) and 2) practical skills (putting in an IV, advanced CPR, learning the hospital computer system). I feel like a big number three is missing, the one that tells us what we'll actually be doing, what our responsibilities are. I know that this is hard, varies not just from department to department but from doctor to doctor. I also know that just as with our first two years of book learning, these next years are about figuring out for ourselves what we need to know and do. Still, somehow knowing we're about to descend into a black hole (in both positive and negative terms; I mean, it sounds bleak but it's kind of cool) without any remote idea of what makes it black is disconcerting. Though I guess that element is part of it.
As much as I don't like it, I admit it is probably good to coat this anticipation with a guard against the negative aspects of medicine. It seems we've been told over and over that we will be criticized, a lot; that people will be mean to us, a lot. It's been good advice to not take it personally because people are at their worst when stressed and sleep deprived, but among our class the natural response has been: why must this be true? I know that for myself I'm more easily irritated and more quickly take it out on people around me when stressed, and rather than falling back on that, I should avoid that crutch. I suppose that the warning to grow lizard skin is for the inevitable fallbacks.
But the nurse who taught us how to scrub in for surgeries left us with the advice to be nice. It goes without saying you should be nice to your patients, but she told us to be nice to everyone, to our doctors and medical teams and to each other. It also kind of goes without saying that you should be nice to your doctors, but I got the feeling she meant, nice in thought and not just in action-for-show. She herself was not about nice-for-show; she was rough when things were rough and kind when kindness was sincere.
Rough is necessary in surgery. I'm looking forward to being involved in them, but it's natural to feel more apprehensive. We had a two-hour session about how to prepare for one. Scrub your arms and hands for five minutes: 10 strokes on each side of your fingers, five across the webs in between, circular motions across both surfaces of your hands, turn the scrubber to the other side and continue the circles as you rotate your arm back to front, two inches above your elbows. We learned how to put on gloves (if you look this up on the internet, you'll find there is a five-step procedure for putting on gloves), how to put on a gown (this entails holding onto a tag at an exact spot and spinning around; I've already forgotten whether it's clockwise or counter). I learned that my glove size is the same as my shoe size. Then stand for upwards of 7-8 hours, half of which might consist of leaning over a patient holding an instrument in place and in place means in place, and remaining aware of what every inch of you is touching (lean on a patient out of fatigue and he may wake up with a hematoma). This indeed means holding your bladder for the duration of the operation. No scratching your face. If you sneeze, that will stay in your face mask until you're out. They've warned us back to back that we will be yelled at, blamed for everything we do wrong and for things not our fault. All while being asked questions to name what's before you, things that are less clear when real than when etched in a deliberate textbook.
In a timely turn of events I just read the Diving Bell and the Butterfly, the book whose words streamed from the blinking of a completely paralyzed man. He talks a little about his medical caretakers, and a lot about his world, the one which in our highest aims we seek to reach.
I haven't decided yet whether the negativity is a necessary tool or an unfortunate byproduct, or where it falls on the space between, but I do think that Survival Fair and third year in general is about pushing us to find ways to fight against it, and in the process, remembering or finding anew or finding for the first time what this is for. It's not for us, or at least not the majority of it. I don't intend to forget myself, though I know that may happen often. I want badly to take care of myself: write, drink milk, run twice a week, respond to emails, talk to people, eat fruits and vegetables. I'm trying my best to keep it simple and possible (I decided against making any resolution about cooking, even just once a month). We already know that there may be months when this list will be tough, but I know how much better I will feel to have things to control and give myself.
On the other end of that, like the operating room nurse told us, this isn't just about us. For the person whose literal cluttered insides are vulnerable and open, and not in the openness of a clean room but of an honest one, we go through what we do and we work to do the most we can. It shouldn't wear you away completely, but perhaps there is reason to wear a little. It wouldn't be realistic to bestow purpose to all negative; some crappy things are just crappy. But I think what drives us is the belief and hope that to see things as they are, messy or clean, is worth it.
Tuesday, June 9, 2009
six weeks
Back in Connecticut, today was the first day of third year. We were advised to be present: to be aware of where we are in a moment and to stop thinking about where else we need to be or what we should do after this moment is over. During the lecture about how to manage stress, it was suggested to write things down as they happen, so they don't slip as days pile upon one another. I'd meant to catch up on some things during our trip to Prague, but that didn't work out for various reasons. One of the things that has frustrated me most in med school is not having time and energy to reflect in thought and writing all the things in which we're immersed. I recall clearly deciding to not spend my life writing because I had nothing to write about, to experience instead so that I'd have something to say; medicine has brought me closer to that, has given me much to say but in the process often takes from me the capacity to form sentences.
One piece of advice was to just get things down, even if incoherent. I used to do that often, but somewhere between that and now, have done it much less. The idea is to capture your immediate impression; that you can return to it later, give it real form and thought later. I worry very much that I never will return to it, that there's too much; that I can't fully describe how I feel in a moment without more time and energy, and so I should only write when I have all the time and energy I need, and since I won't settle for less, I end up doing nothing. While I'm somewhat proud of this stubbornness about taking care about completeness, I realize that in some circumstances you do have to work with limitations, not just ignore them.
In theory this would mean I would jot down the overwhelming amount of stuff thrown at us today, but there is a lot of past too and I'd like to share that first, even if insignificant. I know I can't spend my life catching up to myself, but for the next two weeks before we start in the hospital where I have to be present, I'd like to have that luxury.
So to go back to what feels like way way back, the six weeks I spent at home studying for the Boards was pretty wonderful. I'm not sure how the test itself went, and while I learned a lot, it didn't quite feel like enough. I'll talk about that whole process maybe later. But other things happened, and for those I'm proud and glad.
I ate all my meals with my parents, and my brothers came home on the weekends for the more elaborate meals my mom would make. The first few days I returned, Fremont was gray and green. I studied in a room with a window facing the street, and we live on a busy street. I had three second glimpses of people as they passed from the left edge of my window to the right, or the other way: teenagers walking home from school, missionaries going door to door, parents wheeling strollers, dogs on leashes, stray cats, a man collecting cans in a shopping cart, young couples, old couples, people talking to themselves and each other, various runners with different running styles, a woman singing and running into her notes as they flowed forward and she walked after them.
I ran a few miles every couple days, all on the treadmill after my first week at home, which I know surprises everyone because people think I'm really unathletic (which I am, except for in elementary school but no one believes me when I tell them I was good at sports back then) and because when I do run it's always outside. I started because it got too hot in the afternoons to go outside, and despite sleeping fine for the most part I was too tired to run in the mornings. So I grew to love the treadmill, which faces away from the screen door to our backyard, in our living room. I'd open the screen to make it feel more like outside, and I grew to love the mechanics of running on a machine, of focusing purely on movement (not even forward movement, obviously, just moving), rather than surroundings and surrounding feelings. I was disappointed to realize it'd take me much longer than I anticipated to work up to a decent pace, after many years of irregularity, but it did motivate me to continue. I also started to like milk (I do tally this on my list of accomplishments), because it was the only cold drink we had. It was really satisfying to have everything I needed to run at home. Just changed in my room, went downstairs to the living room for the treadmill, panted my way to the kitchen for milk, then back upstairs to shower.
I finished one book during Boards studying (in my small defense, it was a long one)--The Wind-Up Bird Chronicle by Murakami. It's up there with my favorites of his. Much of it was dark, and I'd go to sleep unsure. Through it all there was something to hang onto, as is usual with even his strangest contexts and characters most disconnected from things. And in this book amidst all the unbelievably expressive and knowing and detail, there were in particular two pages that I may hang onto the rest of my life.
I didn't get to see friends as much as I would've liked, only seeing my high school friends the day before I left for Prague. I did fly to LA for a day to see Iron & Wine at the Troubadour with my oldest friend. Awhile ago I posted about my top songs and none of them included Iron & Wine, even though he is one of my top artists. This is because what I love in his music runs through everything he writes, and the whole experience of hearing Iron & Wine with someone close to me who values that feeling, felt like that, where places and events and things lose definition and become vessels for something ineffable and common in all of them. He ended with Trapeze Swinger, which is a long song and one I'd been listening to often before the show. It's a beautiful beautiful song and one that will always make me think of that moment in the show, and also the walk in the cool night to the venue before the show, and the car ride afterwards which I remember as a long straight road punctuated by streetlights, though I'm not entirely sure it was that way the whole time.
I said goodbye to my great-aunt, and the funeral is something else I'd like to write about, and separately. I wasn't close to her, but I tried to stay close to what it meant. I can't say that I was always able to completely focus on it, with the hectic background of studying and other things, which forced me to consider balance and my role in that. It also made me glad to be with my mom, who is much nicer to me than I deserve and who did teach me to make a couple of her dishes. Not quite as many as I wanted, due to her cooking hours before I got up in the morning; by the time I was getting up early enough, I was trying to make up for lost time in studying. But now I can (theoretically) make my favorite spring rolls and savory crepes? pancakes? Not really like either, but yellow and crispy and eaten with fish sauce and lots of lettuce and herbs.
I also cut off about 12 inches of my hair. I needed 10 to donate to Locks of Love, so the hairdresser asked me if I wanted to keep that extra 2 inches, but I told her to just take it all. So instead of messy wavy hair down my back, I have manageable straightness to just my shoulders. Even though I don't like the look of the haircut much, it felt pretty good to make a dramatic change, after growing it out for two years. Other tidbits at home included getting my white coat tailored to my actual size, getting a new backpack, and finishing a roll of film.
Writing about things awhile after I've thought of them is hard, and dissatisfying in the knowledge that it's inadequate. The intersection of language, or my language, and feelings makes me feel that it's always inadequate, even when I write in the moment, but this feels more so. Still, I'm really very glad to be able to do at least this.
One piece of advice was to just get things down, even if incoherent. I used to do that often, but somewhere between that and now, have done it much less. The idea is to capture your immediate impression; that you can return to it later, give it real form and thought later. I worry very much that I never will return to it, that there's too much; that I can't fully describe how I feel in a moment without more time and energy, and so I should only write when I have all the time and energy I need, and since I won't settle for less, I end up doing nothing. While I'm somewhat proud of this stubbornness about taking care about completeness, I realize that in some circumstances you do have to work with limitations, not just ignore them.
In theory this would mean I would jot down the overwhelming amount of stuff thrown at us today, but there is a lot of past too and I'd like to share that first, even if insignificant. I know I can't spend my life catching up to myself, but for the next two weeks before we start in the hospital where I have to be present, I'd like to have that luxury.
So to go back to what feels like way way back, the six weeks I spent at home studying for the Boards was pretty wonderful. I'm not sure how the test itself went, and while I learned a lot, it didn't quite feel like enough. I'll talk about that whole process maybe later. But other things happened, and for those I'm proud and glad.
I ate all my meals with my parents, and my brothers came home on the weekends for the more elaborate meals my mom would make. The first few days I returned, Fremont was gray and green. I studied in a room with a window facing the street, and we live on a busy street. I had three second glimpses of people as they passed from the left edge of my window to the right, or the other way: teenagers walking home from school, missionaries going door to door, parents wheeling strollers, dogs on leashes, stray cats, a man collecting cans in a shopping cart, young couples, old couples, people talking to themselves and each other, various runners with different running styles, a woman singing and running into her notes as they flowed forward and she walked after them.
I ran a few miles every couple days, all on the treadmill after my first week at home, which I know surprises everyone because people think I'm really unathletic (which I am, except for in elementary school but no one believes me when I tell them I was good at sports back then) and because when I do run it's always outside. I started because it got too hot in the afternoons to go outside, and despite sleeping fine for the most part I was too tired to run in the mornings. So I grew to love the treadmill, which faces away from the screen door to our backyard, in our living room. I'd open the screen to make it feel more like outside, and I grew to love the mechanics of running on a machine, of focusing purely on movement (not even forward movement, obviously, just moving), rather than surroundings and surrounding feelings. I was disappointed to realize it'd take me much longer than I anticipated to work up to a decent pace, after many years of irregularity, but it did motivate me to continue. I also started to like milk (I do tally this on my list of accomplishments), because it was the only cold drink we had. It was really satisfying to have everything I needed to run at home. Just changed in my room, went downstairs to the living room for the treadmill, panted my way to the kitchen for milk, then back upstairs to shower.
I finished one book during Boards studying (in my small defense, it was a long one)--The Wind-Up Bird Chronicle by Murakami. It's up there with my favorites of his. Much of it was dark, and I'd go to sleep unsure. Through it all there was something to hang onto, as is usual with even his strangest contexts and characters most disconnected from things. And in this book amidst all the unbelievably expressive and knowing and detail, there were in particular two pages that I may hang onto the rest of my life.
I didn't get to see friends as much as I would've liked, only seeing my high school friends the day before I left for Prague. I did fly to LA for a day to see Iron & Wine at the Troubadour with my oldest friend. Awhile ago I posted about my top songs and none of them included Iron & Wine, even though he is one of my top artists. This is because what I love in his music runs through everything he writes, and the whole experience of hearing Iron & Wine with someone close to me who values that feeling, felt like that, where places and events and things lose definition and become vessels for something ineffable and common in all of them. He ended with Trapeze Swinger, which is a long song and one I'd been listening to often before the show. It's a beautiful beautiful song and one that will always make me think of that moment in the show, and also the walk in the cool night to the venue before the show, and the car ride afterwards which I remember as a long straight road punctuated by streetlights, though I'm not entirely sure it was that way the whole time.
I said goodbye to my great-aunt, and the funeral is something else I'd like to write about, and separately. I wasn't close to her, but I tried to stay close to what it meant. I can't say that I was always able to completely focus on it, with the hectic background of studying and other things, which forced me to consider balance and my role in that. It also made me glad to be with my mom, who is much nicer to me than I deserve and who did teach me to make a couple of her dishes. Not quite as many as I wanted, due to her cooking hours before I got up in the morning; by the time I was getting up early enough, I was trying to make up for lost time in studying. But now I can (theoretically) make my favorite spring rolls and savory crepes? pancakes? Not really like either, but yellow and crispy and eaten with fish sauce and lots of lettuce and herbs.
I also cut off about 12 inches of my hair. I needed 10 to donate to Locks of Love, so the hairdresser asked me if I wanted to keep that extra 2 inches, but I told her to just take it all. So instead of messy wavy hair down my back, I have manageable straightness to just my shoulders. Even though I don't like the look of the haircut much, it felt pretty good to make a dramatic change, after growing it out for two years. Other tidbits at home included getting my white coat tailored to my actual size, getting a new backpack, and finishing a roll of film.
Writing about things awhile after I've thought of them is hard, and dissatisfying in the knowledge that it's inadequate. The intersection of language, or my language, and feelings makes me feel that it's always inadequate, even when I write in the moment, but this feels more so. Still, I'm really very glad to be able to do at least this.
Thursday, March 26, 2009
beeeeep
The other day we were given beepers. Since we became med students in the fall of 2007 we have visited the hospital weekly to interview patients, learning how to do a history and physical. In a few months we're going to do it not for practice but for real. People will beep us in order to do so. My beeper was much smaller than I expected. Everyone else's were small too, but I don't know what they expected.
In anticipation of the beeper's use, they sat us down today and kind of told us what our third year will entail. In one year we are to do the following "rotations," not necessarily in the following order:
Internal Medicine (8 weeks of inpatient care, 4 weeks of outpatient care)
Surgery (4 weeks of general, 4 weeks of subspecialties)
Anesthesiology (2 weeks)
Emergency Medicine (2 weeks)
Pediatrics (8 weeks)
Obstetrics & Gynecology (6 weeks)
Psychiatry (6 weeks)
Clinical Neuroscience (4 weeks)
We were told that we would be faced with three major changes during this transition from book learning to patient care: we are required to be there, to dress appropriately, and to get grades. Seeing as how I don't go to class, glean much joy from bright accessories, and have stopped taking our voluntary self-assessments, these are big changes for me indeed. But none of those came to mind when faced with a beeper and eighteen pages of logistics about just choosing the order of our rotations.
We're constantly being told not to stress. Don't stress about getting the highest score on the Boards. Don't stress about planning the order of your rotations. Don't stress about controlling your life to get the best residency after graduation. Don't stress about getting poor grades on rotations because you don't know something. These are legitimate concerns that we'll all face when being pimped by an intimidating superior with a million times your knowledge and experience, and I am sure I will be stressed. It seems to me, though, that in the midst of all this reassurance about our performance as students who are responsible for their own futures, I worry most about my performance as a person who is now responsible for others.
Sometimes that thought hits me so hard, especially during all these rites and milestones we have that make this field different than others for me. I find it difficult sometimes to convey our experience in medicine so far, and we haven't even experienced it. I felt a lot during our white coat ceremony, but what it was I can't even say. I just know it was supposed to be a marker for something. During the dinner where we received our beepers and thanked the mentors who have guided us through patient interviews since we started, we were made aware that this is a point of moving on. Combined with all the patients we've met; the science we've learned; the non-science of ethics, insurance, professionalism, social issues, and so on we've been exposed to--medicine has become all-consuming, and while that can be inevitably hard, it's made me think much harder about reasons.
In the past, getting to certain places was about a sort of validation of what came before. Getting into college bundled up accomplishments up until then into a neat package. Getting there was also a means to go elsewhere. I wanted Harvard simply because to my 18 year old self it meant a new coast and possibilities and possibilities. Medical school followed a similar thought process, where my college experience was tied up in an application to medical school. Even as each individual thing I did or learned had its own value for me independent of what it meant for school, to explain it to someone else I had to frame everything in terms of getting here. And I wanted to get here, in order to go somewhere else good afterwards. In between the markers of acceptance and graduation, I had an incredible time and learned so much wherever I was, but that can get lost amidst the bookends.
Now, while we may stress because the Boards and rotations are to lead us somewhere, the concern for me lies in making the present worthwhile regardless of where it takes me. I doubt the people who will let us learn about them at their most vulnerable will care much where we go for residency after school or the kind of career we'll lead. I'm not immune to caring about these things (I would like to be in a path that will fulfill my reasons for going into medicine, in a location I like and with people I love), but harder and more important than achieving them, I would like to do well by the people we've been waiting to care for, in the moment we meet them and not for anything before or after.
In anticipation of the beeper's use, they sat us down today and kind of told us what our third year will entail. In one year we are to do the following "rotations," not necessarily in the following order:
Internal Medicine (8 weeks of inpatient care, 4 weeks of outpatient care)
Surgery (4 weeks of general, 4 weeks of subspecialties)
Anesthesiology (2 weeks)
Emergency Medicine (2 weeks)
Pediatrics (8 weeks)
Obstetrics & Gynecology (6 weeks)
Psychiatry (6 weeks)
Clinical Neuroscience (4 weeks)
We were told that we would be faced with three major changes during this transition from book learning to patient care: we are required to be there, to dress appropriately, and to get grades. Seeing as how I don't go to class, glean much joy from bright accessories, and have stopped taking our voluntary self-assessments, these are big changes for me indeed. But none of those came to mind when faced with a beeper and eighteen pages of logistics about just choosing the order of our rotations.
We're constantly being told not to stress. Don't stress about getting the highest score on the Boards. Don't stress about planning the order of your rotations. Don't stress about controlling your life to get the best residency after graduation. Don't stress about getting poor grades on rotations because you don't know something. These are legitimate concerns that we'll all face when being pimped by an intimidating superior with a million times your knowledge and experience, and I am sure I will be stressed. It seems to me, though, that in the midst of all this reassurance about our performance as students who are responsible for their own futures, I worry most about my performance as a person who is now responsible for others.
Sometimes that thought hits me so hard, especially during all these rites and milestones we have that make this field different than others for me. I find it difficult sometimes to convey our experience in medicine so far, and we haven't even experienced it. I felt a lot during our white coat ceremony, but what it was I can't even say. I just know it was supposed to be a marker for something. During the dinner where we received our beepers and thanked the mentors who have guided us through patient interviews since we started, we were made aware that this is a point of moving on. Combined with all the patients we've met; the science we've learned; the non-science of ethics, insurance, professionalism, social issues, and so on we've been exposed to--medicine has become all-consuming, and while that can be inevitably hard, it's made me think much harder about reasons.
In the past, getting to certain places was about a sort of validation of what came before. Getting into college bundled up accomplishments up until then into a neat package. Getting there was also a means to go elsewhere. I wanted Harvard simply because to my 18 year old self it meant a new coast and possibilities and possibilities. Medical school followed a similar thought process, where my college experience was tied up in an application to medical school. Even as each individual thing I did or learned had its own value for me independent of what it meant for school, to explain it to someone else I had to frame everything in terms of getting here. And I wanted to get here, in order to go somewhere else good afterwards. In between the markers of acceptance and graduation, I had an incredible time and learned so much wherever I was, but that can get lost amidst the bookends.
Now, while we may stress because the Boards and rotations are to lead us somewhere, the concern for me lies in making the present worthwhile regardless of where it takes me. I doubt the people who will let us learn about them at their most vulnerable will care much where we go for residency after school or the kind of career we'll lead. I'm not immune to caring about these things (I would like to be in a path that will fulfill my reasons for going into medicine, in a location I like and with people I love), but harder and more important than achieving them, I would like to do well by the people we've been waiting to care for, in the moment we meet them and not for anything before or after.
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