Taking a Step Back to Move Forward

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This was first written and posted on Doximity’s Op-(M)ed and can be seen by clicking here... I will be writing monthly for them and hope to have a year-long discussion about the trials and travails of being part-time. Whether its enjoying more time with the kids, suffering through a bad Locums placement or learning to be a student all over again, I plan to share it all with all of you. For those that have been keeping up with a lot of my writing, a lot will be familiar. But I hope you enjoy the slightly different perspective.

Taking a Step Back to Move Forward…

“The simplest questions are the most profound.
Where were you born? Where is your home? Where are you going? What are you doing?
Think about these once in a while, and watch your answers change.”
— Richard Bach, Illusions

To an outsider, a hospital often feels like a chaotic place. Varied people flutter in and out of rooms, the color of their scrubs identifying nurse vs. patient care tech vs therapist. Bulky portable X-ray machines compete for hallway space against more streamlined transport carts, shuttling patients to procedures and tests and back again. All this against a soundtrack of monitor alarms in-between intermittent overhead announcements.

For those who work inside the hospital walls, there is a structure and pattern beneath this apparently random Brownian motion. Environmental services with their Zamboni-like machines clean the floors at 4 AM. Phlebotomist follow soon after to draw 5 AM labs. Portable X-rays make their way into the rooms about 5:30 AM. Resident handoffs start at six before the nurses have their shift change at seven. Multidisciplinary rounds tentatively start at eight. Notes finished by twelve so I can get to my first office patient by one in the afternoon.

Patients add improvisation, going off-script to inject their own episodes of distress, instability and crisis. But every day, in each hospital, there is a unique structure and rhythm to the day to anchor and build off of, to manage and cope with the unpredictable nature of the ICU. Almost every day for the last twenty years, I have relied on and used these routines and patterns to navigate and manage my day.

A year ago, everything changed.

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Solitude and Connection

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Two friends (younger than me by more than two decades) are training for the Ironman and I decided to join them for their first of two 40-mile loops. I had already decided to defer my own race entry to next year due to a combination of aches and pains, along with maintaining life-balance, which led to my bike lying dormant in the basement. About four weeks ago, I finally brushed off two years of dust. The few rides done between then and now felt like brief tentative coffee dates after a prolonged break up. So, I impulsively jumped at the chance to join these guys and recapture a bit of pride and youth.

Currently I feel neither proud nor youthful. But I am definitely feeling my age and rather stupid.

First, I spent all of last week barely able to move with a locked-up neck and back. Last weekend’s combination of ICU call and a Midwest water polo tournament did not treat me well. High doses of Motrin and a session with a chiropractor got me the go-ahead to start exercising again. But I might have neglected to mention I had the hills of Madison in mind for this weekend.

Second, I have been on my bike only three times this summer. The longest ride was two hours and covered thirty-two FLAT Illinois miles. Not hilly Wisconsin ones. This was like going from a lazy six-mile run on level ground to a hilly half marathon.

Third, if I was going to do this, I should have ridden at my currently slow own pace. These guys have been training all summer. Their youth, combined with the handicap of my age, makes their current speed out of my league.

Nevertheless, after waking up at four AM and driving to Madison under the backdrop of the morning sunrise, I am now in a world of hurt. Having been dropped relatively quickly by my faster friends, I find myself alone with my thoughts. My wheels spin over the rolling hills; mid-summer length corn lies adjacent to the road on either side. Soon, the corn soon gives way to an open field and a gentle breeze, a nice relief to the morning’s rapidly rising temps. I feel sweat from my brow trickle down symmetrical tracks on the sides of my face, reuniting at the tip of my chin before gravity finally pulls the salty drops from my skin. The wind drones in my ears as it flows through my helmet’s vents. The drive train of the bike generates a soft and subtle background noise with a pattern and cadence matched by my pedaling. Discomfort and stupidity no longer my focus, I am freed to look inward and reflect; an infrequent opportunity these past two years in the absence of long runs and rides.

Thoughts have been fluttering around in my head for a while. Why do I continue to create pain and discomfort through bikes rides and long runs? Why put my body and face between a water polo ball and the goal? Why am I going back to school? What do I want to achieve? In the relative solitude on my bike in the middle of Wisconsin farmland, I can stay and linger with these thoughts for a bit and connect some dots.

My daughter moves like me. She has never been able to sit still. She has learned over the years to channel that boundless energy into dance. Finding within the movements her passion and focus. My own need to swim, bike and run parallels her need for constant motion; my comfort in the pool surrounded by teammates mirrors her happy place in the dance studio. Her desire to make dance part of her life in college reminds me of myself at seventeen using water polo to connect and help find my way as a freshman.

My son is struggling with his future like me. He is in the process of figuring out what he wants to do moving forward in his life. What does he want that to look like and how will he actually make that happen? He reminds me not only of myself at the age of twenty-one, lost and scared about an uncertain future. But also myself now, at the age of forty-eight, asking similar questions all over again. I am probably not the only family member lying awake at night wrestling with the vast openness of the unknown. We both have our own paths of growth and discovery that we are navigating and working through.

The landscape keeps changing. There is a dairy farm now on my right and a field of alfalfa to my left. The bike route this time of year is usually quite busy and for most of the ride there was no shortage of riders around me. But currently I am alone, except for some Holstein cows huddled together, relatively motionless but for their tales whipping through the air. My bicycle and I start to battle a mild but increasingly uphill grade. My breathing turns more forceful and labored, moving the late morning humid air into and out of my lungs. The grade again increases, forcing me to grab the brake hoods, increasing my leverage on the pedals. I have some rough miles ahead of me, both on my bike and off. But instead of feeling stupid, I am filled with gratefulness and connection. To an observer, I am riding slowly up a hill in relative solitude. But in reality, I am not alone. Madison and Maya are right by my side.

There Are No Words

Picture Credit (John Moore/Getty Images)

“…if we forget, we are guilty, we are accomplices.

“we must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Sometimes we must interfere.”

“When human lives are endangered, when human dignity is in jeopardy, national borders and sensitivities become irrelevant. Wherever men or women are persecuted because of their race, religion, or political views, that place must- at that moment- become the center of the universe.”  

Elie Wiesel 

Over the last few weeks, I read the news. I saw the pictures. I agreed with the outrage expressed in op-ed’s, evening news and twitter feeds. I shared and voiced my thoughts and opinions on the heinous actions of my government, separating in traumatic fashion children from their parents. My thinking brain has been shocked, horrified and outraged and did not have to stretch far to appreciate the parallels to the Japanese internment camps.

But my heart remained protected, wrapped up and insulated using the same tools I use to manage the emotional burden of caring for the critically ill.

And then I heard the tapes from Pro Publica.

I can only imagine the trauma that those children and their parents are enduring. I’m sure it falls far short from reality.  Although I cannot draw a direct comparison,  I do know how I felt when I was separated from my child in a way I never hoped to be.

I ached in a way I had never ached before. The weight of worry in every breath. Fear of the unknown fueled racing thoughts. My vision blurry and tired from holding back tears. My hand constantly drawn to my chest near my heart, pulled by a force from my core. A place I have felt only a few times before. This place inside, beneath skin and bone, ached with such weight and depth that it often forced me to the floor in attempt to ride out the waves of pain rolling through me.

I was overwhelmed and felt helpless. Yet I knew where my child was and who they were with. I knew those people cared.

Now, imagine you’re five years old in a foreign country with a foreign language. Cold concrete floors partitioned by chain link fences all around. No parent to squeeze hard and cling to. No family member to hug and hold, to feel their strength and resolve as an answer to your overwhelming fear. Only uniformed strangers with weapons at their side or tin foil blankets to turn to for any potential warmth.

There is no insulation from their cries. And there shouldn’t be. If you have not heard the tape, I ask you to listen.

Immoral. Unconscionable. Heartbreaking. Traumatic. Terrorizing. Those words, as strong as they are,  are insufficient to describe this current horror. There has already been too much rhetoric and not enough action. So I am going to do what I can do.

I am writing. I am donating. I am calling. I will vote in September and will help as many others in my community and neighboring states to do the same.

There are plenty of organizations that need your help. There is a need for lawyers, translators and donations.  Here is a link to a website at SLATE written by Dahlia Lithwick and Margo Schlanger. They are continuously updating the page with places that are helping in this battle.

Not much more to write. It’s time for me and my family to act. I’m asking you to act as well and share what you are doing. I’ll be sharing here over the next few days what my family chooses to do.

Together, we can be better than this.

 

 

 

 

 

 

Top 5 Lessons Learned for the New Interns

Welcome new PG-1’s! One day you wake up a medical student. Then by the afternoon you are a MD. A few short days later, you are now in the hospital no longer looking for someone to co-sign your orders in the EMR.

It’s a crazy time, full of excitement as well as an inordinate amount of stress.

My list is not for your first day of the first week. But maybe bookmark it for after you get your sea legs under you. After you know where to park the car and where to get that much needed cup of coffee. This is for after you figured out how to login to the EMR and PACs system and know the pattern (or lack thereof) to your days on your first rotation. Then, come back here and re-read. When you have the bandwidth to actually process. There are many pearls out there for new interns. There are handbooks, pocket guides along with Twitter full of words of wisdom. The five I have written about here I think will serve you well as interns and beyond.

  1. Don’t forget the chief complaint.

My closest calls and near misses over the years have been when I neglected to pay adequate attention to the patient’s chief complaint. They may be in florid heart failure with a pulse ox of 70% and not making any urine. But all they care about is the pain in their calf. While I am placing them on non-invasive positive pressure ventilation, nitro drip and Lasix, two hours later I find them in the OR for compartment syndrome. Their chief complaint may not be at the top of YOUR problem list, but it is at the top of THEIRS. It may not always end up being a life or limb threatening process, but then again, how do you know if you don’t check it out. Always respect the patient’s chief complaint.  If you do not bother to pay attention and address it, what else is your patient telling you that you are not hearing!

2. Ask that question!

If you are uncomfortable asking as an intern, how will you do it when you are an attending? I will let you in on a little secret. We (the attending’s) do not know what’s going on all the time. But I do know where to go to get help. What resources I have in the form of other colleagues, partners, consultants, etc. You are not expected to know everything. Definitely not as an intern. But we doctors can be an interesting bunch. We often feel like imposters, especially early in our training. That we do not belong. Yet we have pride and ego that compete with our feelings of insecurity.  This is an awful construct to have in your head.  Break it. Ask the question. I am willing to bet someone else on rounds has the same one. By asking, you encourage the next person to speak up. By sharing what you do not know, you foster an environment that encourages learning and is better for patient care. More importantly, you will recognize that this doesn’t stop after intern year. Welcome to being a life-long learner

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3. Approach with caution the patient with psychiatric illness.

It’s hard when the patient’s history of mental illness gets put up front during sign-out from the ED or on your chart review. Our biases often kick in whether we intend to or not. Often the patients ability to give a good history and report symptoms accurately gets called into question and their voice gets tuned out in the shadow of their mental illness.  Patients with mental health issues can just as easily develop physical illness. Which often in turn leads to exacerbation or decompensation of their underlying psychiatric diagnosis. Too often we dismiss out of hand their complaints or the “pan positive review of systems”. It is hard when someone’s psychosis or mania or anxiety is raging to discern what is the truth. But be disciplined and approach all patients with same level of concern.  Don’t stop listening and tune the patient out. That abdominal pain, even though it is the 5th time they have been to the ED, can still be an appendicitis. 

4. Don’t fear the family.

I remember dreading walking into rooms with family members. They were more able in body and mind to ask questions and were not so easily dissuaded by my quick in and out of the rooms trying to get thru my morning pre-rounds. I feared them. Not just because of the time they took that I did not have, but also, I felt they would expose me for what I was. An imposter. Unable to answer their questions, I feared more what they made me think and feel about myself.

They fear too. They worry about their loved ones. They are confused, out of place, disoriented and are trying to advocate in the best way they know how. Don’t fear them. Lean into them. Sit down. Answer questions even if it means saying you do not know. Start getting comfortable with diagnostic uncertainty and being able to talk about that with patients and families. Honesty combined with empathy goes a long way towards building trust and confidence.

5.   Recognize wins.

I have written about this before in  another post  10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit  but I think its important enough to include here as well. Learn to retrain your brain. As physicians, we tend to focus and dwell on what went wrong. The challenging patients and families. Frustration over missing labs or delays in imaging. The complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of medical illness.  Treating a “routine” COPD exacerbation and managing them through their hospital stay to discharge without any drama or significant adverse event is no easy task. But we fail to value our role in this as a win. It is viewed as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. We focus so much on what goes wrong or in our perceived failures to help or heal our patients we end up ignoring all the positive around us.

Best to all the new interns on the start of a new journey. Exciting times lie just ahead. If you enjoyed this post and want to hear more thoughts on medicine and work-life balance, please sign up to follow this blog!