Snow Day

I woke up to a blanket of white covering the ground. Unlike in childhood, this was not met with excited anticipation. Forced to skip my morning coffee, I layered up in my thermal gear and put on my boots, the blister on my heel reminding me to buy a pair that fits properly. I struggled to find gloves and settled on a mismatched pair as I braced for battle with the cold. I tried not to tweak my back while repeatedly yanking the starter cord on our stubborn snow blower. As I began to clear the thick snow off the driveway, the layer of ice hidden below was a reminder that I was not quick enough to clear the driveway last time. Obstacles and challenges now loomed ahead as I anticipate colder temperatures, icy windshields, hazardous driving, and ill-fitting boots and blisters.

When did snow become the enemy? When did it become a chore? When did it become something that added to the weight of my day?

I was nine years old when one of the biggest blizzards in Chicagoland history hit. My school day was replaced by a snow day. Multiplication tables and PE class were swapped for snowballs and snow angels, while mini-mountains of snow popped up all over the neighborhood.

I remember the frustration of trying to make a snowball out of fresh powder, the crystals sliding through my fingers like weightless sand. And finding success with heavier packing snow, hearing the scrunchy sound made while rolling it to form a giant snowman.

I remember hot chocolate in my stomach any money in my pocket after shoveling driveways in the neighborhood.

I remember a blizzard in Madison, Wisconsin. A snow day in college, of all places! Playing tackle football in powder up to my knees, my quads and hamstrings burning. Hot and sweaty, despite the cold air, and the sting of snow on my face after a tackle. The pleasure of finding that perfect balance, not falling backwards on my ass or forwards on my face, while skitching on the back of a car all the way down Langdon street.

I remember the joy in my son’s eyes the first time we went sledding, on a snowy day in Michigan City, Indiana. The cold air was no match for the warmth of Madison’s smile.

When I was younger, snow was white and light, scrunchy and fun. An invitation to play. An opportunity to explore. A far cry from its impact on me now.  Snow is now an obstacle to be shoveled, a hazard for my teenage drivers, slush and salt to erode the underside of my car. It’s work now.

My thoughts turn from snow to my relationship with medicine. Another area in my life that has evolved from joy and excitement to frustration and challenge.

I remember the first time I put on my short, white coat and entered a real patient’s room to take my first history. I was hesitant to cross the threshold, nervous I’d be discovered as a fraud, an imposter. But excitement trumped anxiety as I stepped into the room, introducing myself as a student-doctor for the first time.

I remember the pride of wearing a stethoscope around my neck. The thrill of learning and doing each new procedure, pushing through my fear of causing harm. My growing sense of accomplishment as I read up on an unfamiliar disease or diagnosis adding to my knowledge base. Each patient a potential puzzle of signs and symptoms to piece together, not knowing what the ultimate picture would be. It was unknown and exciting. A snow day.

Somewhere along my path, medicine, like snow, got flipped on its head. More electronic medical records and charting than direct patient care. More patients to been seen but not more hours available in a given day. Journals and review articles pile up, still left unread. And instead of hot chocolate waiting for me at the end of a long day, there are only unfinished documentation and lingering worries over difficult decisions made.

More work than play. More obstacles than challenges. More conflict and tension than excitement and possibility.

The other day, a medical student I’d hardly noticed on my ICU service asked to see a new admission. I looked up, and saw the enthusiasm in her eyes. And, for a brief moment, I saw what she saw. A giant snow covered sledding hill ready to be climbed up and slid down. And I longed to be there on that hill, launching myself off the edge and feeling the cold air stinging my face, not knowing when I might finally come to rest. Ready and eager to race back up to the top and do it again and again, until I no longer felt my fingers and toes.

And it feels like a snow day again in my ICU.

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Defending the Lob, Managing the ICU and Emotional Intelligence

The lob shot.

As a goalie, it’s my nemesis. It was my major weakness in college and even more so today. Standing (or more appropriately treading) 6’3″ tall, with an even longer wingspan, I have always been eager and ready to explode up and out of the water, my arms outstretched, to intimidate a shooter. My height, along with my gangly arms and a quick first reaction, are great tools to disrupt, alter and ultimately block my opponents’ shots.

But my kryptonite is the lob shot. It turns my strength against me. A patient opposing player, by waiting a split second, lets my aggressiveness work against me. By allowing me to rise up and out of the water first, a shooter can then release an agonizingly slow arcing shot, up and over my now sinking self, to then drop into the opposite corner of the net. I react. They wait. And I’m beat.

When I correctly anticipate the lob, it’s demoralizing for the shooter. With minimal effort, the ball is not so much blocked as “caught” in humiliating fashion, usually deterring the shooter from another. But when my legs have already committed to a direct shot, all I can do is swivel my head and watch as the ball takes its time, teasing and taunting me, just out of arms reach, and lands in the net.

In college, it took a while to develop patience. To dial back my brashness, my impulsivity. Wait that extra split second. Take in the arm angle and the eyes of the shooter. Trust myself and my abilities to make the block even if I delay for a brief moment. My teammates challenged me with lobs over and over again in practice, until finally a change occurred. Thinking, instead of just reacting. Using my frontal cortex, instead of my primitive brain. And for a while, I had the upper hand against my nemesis, and my opponents as well.

Tempering my first reaction has never been easy, either in or out of the water. My initial response to life’s challenges tend to be more reactionary and visceral. In one’s college years, that lack of patience and emotional intelligence is somewhat expected, if not the norm. Not so much when in mid-life and caring for the critically ill or teenage children.

The ICU will never be mistaken for an Olympic sized pool. And my children, despite how it may feel, are not opponents on a challenging team. But the unique nature of an ICU and family dynamics make both areas ripe with opportunities for a battle between my brash, impulsive tendencies and my more mature, deliberate and thoughtful side.

The space that exists within the confines of the ICU is awash with challenges. Rooms are filled with the tension that accompanies the acuity and intensity of critical illness. ICU physicians are tasked with navigating multiple health care professionals, who frequently have honest differences in opinions, and sometimes supercharged egos and attitudes as well. Families and surrogates of patients, residents, nurses and students all operate in this landscape, within their own sphere of swirled thoughts and emotions. There are a multitude of relatively quick decisions that need to be made. Do I intubate or not? Do I send them on a road trip for a CT or stay in the more stable confines of the critical care unit? Do I commit a patient to an invasive procedure with potential complications or hold off and continue with the status quo?  But it’s not just the decisions themselves. There is a qualitative component as well. Do I take the extra time to explain my thought process to the nurse, resident or student at the cost of delaying decisions for the next patient? Do I provide more than a cursory update to a family as I exit a room, or do I sit down and invite them to share their angst and fear. Do I do so at the cost of delaying the start of my office and the patients waiting there? Do I share my inner head voice and its whispers of fear, concerns and self-doubt? Or do I project unwavering confidence and certainty? Challenges lie not just in making decisions, but in the manner they are carried out and executed. To grow, not just as a competent clinical doctor, but as an empathic physician as well, one needs emotional intelligence to navigate such complex waters.

These days, back in the pool, I find my old nemesis is back to taunt and haunt me. My height and wingspan may be unchanged, but the same cannot be said about my explosive move up and out of the water. Over-eager and anxious to defend a shot on goal, I now have the added challenge of being a bit slower and quite lower out of the water. I don’t have the luxury of waiting that split second anymore.

I find history repeating itself, with my current teammates showing the way. They challenge me in practice, frustrating me with lob after lob. But they are not content to stop there. They let me know that I may be the only one in the net, but I am not alone in defending it. Through their efforts in games, fighting for position, and playing a team defense, they buy me back the time I have lost. They remind me to trust them. And in turn, trust myself, allowing me to tap into my thinking brain in order to defend the lob.

My experiences with the team continue to parallel my life. Just like success in the net is a result of a team effort, so it goes in the ICU. I’d be lying if I said the years have not affected the excitement and enthusiasm of the young attending physician I used to be. There is now a component of fatigue and burnout that I often need to shake off before rounds. Some days it feels that I am on an island when dealing with a crisis or challenge. That is neither true nor accurate. The nurses, residents and students, along with my physician partners are teammates too. Together, the challenge of taking care of the critically ill seems less daunting, giving me the time and space to harness my thinking brain.

There are moments when instinct and gut reactions are critical for success. But when I am able to bring both parts of my brain to a challenge, the enthusiasm that comes with  impulsivity and brashness along with the wisdom that accompanies maturity and thoughtfulness, good things happen. Not just in the pool or ICU, but in life as well.

 

My wife miscarried while I was on call. What this medical resident chose to do.

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The day began the same as yesterday. As well as every day prior to that for the last few months. I was tired. Exhausted. The type of fatigue that envelops your brain in a dense fog, altering the way you see and hear the world around you. The type that impairs your ability to think clearly and process efficiently. It was the cumulative fatigue from too many nights of disjointed and ineffective sleep. My two children the culprits at home, my pager when at the hospital. The alarm clock told me it was 5:00 am and time to start moving. I was the senior resident on call for a busy general medicine service. I got ready mindlessly and drove to work, leaving my three-year-old son, ten-month-old daughter and pregnant wife behind.

The page from my wife would come a few hours later, while in the middle of hearing about a new admission. I called her back, expecting a generic morning update on the kids.

“I think I’m miscarrying.”

In my worn-out state, there was no reflexive response. Like the origin of a wave as a swell forms and the water gently rises, confusion first surfaced in my head. As the swell of emotions picked up momentum and power, sadness and feelings of loss crashed in. Then guilt over fleeting thoughts of being saved from even more sleepless nights another baby would bring. As the waves passed, I was left with loneliness. So far away from my wife at the moment when she needed, WE needed, to be together. I did something in that moment I had never done before. I called the chiefs and asked them to call in the resident on jeopardy to cover for me. Within a few hours, I was home at my wife’s side.

We sat together. We talked. We cried.

But as a few hours passed, the fact that someone else was covering for me caused increasing tension. Someone was doing my work for me. Admitting patients with my team, because I wasn’t there to do it. And as the sun set on the day, my wife turned to me and said, “It’s ok. Go back to the hospital. I’m alright.”

And I went back.

Thinking back to that moment, my stomach still twists in knots. How could I have walked away? How did the culture of medicine lead a fatigued, and emotionally exhausted, young doctor to leave his wife, who had just miscarried hours ago, to care for two young children on her own?

Did it start in medical school? Initial thoughts of self-doubt, and feeling like an imposter, slowly faded as we internalized subtle, and some not so subtle, comments from faculty. “You deserve.” “You belong.” We were told we were on a path to a higher and more noble calling, with great purpose and responsibility. Something bigger then ourselves. Whether from self-doubt or self-importance, we were driven to study. We spent hours reading and learning, dissecting and memorizing. We prepared for finals, mini-boards and shelf exams. And while doing so, our friends of old, no longer enmeshed in academic studies, enjoyed the perks and freedoms that came with new jobs and real incomes. We were too tired and too immersed in our narrowly focused world to connect with our friends. And as the dynamics started to shift in those friendships, we became a little more isolated.

Did it continue when we began our clinical rotations? The residents we looked up to as role models were always present and available. They taught us clinical pearls, ran codes confidently, and handled emergencies calmly. They were described as “strong.” So we emulated them, making ourselves present and available as well. For our assigned patients or a potential procedure. To be noticed. To be evaluated. To be appreciated. Those traits were deemed positive, earning merit. Never mind life outside the hospital walls. Reading a book for pleasure, enjoying a run along the lake, and being emotionally and physically available for our partners and children weren’t skills that made it into letters of recommendation.

Did it continue in residency? We took on more responsibility for our patients. Admit them, document them, draw their blood, administer antibiotics, check the labs, update their families, and plan their discharges. “To do” lists to be checked off before we could sign out and go home. In one month we would work twenty-six days. Seven of those were spent working overnight, non-stop into the next. Four days a month we were allowed to keep for ourselves. But those four days did not make up for being absent physically and emotionally for twenty-six. Not there to take out the garbage or help with laundry. A no-show for a friend’s birthday party. Too tired to take a turn rocking a child back to sleep in the middle of the night. Exercise or making a home cooked meal was off the table, when just keeping your eyes open for the car ride home from work was considered a win.

Did it continue in fellowship? Being on service or working in the clinic was not enough. There were patients to recruit for trials, night-classes to attend, and research to do. We needed to write another chapter and apply for another grant. That’s what our mentors and department chairs did. In the meantime, we weren’t there for our own children’s scarlet fever, chicken pox, recurrent strep throat, first steps and first words. What free time we had was spent moonlighting, as we tried to keep up with ballooning school loans, mortgages, and college savings for our kids.

 At every step on the path to becoming physicians, the messages were clear. Be present. Be available. Leaving early was weak. The students, residents and fellows who stayed were dedicated and serious. Impressions were formed based on being visible. Evaluations were determined by our perceived dedication. But if, in the process of being ever present and available, we struggled to make it through the day, how could we be there for ourselves? To rest and recuperate. To think and process. And if not able to care for ourselves, how could we care for others?

It’s no wonder that in a 2015 JAMA systematic review, average depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2%. In a similar article in JAMA 2016, the prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. And these numbers don’t address other mood disorders, such as anxiety, or the dysfunctional and harmful coping mechanisms of alcohol and drug use. It’s not surprising that there are so many struggling or failed marriages among physicians, as well as rampant burnout.

In medical school, we are taught about cells, tissues, organs and systems. We learn to write histories and perform physicals. We are preached to about antibiotics and anti-hypertensives. But where in the curriculum are we taught to care for ourselves? When in residency were we told to go home and make sure to be there for our families? When in fellowship was physician wellness placed on the same level as grant writing and lab techniques? Why is focus on family merely tolerated by our peers, instead of modeled and emulated? Too be fair, there have been a few mentors and role-models who showed us how to not only set appropriate limits and boundaries, but taught us that it was acceptable to protect our home lives from our work lives. But they have been outliers. Exceptions. Too often their solitary voices drowned out by the masses.

For too long, the culture of medicine has promoted this choice as binary. Spending time in the hospital to learn and care for patients versus spending time with our families. A zero sum game. But it doesn’t have to be. Why can’t there be a culture that promotes both? So far, attempts to normalize and humanize training have narrowly focused on specific issues such as work hours and work environment. But the culture of training new physicians also needs to change. Setting appropriate limits and boundaries, as well the concept of physician wellness, should be as prominent in the curriculum as human pathophysiology. We talk about developing the skills required to be a life-long learner in today’s internet-connected fast paced world. So too should we talk about promoting clinical excellence and dedication, but not at the expense of their families or their own happiness. Spouses and children should not bear the consequences of a flawed system.

There are only a handful of things in my life that, given another chance, I would do differently. My choice to pursue a career in medicine is not one of them. I love this profession and the unique opportunities it provides to help people in powerful and meaningful ways. But I do wish I could go back to that day during my residency when my wife miscarried. I wish I had stayed home with her.

“Doctor…She wants a chance. She wants to live!”

“Doctor…She wants a chance. She wants to live!”

How often have I heard those words? Or some version of them? The location of the conversations varies. I might be standing outside the curtain of an emergency room bay or sitting on a worn chair inside a cramped waiting room adjacent to the ICU. Possibly on the phone in the dark of my bedroom at some pre-dawn hour. Those words, coming from the mouth of a spouse, a child, or a sibling are usually imploring and pleading and occasionally defiant and demanding. But always beneath the surface, at its origin, is fear.

Critical illness, almost by definition, does not come on slowly. Occasionally it starts as a quiet whisper, allowing time for patients and families to absorb and adjust. But all too often, it presents as a roar. Infection takes hold and explodes. A vessel once open becomes completely blocked. A beating heart suddenly arrests. An aneurysm ruptures and bleeds into the brain or belly. An accident or trauma, completely unforeseen, literally crashes into a life.

The brutal and cruel physiological disruption these insults cause a patient are usually obvious to both the care team and the family. But the additional traumas to the family and friends left to make decisions in the wake of critical illnesses are more subtle.

Some choices can be relatively simple, like placing large IV’s or draining a collection of infected fluid. But what about issues of life sustaining or death preventing treatments such as ventilators for breathing, powerful infusions of medicines to make the heart beat quicker and squeeze stronger, a machine outside the body to filter and clean the blood the kidney cannot, or chest compressions and electric shocks when the heart completely stops? These decisions are literally of life and death. And as physicians look to surrogates to help guide our interventions, we often ask, “What would the patient want?”

“Doctor…She wants a chance. She would want to live!”

And there lies the dilemma.

A chance to live. It seems like a straightforward statement.

Critical care is an amazing field. With appropriate aggressive intervention we are often able to halt the progression of and stabilize dangerously low blood pressure or oxygen levels. We can cool a patient’s core body temperature to protect injury to the brain, perform emergency surgery to repair leaks in large arteries or perforations of parts of the bowel.

But what does it mean to say we want to live?

Is it just a heart that beats? Lungs filling with air while lying in bed? Skin warm and damp on hospital sheets? Liquid calories delivered to the stomach by a plastic tube? A hand held by family sitting at the bedside? Light filtering through a window, giving just a glimpse of what lies on the other side?

Or is it a heart able to soar with love or ache from loss? To breath in air while laughing or crying? Sweat dripping from a brow, stinging the eyes, while working hard in the yard on a hot and humid summer day? A stomach full, from one too many pieces of Chicago style pizza, or a brain buzzing from that first morning cup of coffee? To be able to hug or be hugged and feel the warmth of an embrace on the surface of your skin and on your spirit?

And there are an infinite number of possibilities between these two extremes. Our interventions are often good at preventing death. But not always as effective at helping us live. And what is living? To you? To me? In my thirties with young children still to raised? In my seventies with grandkids to watch grow? What is enough quality in life to lift our hearts up high, when our bodies are still tethered to the bed?

Most of us only glance at these questions. To see them obliquely. Set them aside to deal with tomorrow. And the sequence of routines in our day to day lives help us do that, beginning with the starting gun of the morning alarm. The routine drive to work where we put in our time. Then the race to a soccer practice or baseball game and dinner on the go. Help with homework, pay some bills, read some emails, off to bed and then repeat. On our way to the next job, the next raise, the next game, the next tournament. All with our distracting smart phones in hand. To photograph, to read and reply, to text and tweet.

These questions about what makes life worth living are complicated. Not only do they make us recognize our own mortality, they also force us to confront the lack of mindfulness in our day to day lives. To separate patterns and routines from what is purposeful and meaningful.

By answering these questions directly, we can create two powerful gifts. The first is for our families, loved ones and surrogates. Having discussions with them ahead of time decreases their burden, by providing a better understanding of what it is that makes life worth living. So they may be more prepared to speak for us, if and when we cannot.

The second gift is to ourselves. Not for the future, but for the here and now. As we recognize what gives us purpose and meaning in moments of mindfulness, we learn what we want to do, not what we feel obliged to do. And in doing so, we then learn what truly makes our hearts soar.