In a hospital minute (NaBloPoMo Day 8/30)

A lot can happen in a hospital minute. A baby is born. A life-changing diagnosis is made. The wrong medication is sent to a patient’s room. Sometimes a minute lasts a lifetime, starring at your feet in silence when asked a question on rounds, waiting in line at the coffee bar, riding the elevator up to your car – because car = home = sleep.

Yesterday I spent roughly 750 minutes in the hospital. My favorite minutes were:

1. Playing Minion Rush with a patient on her iPad. I lost
2. Filing that note I spent 2 hours writing. It took some work; I didn’t know half the words I put in there
3. Devouring a giant chocolate chip cookie
4. Watching the family dead in the eyes and acknowledging their fears when

Then I left, went home, and then to a concert. Then this morning I woke up looking like death, which is never ok, but definitely not cool when working with children. Thankfully, they are usually too busy screaming their lovely heads off to notice.

There is time to slow down a little and take in the minutes. There is (almost) always time. In medicine, we are mostly Type A gotta go-go-go people who add more things to their to-do list when it’s starting to thin out because the thought of an empty to-do list is simply incomprehensible. Not only do we make to-do lists, we draw check boxes next to each item and develop an elaborate code to keep track of tasks within tasks. A half filled box means the test or the phone call has been made, but the result is still pending. Some use color codes. Indeed, medicine is the only workplace where carrying one of those four-color-in-one pens, the ones we geeked over as middle schoolers when they first came out. Then we “run the list [of patients]” and make sure no tasks have fallen through the cracks. The complexity of patient care, the volume of patients, the frequent transitions of care between teams, and lest we forget the fatigue that sets in in the nth hour, make it imperative to keep track of what we do.

I never make a “play Minion Rush” box or a “ask about the sibling who came to visit yesterday” box. Since the start of intern year, I am now making check boxes for my grocery list or for neglected bills that need tending. Funny enough, things like “go to yoga” or “email back the dear friend who wrote to you from halfway around the world” never seem to merit their own boxes. Nor do I ever make “do nothing” box. A “live in the moment box”? Say whaaaat?

And yet – and yet – aren’t those boxes the ones that really matter in the end? I won’t remember that I ordered the correct heparin flush, but I will never forget sitting on the floor with a child who launches minions onto a conveyer belt and laughs her head off every single time.

There is (almost) always time. I haven’t found extra time this month so far to write daily because suddenly quantum physics no longer apply and days are in fact 25 hours long. I am taking the time. I am choosing to do what matters to me. To live outside the boundaries of a check box. What a concept.

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The Small Things (NaBloPoMo Day 6/30)

I saw a lot of goodness today.

Today I did things that are essential to my development as a resident and my resilience as a human being. Things that don’t always get recognized as essential; things that I rarely have time for. I went to counseling and dreamt big about career possibilities (they are endless). I spent 20 minutes outside in the sun surrounded by a ballet of orange leaves and took a few deep breaths – and stumbled upon some very big words (see below). I bought an Elmo balloon and paraded it around the hospital. I went to see a patient who has been in the hospital a long time and watched him hug the Elmo balloon. I sang happy birthday to him alongside his family. I was hugged. I watched a parent read to their child while they were waiting for me.

I felt a lot of goodness today. I know it is around us everyday, but we don’t always shift our focus and allow ourselves to receive it. However if we set intentions – for me, writing daily about the things that build me up and crush me – if we dedicate just a few minutes each day looking for the goodness, we find we don’t have to look very far. It is already there. All around. All the time.

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We Are Humans (NaBloPoMo Day 5/30)

There is a book club organized by attending physicians in my department and tonight I attended for the first time.  I had never participated in a book club  before, but I had read the book (80% of it anyway), and I wanted to meet fellow physicians with a penchant for the written word other than a New England Journal of Medicine article.  The book club meets monthly at one of the attendings’ house to discus the previous month’s book over a potluck dinner.

We did just that, in between scoops of homemade artichoke dip, sips of wine, and baklava  ordered from a middle eastern pastry shop out East.  We debated the characters, the storyline, the ending.  We still had a hard time leaving our professional thinking caps at the door when discussing a medical aspect of the story.  Inevitably the conversation broaden, and next think we know we are sharing our weirdest dreams,  confessing to reading horoscopes fervently (how so un-scientific of us), and dreaming of having a Tarot card reading or being hypnotized.  More pastries.  A debate whether to read Brave New World or The Lovely Bones next.

See what we did there?  We talked, we socialized, we related.  We discussed the meaning of dreams.  We are humans.  I only wish our patients could see us in that light. I suspect  that many of our patients doubt our “human-ness.”  In the hospital, we may appear in a hurry, or lost in our thoughts, or robot-like as we spit out a list of differential diagnoses longer than the set of references at the end of said New England Journal of Medicine article.  We may seem aloof and emotionally detached.  Sometimes we are, whether it be by choice, as a protection mechanism against emotionally charged medical dilemmas, or by default, as a result of chronic sleep deprivation. But tonight in someone’s living room, we talked and laughed and each shared a piece of our emotional life through our reactions to the book.  And I can assure you, we are humans just like you.

(What is NaBloMoPo? Lookee here)

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Ask the right question (NaBloPoMo Day 4/30)

“Have you seen my [Nintendo] DS?”

Some patients take “do you have any questions for me” very seriously when they come to clinic.  They have a list.  They take notes.  Others stare at you blankly, overwhelmed by what they have just heard. Or they are simply befuddled because your explanation of how DNA is a 4 letter code largely responsible for their tantrum-ing 4 year old didn’t quite make sense.

As physicians, we welcome questions.  They indicate that the patient is taking ownership of their health, that a partnership is being forged, that we did a great job explaining this or that, that our compliance rate will go up and our rate of no show will go down.

“Have you seen my DS?”

I was my the way from one clinic area to another to sign paperwork when this little one appeared out of nowhere and accosted me.  He had no hair, except for the thinest of fuzz tethered to the nape of his neck, and was dragging an IV pole with multiple infusion bags attached to it.

“Have you seen my DS?”

“No, my friend, I haven’t.  I’m sorry.  Is it in your exam room?”

“No.  It’s very expensive. I have to find it.”

“Have you asked your nurse?”

“Yeah but she doesn’t know.”

“Well I think she will be your best bet to find it, if it is here.”

He spun his heels and his IV pole in unison and began marching down the hallway.  There was a certain spring in his step, a determination to find his DS no doubt.  I watched him walk away.  He kept the IV pole, almost twice as tall as he was, close to his body, so that there was plenty of slack in the tubing.  Clearly he was a pro, a veteran of the cancer wars.  But none of that mattered because in the moment he was just a kid who couldn’t find his favorite toy.  And while I couldn’t answer his question, I was lucky enough to share that moment with him, feel present, and talk about what really matters (the DS, not the illness).  I really hope he found it.

It’s all about asking the right question.

(What is NaBloMoPo? Lookee here)

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Affirmation (NaBloPoMo Day 3/30)

Well, this is off to a bad start.  Day 3 of pledging to 30 days of daily writing during NaBloPoMo and here I am at the 22nd hour.

I didn’t work today so I had to make up extra excuses not to sit down and write. Those excuses were, in no particular order: laundry, because 11 clean pairs of underwear may just not be enough for the week; hiking on a gorgeous Fall day; another Reese’s peanut butter cup, because afterward my belly hurts and I can’t do anything; dishes, because I don’t have a dishwasher; a research paper I started 18 month ago and have neglected to finish; Sunday Night Football because…

My name is _____ and I am a procrastinator.  I didn’t use to be one.  In my heart of hearts I know that procrastination doesn’t serve us well,  so why do we persevere?  Because there is something to gain, obviously, or else our highly evolved minds wouldn’t spend so much energy scheming to postpone the inevitable.  What might be gained?  Sympathy, when we whine to whomever is around about our endless to-do list.  A good pep talk.  A swift kick in the head.  The desire to appear tough and masterful when perhaps there is just too much going on.  The failure to recognize that saying “I can’t do it all” isn’t weakness but courage.  There is grace in vulnerability.

I am imperfect and I am enough.

Those are the words of Brene Brown, Ph.D., a social scientist turned Oprah regular who studies shame and courage, vulnerability and empathy.  Her TEDTalks are well worth the time.

I know exactly why I haven’t finished that research paper.  Fear of not producing good enough work.  Fear of how I will feel when asked to rewrite a better draft – even though rationally I know that it is only by revising and rewriting that we produce better work.  Fear that I have disappointed the lead scientist on the study and not wanting to hear their reprimand, one I deserve in its entirety.  And yet I think about this darn paper almost every day.  So there.  Maybe now that I have named the fears, I can actually get it done.  It may not be my best work, it may need multiple additions and revisions and maybe even a major rewrite, but it will be my work, the best I can do at this very moment.

I am imperfect and I am enough. 

(and it truly was a gorgeous Fall day in the great state of Tennessee)

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NaBloPoMo — Go

NaBloPoMo.  It sounds like alphabet soup.  No wait, that’s the name of my future cancer ass-kicking kid musical – but more on that later.  NaBloMoPo.  It sounds like something I  would coo at a wee patient wearing one of those awesome baby hats crocheted by a saint with non-arthitic fingers.  Or a new flavor of bubble gum from Willy Wonka’s Chocolate factory.  Or a remote zen sanctuary in Burma.

November is National Blog Posting Month – a spinoff of National Novel Writing Month.  A challenge to those of us who fear the 50,000 word requirement but fear we will be less of a writer if we don’t rise up and start typing.  Click here to see the 1,500+ brave souls who have taken on the challenge as of Day 2:

I fully realize that the slow realization that I have semi-abandoned this blog under the disguise of being too busy/grumpy/sleepy/weepy or otherwise in the hospital is fueling my interest in NaBloPoMo.  But there is more to it.  Writing is an exercise, the soul-illuminating kind.  The “oh I thought this was on my mind but clearly it wan’t since I just spend 20 min writing about that” kind of exercise.  I spend the better part of my day in the hospital carefully documenting patient care.  I already write every day.  I use buzz words like “no hepatosplenomegaly” and “review of systems otherwise negative”.  I outline a patient’s “disposition” using neatly typed 1. , 2., and 3. bullet points.  I write a lot, but how much do I actually say?  In medicine, we have to be reductionist and clear in our communication.  We have to use a format that other healthcare providers can understand.  We have time imperatives.  We know – or at least I like to think we do – that a patient’s narrative cannot be told in bullet points and outlines, that behind the history of present illness there is a litany of questions and emotions, hopes and fears.  That the (insert age here) year old (insert ethnicity here) (insert gender here) with (insert chronic condition here) presenting with chest pain has as much going on with his physical heart as with his metaphysical one.  But we, physicians, don’t usually talk about that and we certainly do not document the more delicate matters of the heart.

And yet nothing in medicine makes sense without some understanding of the greater story.  What is the patient’s understanding of their illness?  How does the illness change their identity?  How does this medical interaction, right now, shape the rest of the relationship between the patient and the medical system?  Can one encounter change everything?  Can the patient and the doctor emerge strengthened, renewed, and more compassionate?  Yes we can.

And so in the spirit of NaBloPoMo, I will type my heart out daily and reconnect with the exercise that is creative writing (and double post as needed to make up for lost days).  As an added (self-imposed) challenge, I will write about emotions and feelings.  The soul-elevating kind as well as the heart-destroying kind. My own as they bubble up in response the people and things I see in my field of medicine.  The stories and tidbits that don’t make it into the hospital notes.  I will do this because this is how make sense of life happenings.  I will do this because I am willing to split open.

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Under Armour

A few weeks ago, I bought my first ever comfy-yet-sleek-semi-fitted-always-dry-performance Under Armour sweater for those long cold nights in the Emergency Room.  Black, with holes in the sleeves for my thumbs, and my institution’s logo on the front, I had a shield to brave the ER, a shield I felt I needed so desperately.

Last Sunday, back on the wards and working in a windowless room while a gorgeous Fall day was unfolding two doors away, a fellow intern and I took advantage of a quiet moment to sit outside in the playground – perk of being in a children’s hospital – and eat lunch.  It was warm and sunny.  I took of my Under Armour sweater that I had put on at 5:30am before heading in to work.  A little guy made his way over to us.  “Hey guys. Guys!” he said.  We said hey back.  He told us his name.  We told him ours.  He told us his age.  We didn’t tell him ours.  He told us that “the teenagers were coming and he was going to destroy them.”

He had a hospital armband around his wrist.  A simple seatbelt across his lap secured him to an armless wheelchair.  He rolled over to a bush, grabbed some leaves, came back over to us, crushed the leaves and said something about how they were weapons against the teenagers.  I encouraged him, I tasked him with saving us, even though I had no idea what fantasy was unfolding inside his shaved head.  For the next half hour he wheeled himself back and forth, checking in with us, still in character, still fighting the imaginary teenagers.  I suddenly realized my pager had gone off twice.  I put my Under Armour back on and headed back to the windowless room, my eyes unable to adjust after being in the sun.

I was dying to look up his medical records.  Was he paralyzed?  Was he a cancer patient? Did he have surgery? Was he in remission?  Why was he outside (seemingly) alone?  But he wasn’t my patient.  And he was so much more than a patient.  He was a kid having a grand time on the playground.  He came to meet us, he talked to us, he shared his play fantasy with us.   He simply was himself – wheel chair, illness, imagination and all.  No shield, no armor, no distinction between all the many parts that make him who he is.  Authenticity makes for the richest of interactions.

So whenever I put on my Under Armour, I think of him.  I think of the energy poured into hiding under a sweater, putting on a brave face, or keeping a safe distance, when it is so much simpler to be show our true face — flaws, qualities, fears, and all.  And so much more rewarding.

Time to come out of hiding and play.

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July Intern

On the 31st day of residency –  I think that was yesterday, although I can’t be sure, days morph into nights that morph into an artistic blur akin to a Jackson Pollock canvas. But I digress.  July 31, the last day of the first month of residency.  The last day of being a July Intern.

I was working in the emergency room.  Dental traumas, angry tonsils, bad falls, abscesses, new onset of diabetes.  And then her.  I met her in one of the smaller room off to the side.  She greeted me with a broad smile and that simple carefree attitude the wee ones carry so effortlessly.  She had had some pain and found to have old fractures on imaging studies.  Some lab work at her primary care physician’s office was abnormal.  I was the first doctor to see her and her family.  I listened to the story, asked follow up questions, examined her, talked about CareBears.  I had the vague sense that something was wrong, that the facts didn’t add up.  But add up to what?  It was just a vague sense, my brain unable to do much more than cobble together an account of my findings to the attending physician.

A few more patients.  The vague notion that I needed to pee.  I checked in on her frequently, updating her parents on the tests we were running.  An x-ray.  An ultrasound. Talk of an MRI.  Consulting teams were brought in.  I watched the Child Life specialist – the best of the best people in the hospital – explain to her how IVs work and why she needed one.  She had that serious look on her face, but it wasn’t one of worry.  Just a sense that this was important and that she wanted to do her part.  We talked to her about the MRI machine, how she would need to be very still for a little while. “I’ve done it before”, she squeaked.  That pure unadulterated pride of having done well.

In another room, my first family meeting.  A child had taken a fall and I was to deliver an an update on some very reassuring results.  12 pairs of eyes fixated on me.  Stillness in the air.  I tousled the child’s hair while I delivered my good news.  Outstretched hands flying from every corner; handshakes heavy with emotions.  I don’t think hearing “Thank you, Doctor” will ever loose its meaning.

Checking in with the attending physician, who was now sporting a furrowed brow.  “Not good.”  In a split second, it all fell into place in my brain.  The images, the lab work, the physical findings, the pain.  She had cancer.  More tests were ordered.  I updated the family on the need for tests and hinted at the likely possibility of being admitted to the hospital.  I still hadn’t peed.

I missed the initial conversation with the family, busy with other patients who equally demanded my attention.  More consultants were called.  The attending came to update me after sitting down with the family.  He had used the word “cancer” and a few others equally scary ones.  Two parents in a tiny exam room, their baby in a hospital gown, an episode of SpongeBob on the TV, a constant stream of people walking past the glass doors, unaware, unburdened.  What could possibly have gone through their minds?  I went back to see her at the end of my shift to let her know I was leaving, but someone else was going to look after her.  “Will I see you tomorrow?”  I explained that different people work in different parts of the hospital, but that I would pay her a visit before my next shift.  She told me she had plans to paint, because the Child Life specialist had told her she could have a paint set in her room.  I asked her what she likes to paint.  “Whatever inspires me at the moment.”  She then bid me a good night.  I exchanged a long glance with the family.  Another lengthy hand shake.

I forgot about it for a little while as I struggled to wrap up my work.  But when I stepped outside – after I had finally peed – I remembered.  I went to yoga, hoping some deep breathes would wash away the sadness of the day.  Not even a little.

I have learned a great deal during the first month of intern year: practical things, procedural things, administrative things, textbook things.  But mainly I have learned that the simple act of presence, whether the news is good or bad, is some of the best medicine physicians can offer.

Even when you’re just a July Intern.

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The Long View

Has it really only been two weeks since the start of residency?

How quickly do we loose the bright eyes and bushy tails and only see the grind of a new job?  Too quickly alas.  And while there is welcomed comfort in predictability, there is also a great danger of loosing sight of the bigger picture.  Nowhere perhaps is that risk greater than in medicine, where we refer to patients by their room numbers rather than their names and spend more time behind computers documenting the care we attempt to give than laying a sympathetic hand on a shoulder.  I understand why this happens.  The hours are long and the work is difficult.  After just two weeks, I can already sense that subtle feeling of discontent rearing its ugly head: too much work to do, not enough time to wind down, underdeveloped working relationships, strained personal relationships, no milk in the fridge.

 I was on the phone with my darling – a fellow medical type – the other day.  He was watching a documentary on a rather controversial medical topic.  My first reply was: “On your day off?  Why?”  He said that it helped him put some compassion and emotion back into the charting he needed to do later on (on his day off).

Some months ago in medical school, I wrote a reflective piece on a patient I had seen during my geriatrics clerkship.  I later submitted the piece for publication with The Intima, an online journal of narrative medicine.  My piece, The Lady in Pink, was published, and I was also asked to write a blog post connecting my story with another writer’s piece as a way of keeping the narrative going.

 This is why I write.  I write to keep the feeling of discontent at bay.  I write to keep perspective and remind myself that it is never about the paperwork or the presentation I gave to colleagues or the fact that I finally – finally! – know how to order this medication without looking it up first.  It is always about the people and those moments where we connect as human beings.  It’s me sitting at the bedside and painting with a child when I could have gone home and napped an extra 30 minutes.  It’s watching my boss sit down on the edge of the chair next to a parent and asking if all their questions have been answered.  It is always about the people.

When the reasons for connecting with others are illness, wellness, and hopes for a full life, what could be more meaningful? 

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The Doctor Is In

Forget the first one hundred days  and let me tell you about the first seven days.  July 1 came and went and I’m still standing.  It’s an incredible privilege to introduce yourself as a doctor, especially when you know that your doctoring abilities haven’t changed an iota between the last day of medical school and the first day of residency.

The first seven days of residency.  Seven first impressions.

1.  Teamwork:  It works.  Everything is a challenge, from finding the bathroom to faxing records, but everyone is here to help.  People have been incredibly nice and patient and understanding and smiling.  Such a supportive learning environment makes it ok to ask questions, reduces stress, and prevents mistakes.  Yesterday I baked scones for my team.  Because support is a two-way street.

2. Pager: I’ve set my pager to vibrate, because I jump every time a pager goes beep beep beep.  Pro: my heart rate only climbs 20 points when I get a page.  Con: my phone is also on vibrate, so I’ve experienced frequent let-downs thinking I was getting a text from my darling or from wifey-love when it was a page about poop.

3.  Poop: We care about poop a lot in Pediatrics.  Especially when you get report that a patient has pooped a Cookie Monster sticker.  A reminder that young children put anything in their mouth.

4.  Stairwells: I’m pretty sure it’s been entertaining to many to watch me run around the floors looking for a patient room.  Getting a sense of the hospital is not as trivial as one might think.  I have figured out where the bathrooms are.  I have yet to the elevator to elf kingdom.

5.  Coffee: The hospital coffee shop is closed on weekends.  So not ok.

6.  Playtime:  At night when things slow down, I get to play with kids, chat with teens, and cuddle with wee peanuts.  Best job ever.

7.  Sleep: The general advice is sleep when you can.  I have several friends who were interns while I was still a medical student.  They talked about sleep, dreamed of sleep, slept any minute they could.  Well, I get it now.  I’m on a q5 call schedule, meaning I alternate between regular days, long call days, and night shifts.  Not very conducive to a regular sleeping schedule.  I was worried about that but guess what?  I’m so tired after a shift that I fall asleep anyway.   Even after after coffee.  Even on a Saturday afternoon when I’m off and it’s sunny outside.  Sleep – my precious.

I’m not sure I’ll be able to continue blogging on a regular basis.  So should this be the last post for a while, here what I know now, looking back at 8 months of blogging and the road to residency:

There is nowhere else I would rather be.  And that is a very, very good feeling. 

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