whitecoatdiaries

[whitecoatdiaries]

The Notebook

We’re seeing a patient on endocrine consults who can’t regulate his sodium following brain surgery. I’m taking care of adults this month but he’s only 20 and his Mom does most of the talking in the room. The first day I meet them we’re only a few minutes into our conversation when she pulls out a worn spiral-bound notebook that I can see from across the room is full of pages and pages of cramped, furiously-scribbled notations. I’m surprised by how viscerally I react. 

I know this notebook well. Last month I spent 6 straight weeks in the PICU. I conclude at the end of the month that there’s no place in the hospital as full of suffering as the pediatric intensive care unit. The parents are devastated: they shriek and panic and fall apart in front of me. I become adept at placing one comforting hand on a shoulder and using the other to grab the nearest chair, gently guiding the parent to seated (syncope is a common and generally avoidable occurrence here). One morning we round for hours with the steady wailing of a brand-new mother in the background. She delivered without ever attending a prenatal appointment. I find that parents’ grief is almost always flavored with anger, or guilt, or some confusing, human combination of the two.  

The parents’ suffering is unmistakable. They do not ‘give up’ on their children-- they cannot. For 6 weeks I watch the vigil one Mom keeps over her 5-year-old. Her respiratory failure is so severe that even the ventilator can’t keep up. In some cases, we offer ECMO, which uses two surgically-placed catheters to drain the blood from the body, oxygenate it using a machine, and then return it to circulation, effectively bypassing the lungs. The decision to offer ECMO is a complicated one. It is an incredibly money- and resource-intensive intervention with significant morbidity, and most critically ill patients will die on it. The prevailing logic is that it should only be offered when we anticipate patients have a ‘reversible’ injury that they will recover from in a relatively short period of time (the longer a patient remains on ECMO the more likely they are to have a stroke, or other kinds of organ failure). We don’t know the cause of this 5yo’s respiratory failure so the argument is made that it could be reversible and that ECMO should be offered. It is, and she’s on it for 6 weeks. The team is divided. She shows no signs of getting better. We order medicines and infusions that cost thousands and tens-of-thousands of dollars apiece. Statistically, no one think she will survive this. We bicker over her lab values, her treatments, her oxygen and CRRT goals. The phrase “arranging the desk chairs on the Titanic” etches itself into my skull those 6 weeks. But her mother can’t give up. She won’t. The dynamic between the family and the team becomes vaguely adversarial at times. We often feel like we are being forced to torture a child that we know is almost certainly going to die. But children are difficulty to prognosticate about, and every so often they make miraculous recoveries, and so the parents hold out hope. And we consider that there is some sliver of a chance that she recovers. And so we do as we are told. One late night on my way to the cafeteria I see the child’s mother hunched in the hallway, bolting down a hot-dog just outside the doors to our PICU (food isn’t allowed inside, and there are no bathrooms for family inside the badge-swipe-gated doors either). She looks exhausted and famished and oddly guilty when our eyes meet, mid-bite. My heart breaks. The mother suffers. The child suffers. We press on, presenting our numbers and vent settings and rattling off the mile-long list of medicines she’s on every morning, resenting the Unit and the Family but probably mostly just resenting God and this God-forsaken place. 

The parents suffer. The child suffers, in spite of but often because of us. With adults there is sometimes a moment of relief when we switch from aggressive interventions to comfort-focused care. After years of hospitalizations and side-effect-laden medicines and painful procedures, the patient rests. I get to see the family exhale. The patient opens their eyes, in a moment of lucidity, and says, softy “no more.” We listen. We are liberated from our treatment goals. 

This moment rarely comes for children. There is no exhale. There is only a white-knuckled do-everything that seems to last until the very end. 

And so I meet The Notebook. It usually sits on the bedside table, within easy reach of the parents. When we mention new medicines, changed doses, or trending lab values, the notebook comes out. My words get transcribed word-for-word often, and if there’s time I pause, spelling things and repeating phrases. Most families with chronically sick kids are well-accustomed to the frantic pace at which we conduct rounds and so their scribbles are hazy, misspelled, phonetic interpretations of the bizarre medical language we speak and only sometimes translate. 

They flip back nervously, looking for evidence that their child has been on this medicine before. They know the patience of the medical team wears thin and so the page-turning becomes frantic. Somewhere in their notebook they are sure they have an answer to whatever today’s issue is: uncontrolled secretions, vomiting with the tube feeds, flushing skin after an antibiotic. It’s hard to watch.

The parents of chronically-ill children are often the most complete medical records we have. They know this and so police our treatments carefully, quick to interject if their child has had a problem with our proposed treatments. As the medical team, we feel complicated: we rely on these parents and their exhaustive lists. They coordinate the 15 specialists, fill the meds, know how their child best tolerates their feeds, know which meds best control secretions. But like all people, they are prone to all kinds of bias. My criteria for an ‘allergic reaction’ is strictly defined by a histamine-mediated response causing a certain set of symptoms. My patients’ parents criteria often feels like anything that correlates to a bad day, a weird look on their face, or an unexplained episodes of vomiting. They collect all of the information meticulously, scribbling in their notebooks, but it’s not always clear which information is important. 

On bad, cynical days, I often think that we create monsters in the parents of chronically-ill children. They have learned that making demands, throwing tantrums, and raising their voice tends to bludgeon the team into doing what they what: prescribing antibiotics we feel are unnecessarily, keeping patients in the hospital who are ready for discharge, avoiding treatments that could be beneficial. If a patient’s safety is truly being compromised usually someone puts their foot down, but we make compromises all the time that feel ridiculous. At one rapid response, we can’t get a 7-yo neurologically devastated child’s oxygen saturation up out of the mid-80s. The primary and intensivist team quickly runs through the utility of different interventions in a medically urgent scenario-- if her oxygen saturation continues to fall, she could die in minutes. Upset that she’s not being listened to, the Mom piercingly dog-whistles at us to give us a piece of information that is irrelevant and unhelpful. We listen, calmly, placate her, and continue on with our discussion. 

Afterwards, on returning to the PICU, I get angry. I do not intend to be whistled at like a dog in my adult life: not by men, not by strangers, not by my patients. 6 weeks of being treated poorly by parents starts to wear you thin. Their frustration and poor behavior is explainable, and each time I reach inside my reservoir of patience (filled on the occasional day off and unfortunately hoarded for my patients at the expense of those I love) and smile calmly, waiting for the tirade to end, but it gets old. 

So when my patient’s mother pulls out the notebook, I both flinch and tear up. I can read her anxiety from across the door. I know intimately this impulse to record as an attempt to exercise control over the situation, control which I know will not be afforded to her this hospital stay. Her child’s short-term memory has not been the same since the surgery and he looks at her, worried, when we ask him basic questions. She rushes to answer them, trying to soothe him, promising over and over that it’s just temporary, that he’s still recovering. I don’t know that it is. I don’t know that he will. I know that there will be many, many questions that come from this notebook that we will patiently answer, and that our answers won’t change a thing. 

#PICU #Dark Nights of the Soul #Palliative Care

[whitecoatdiaries]

And then slowly, suddenly: life becomes what it is. 

Most weeks, I call a friend or two. I show up to my job and do my best. Some weeks, I see my parents, run a few miles, cook a meal or two. My novels go mainly unread. My weekends last one day. I’m not the friend I want to be, but I am still a friend. I fall in love in a startling, singular kind of way, which makes me daydream about quitting my job and riding off into the sunset but also gives me some strange abstract vision to orient myself towards, a reason to work when I feel disconnected from what brought me here. 

The world has lost some color. It’s not just the volume, and it’s not just the magnitude of what we see. I don’t know what it is. I don’t write much any more because when I do I keep getting stuck on trying to explain what it is of myself that I’ve lost that I miss so much. 

I know that all things pass. I know that the world may or may not burn. I think I should stop thinking so big, that there’s no sense in trying to understand why people suffer or why our healthcare system is so broken or why the rich seem so intent on grinding anyone they can get leverage over into the dirt. It is probably time to try and fit myself into just one day. There is room enough for me there. 

[whitecoatdiaries]

I hate being the senior resident. 

Twelve months of residency passes and on the thirteenth I walk in to find all of a sudden I’m supposed to be running the team. I’m responsible for wrangling the attending, overseeing the interns, teaching the students, and essentially protecting my patients from the rest of my team. 

Last month out in this large community hospital I did nights, which I loved. I covered 40 patients and admitted 5 every night, sat in an empty workroom, had no one to ask questions to or look for guidance. But my thoughts were clear and organized, I budgeted my time carefully, made thorough plans, did the right thing. I’m always relieved at the end of the day when the rest of my team is gone and it’s just me, answering pages and calling back nurses. Time and quiet to think. 

Now I have an intern who isn’t stupid but doesn’t give a shit about our patients. He keeps trying to discharge the 96-year-old who’s just had a stroke and can no longer feed or bathe herself as she was doing 1 week ago. Her daughters promised their father that they’d never put her in a facility and they’re scrambling desperately to arrange for 24-hour-care for her. She’s medically ‘ready’ for discharge 24 hours after admission: our tests are done, we’ve stopped any medicines that could be contributing, optimized her blood pressure, have had her seen by speech and physical therapy. But the daughters with their red-rimmed eyes carry envelopes with contact numbers scribbled all over them, try desperately to figure out how to get her home. My intern says “she’s ready now. We told them one more night last night.” I stammer, struggling to explain why we’re not sending her home tonight. “She’s dying,” I say finally, and he shrugs, irritated he’ll have to write another progress note on her tomorrow. 

My med students are more attentive, but they say things awkwardly sometimes, and I flinch (hopefully just inwardly) when I hear how things must sound to families. On my last rotation I would jump in and just run rounds, unable to witness painful family interactions, unwilling to try and placate a family angered by our tactless and transparent plan. But that’s no way to be a senior resident, no way to teach the students and interns, so I bite my tongue over and over again. 

I wake up with a sore in my mouth from chewing on my lip. My shoulders ache from being hiked up around my ears. After working two weeks straight I come home and sob into I.’s shirt like a child. I want to quit my job. We give so many new cancer diagnoses. I take care of so many alcoholics who are already dying of their disease. I live in terror that I miss some error made by my intern, some negligence. My commute to work is 40 minutes each way without traffic, often something like an hour and a half otherwise. Sometimes I get home and leave again for work within 8 hours. I forget that I have afternoon clinic two times in two weeks and on my frantic drive over am sure that they’ll fire me. 

I don’t know that I have what it takes to be a doctor. I’m not type A, not organized, don’t get any pleasure from checking off my to-do list. I hate checking my emails, fuck meetings, fuck academic hierarchies, fuck doing things to put them on a resume. I like to think about the symptoms and puzzle my way to a diagnosis, start to master the art of management, the setting of expectations, the way to prepare yourself for a neat and graceful discharge. How to bring families around to a slow and gentle understanding. How to leave room for their interpretation while opening communicating my own. I love to lean in close to the emaciated drunk who smells like a GI bleed and smile until he smiles back, to hold the hands of the demented, to talk the delirious back into bed without IM injections or restraints, to distract the toddler while I look into her ears, to tease the old man waiting for hospice. 

On nights I had one hour where I got two admissions, had a patient with active rectal bleeding, another with chest pain and EKG changes, and another old delirious woman who started threatening to fight the aides. I quickly eyeball the new patients and their charts, make sure they’ve gotten the fluids and antibiotics they need, put in the orders to get them out of the ED. I review the repeat EKG, order a type and screen, consult VIR for embolization, make a note to follow up the H&H. At that moment a behavioral response is called and so I excuse myself to find the patient I admitted a few nights ago to be half-out of her room, accusing the nurses of conspiring against her, her body language all fear and anger, she yells, demanding to go home. The situation escalates in front of me, hospital police ready outside the door, the largest aide with his chest puffed out. I won’t abide by anyone hurting my staff and won’t hesitate to order sedatives and restraints if they’re needed, but I think this woman will recognize me. I enter and crouch down, ask about the stuffed animal in her hand, about her granddaughter. She deflates a little. She is angry, telling me she has to leave. We sit on her bed together and I ask her about her garden when she starts to get upset, I compliment her painted pink nails. After about 30 minutes of my best low, soft voice she relaxes. We talk her into crawling into bed and I tuck her in. We turn the lights out and leave the TV playing softly in the background. I creep out and run back to the ED for the next admission. 

I say that I want to quit my job but I. knows that I don’t. I’m not sure how I’ll do this for the next 3 years. I just want to be left alone with my patients and their families. 

#internal medicine #Dark Nights of the Soul #can i graduate

[whitecoatdiaries]

On an elective month, I spend a few days in geriatric clinic. 

Our first patient of the day is wearing pressed gingham, sits up, pairs her small feet in neat shoes and striped socks on the ground in front of her, smiles warily at me. I know already from the chart she has advanced dementia, and lately they’ve been trying her on an assortment of different SSRIs and antipsychotics to get her to keep from wandering out of the house and flying into a rage at her husband.

She’s in her early 90s and so is he. They live together in a small home. This morning she got out the step ladder to try and hang some photos that were important to her. His shoulders are slumped underneath his collared shirt. 

She is unable to answer any of our questions, really. Can’t remember this morning, or yesterday, or whether she wears glasses, or if she takes medicines. She smiles and gives half-answers. Fear and irritation pass over her face frequently but only for a moment. She puts on a good front for us. 

Her blood pressure is high, so I retake it in the room, with her sitting and standing. I take her arm and brace it against mine. While I watch the pressure gauge, I feel her fingers switch, then trace the inside of my upper arm. Her dry soft hand moves the way you’d absently stroke a cat behind the ears. For the rest of the interview I sit on the exam table next to hear and smile when I catch her eye, my best disarming-smile, the one I use on toddlers and psychotic patients. She smiles back, winking. Later on she leans towards me extending a finger, lightly traces my left eyebrow, whispers “that’s you.” We smile many times like we’re in on a secret nobody knows about. I can see her consciousness surface and recede, observe what it leaves in its wake. 

I look at the two of them and think about the weight of love, and how little we can anticipate about what it brings us. Who were they 50 years ago, or 20? How many people have they been since meeting? How do you choose a lover to move beside you despite everything that comes? How is it possible that these two will be inevitably separated by death? Will they? 

#geriatrics #today in clinic #Valley of death

[whitecoatdiaries]

switch day

Another busy day: admission after admission, a behavioral response, desatting 3-year-old transferred from the PICU this morning, 10 notes to write, update the hospital courses, review the labs ordered for the morning, sign out to the night team, call the new interns and walk them through each patient, and then out in the sunlight where you call one of your oldest friends on the drive home, up the apartment stairs where I. is watering your plants and then, just-like-that, intern year is over! 

No part of it has been easy but nothing was impossible. In a year I become fluent in a language I’ve studied for years, things become because muscle-memory and second nature. In a year I grieve and give-up, sob uncontrollably on a bench outside of a baseball game and then in my friend’s arms, curse all manner of societal forces and case managers, let things show on my face that I shouldn’t. I am ground down, learned-helpless, exhausted, wounded. 

I lose my ability to put a positive spin on things at the end of the sentence. Sometimes I say “today sucked,” and have nothing to follow it with, no optimism for tomorrow, no silver lining. 

But it’s still summer, and last week we spread out a blanket on the grass and the band played and the children ran around on their healthy limbs, not scared of me, parents blissfully only half-aware of their movements. I soak in every minute that I’m not in the hospital. I meet someone that my heart jumps toward, dizzyingly. I’m astounded to realize that there are the old movements of love and vulnerability that I haven’t forgotten. 

And tonight I start on nights on one of the busiest services. I’ve been afraid and anxious for months. I wasn’t ready for intern year and I’m not ready for this, either, but I do need a change. 

#switch day #end of an era #goodbye intern year

[whitecoatdiaries]

This month I tell 2 families that their toddlers (once walking and talking, now limply smiling at me from the bed) will die slowly of progressive neurological disease. I help chemically and physically restrain a 9-year-old who is trying to rip out his IV and kick his nurses. Later he calms down and without warning touches my butt and says “you’re cute.” I admit several medically complicated children who aren’t growing because their families don’t have the resources to feed them. I take care of a 9-year-old boy who tried to kill himself after being detained at the border for months (he fled his home the day his cousins were shot in front of him). The boy won’t meet our eyes when he tells us he doesn’t want to die. The mother of the newborn baby in my care goes into active opiate withdrawal in front of me, sobbing. She was abused for the first 15 years of her life and can’t stop using drugs. Her boyfriend is her transportation but he hits her. A child is admitted for bruises and fractures and in the room, her father grabs her with a finger and thumb on either cheek, exactly where her bruises are. The news is full of children being separated from their families. Sometimes I think I hear the howling of all the suffering souls on the earth. The noise drowns out everything. There’s nothing beautiful to write about it, nothing to say. No way to spin it, to make it comforting, to learn a lesson. I should pray but I’m too angry and sad. 

There’s no justice in this awful, fucked-up world. 

#Dark Nights of the Soul

[whitecoatdiaries]

Months go by and I struggle to speak. 

I can’t write about intern year. I can’t describe the hardest thing about it: how it breaks over you, again and again, until you can’t remember anything else. As a student I savored my interactions with people, noticed the smallest details of their clothing and speech, saw subtleties of human emotion everywhere I looked. There is no room any more for small bites, to consider a moment in isolation. Now I am thrown against an impossible wall of human suffering, do a desperate defensive dance, hoping I can guess what my attending wants, hoping my patient’s parents will accept our plan, hoping my pager doesn’t beep again and again and again. 

It’s hard to feel like anything matters. In the morning I unwrap the infants and stroke their soft skulls. Their hearts beat fast like a rabbit’s, chests heaving. I swaddle them deftly and hold them in my arms, humming. Outside the sun hasn’t yet risen. 

It isn’t fair when your child is sick so parents get mad at whoever’s closest. I get even better at being yelled at. I learn to give people nothing to push against, apologize specifically and creatively, sit in an accepting quiet after the apology, leaving the silence open for another raised voice. After a day of this sometimes I feel brittle, like I can’t absorb one more emotion, not even love. 

#intern year

[whitecoatdiaries]

I fly through the corridors of the giant community hospital where I rotate this month. According to the step counter on my phone I walk at least a couple miles every day: from the workroom it’s down 3 flights to the ED, 1, 2, 3 flights up to the medicine floors. I learn the back corridors of the hospital, the shortcuts, the quickest way to the cafeteria. 

My white coat is grungy around the collar and my hands always smell like coffee. My pager buzzes and buzzes. I practice multi-tasking, doing 5 interrupted things at once, surrounding each other like nestling dolls. I start my notes, get paged to discharge a patient, halfway through putting the orders in the withdrawing patient on 6 demands narcotics, on the stairwell up we get our third admission of the day, so it’s sit down in the room with the patient, order the lidocaine patch, finish the discharge orders on the computer in the ED, read the chart, put in the admission order, meet the patient, set aside the rush of the day to listen to the story, to think through the physical exam, then there’s another note to finish, and another, and the pager buzzes, and someone else on the floor has chest pain, the EKG is ordered, follow-up on the 2 PM labs, another admission, another discharge, over and over until 8 pm, when we look over the orders one more time, update the hand-offs, signout to the night team, and then my favorite part of the day, my senior and I walking out to the parking deck, our shoulder blades finally gliding down our backs, the cool area around us, laughing and familiar, that tired wound-down feeling when the work is done. 

#internal medicine

[whitecoatdiaries]

6 weeks of NICU. I grow up with the babies. There are two twins who were born 10 weeks early just before I came on service. Their arms and legs are spindly and sticky, brown fat absent, skin not yet epithelialized. They have the fine hair of anorexics on their shoulders and faces, big bellies that protrude with each breath. We put tiny CPAP masks on them to inflate their immature lungs, spike their blood with caffeine to remind the premature brain to breathe. Each morning I sneak a tiny stethoscope over soft un-ossified ribs. Their limbs splay wildly, infant reflexes on overdrive in an unmyelinated brain, their mewling like new kittens, almost impossible to hear over the bubbling CPAP and the humming radiant warmers and the beeping of the continuous monitors. 

On rounds I report their weights, climbing steadily, 20 or 30 grams each day. At birth they weren’t even a kilo, and by the time I leave they’ve doubled their weight. Every week or two I get a day off, and am surprised to find that after only 24 hours away they seem to have grown, their cheeks chubbier, arms and legs plumping up. The day before I rotate off service C. is tried off of her CPAP and ‘flies,’ as we say, lays unbothered in her crib (she’s long outgrown the isolette), breathing just fine on her own. 

We won’t know for years whether or not their development will be affected. One of the twins has a tiny brain bleed in his cerebellum, which may make it impossible for him to walk or stand up straight. Equally possible is that he’ll grow up without any deviation from typical development at all, that he’ll stand and walk and run not much later than anyone else. This uncertainly means that I never quite feel like I’ve got my legs under me. 

Between weeks 30 and 32 we watch them neurotically. This is the age that premature babies are most at risk for necrotizing fasciitis, a devastating infection that kills a third of babies outright and leaves another third with major complications. The infection is notorious for coming on quickly, out of the blue. Babies look fine one day and the next are septic, their blood swimming with bacteria, intestines necrosing, turning a nausea-inducing black hue when opened operatively. The signals are subtle: an elevated heart rate, a slowly climbing oxygen requirement, new apneic episodes, all of which can be part of a normal premie day. 

I eye all the babies with suspicion on my early morning pre-rounding. On my walk into the unit first thing in the morning I glance in the pods, afraid to see the ventilator towering over my patients’ isolettes. 

We go to all high-risk deliveries, often 5 or 6 a day, if not more. They call us just before the baby arrives, and we only have a minute or two to turn on the warmer bed, to prep the facemask and oxygen, to dial up the vacuum suction off the wall. If the baby’s heart rate tracing makes us nervous or if they’re less then 35 weeks we pull our intubation supplies, guessing at the size ET tube we’ll need if the child doesn’t breathe on their own. If the baby comes out crying we all exhale, finally breathing ourselves, but it’s not always that way. 

I see babies come out blue and floppy. Often they are just stunned and spring awake when dried off and suctioned, or perk up after a little oxygen. Delivery seems to be a violent process for everyone, baby included, and I’m shocked all over again at the brutality of life. And sometimes the babies come out looking bad and never revive, their hearts un-startable, the lungs so small and crumpled that we can’t inflate them, or in what we call ‘interrupted fetal demise,’ which is when they die in the womb and our monitors pick up their dwindling heart rate and we rush their mothers to the OR and the OBs do a STAT c-section and we tear them out of the womb to see if the damage is reversible, but it feels like it never is. I’ve witnessed what feels like an unimaginable amount of horror this year but learn that there is no hell fresher than a dead infant, an ancient part of my brain recoiling in anger and fear and shame at the sight. 

I’ve always imagined myself to be not far from having children, playfully resting a hand on my stomach to scare boyfriends, well-acquainted with the crystalline pull of longing that comes with an infant in my arms. These last few months I still scoop up every child, laughing, but along with delight I am gripped with fear. I already live with intrusive thoughts, nightmares about what could befall the people that I love, and having a child seems like the ultimate opening of oneself to loss. My waking hours are filled with the worst-case scenarios. It feels like madness to make my heart even more vulnerable than it already is. 

I have a few days off for New Years. We drive north to see my cousin-brother’s 7-month-old. His eyes are large and liquid, his skin creamy and pink. He babbles and looks around, eyes lingering on our faces. His world is soft and expansive, full of pureed fruit and bright cotton prints. He laughs and coos continually. He looks at me and smiles. I have no choice. I smile back. 

#tyrant babies #nicu #Dark Nights of the Soul

[whitecoatdiaries]

The days shorten and the clocks change, mechanized, without my knowing. I creep to and from work in the dark. A week passes without natural light; on my day off I squint at the glare. I start to feel the edges of myself subsumed: it’s not the piecemeal swallowing that I thought medicine would take, a bite from my spontaneous streak, another out of anti-authoritarian tendencies. Instead I slink home unable to think a single thought of my own, find that my dreams drag me back into the hospital. 

Just a few weeks ago I was on vacation,  begging my friends to take me to art museums and parks, to tell me about their lives taking and teaching classes, as architects and grad students and journalists and editors. I pack a tote bag with 3 all-black outfits and my favorite pair of boots and crash on couches and in my friends’ beds. I am unhurried and savor every moment. I revisit all the old corners of my mind. I remember all the things I’ve forgotten to miss: intimacy, slow and sleepy mornings, staying up late because the company is good. My cousin teaches me her skin regimen: scrub this scrub, smooth this potion, layer this salve, 2 drops of ice-cold tincture from the fridge, a layer of cream and then a rosewater mist. It is elaborate and purposeless, an aesthetic ritual that could not be more different than the way I roll out of bed in the dark, drag on scrubs and sneakers, try not to catch my tired face in the mirror on the way out of the door. 

I complain and grow tired of it. At times the future seems like a vast, unscalable wall. I reorient my sights: on the tiny child in the incubator, belly heaving up and down, arms flying up in the startle reflex. I know, despite all my moaning, that this quiet moment is why I’m here, what I was made for. 

[whitecoatdiaries]

I switch to peds. Instead of critically ill adults with multi-organ failure in the ICU I see healthy children in clinic, who come to me for their runny noses and ringworm and ear infections. My clinic serves mostly poor, immigrant, and refugee populations. One drive home I feel my heart uncurling, remember that these families are the ones that I came to medicine for. Our clinic is generously scheduled, with lots of residents and patients booked only every half hour or so. Without the demands of productivity and efficiency I feel like a med student again, making small talk and lingering, waiting until every “I know this is probably nothing, but...” is addressed, until I see brows unknit, until the toddlers aren’t unnerved by the sight of me. I ask parents to leave for all patients over 12 or 13 and ask about sex and menses and alcohol and drugs. After one visit a 4-year-old boy with a stomachache rushes up to me on the way out and hugs my legs, then dashes off. The moment is sweet and stays with me. 

I also cross-cover in the hospital on a few nights and weekends. One night at 2am my pager beeps. There’s a pediatric code in the ED, a 4mo child presumed asphyxiated, whose father has just been taken into custody. We code the tiny body for an hour and a half and I suppress the urge to vomit. His mother is present and gets violent in the hall outside of the trauma bay, is restrained several times by the cops that came with her so we are afraid to let her in the trauma bay, but she calms down and we bring her back as the code winds down, when it becomes obvious that no amount of chest compressions or rescue breaths or doses of epi are going to bring this baby back. So she is there when the PICU doc calls calls time of death, she pleads with a god who feels impossibly removed and reaches for her child, screaming and sobbing apologies. It isn’t clear whether the police will be taking her into custody as well. The whole room is so full of pain and senseless suffering that I can’t move. Afterwards the unit is quiet and so I go lie down in the call room, but I can’t think about anything but the small body on the stretcher, how long it takes to pass the tube through his vocal cords, the tiny wet diaper a nurse changes furiously before handing him to his mother. 

It’s the days off that are hard. I understand why doctors become addicts, the appeal of erasing or escaping cognition. I sink myself into novels, follow complicated recipes for baked goods I’m not hungry for. There are many things built into our program to address burnout, time set aside for conversation and commiseration. I’m thankful for this fellowship, to be heard, but am not sure what mental health going I’m supposed to be aiming towards. How can we see what we do and remain unshaken? How could I ask for an unbroken heart? 

This month I’m in the newborn nursery. I see healthy baby after healthy baby, examine them carefully for signs of rare congenital illness or complications of birth, and finding them well, rewrap them in their onesies and caps, swaddle them, coo their brand-new names, congratulate their parents, bless them with my stethoscope and penlight, and move on to the next room. In the bright world I celebrate alongside their parents, imagine futures full of birthday parties and school plays. But there is a shadow world that I can’t escape that reminds me all of the things that go wrong, that reminds me that some of these babies will be neglected, abused, will grow up hungry, will be paralyzed in car accidents, will be raped as teenagers, will become addicts, will try killing themselves, will suffer needlessly, will be steeped in loneliness, will wish they were never born. There is a darkness to human life that I’ve never been afraid of but now seems to seep up through the ground somedays, inescapable, staining all my shoes. 

#Dark Nights of the Soul #Pediatrics

[whitecoatdiaries]

In the same breath, I love my work as much as I’ve ever loved anything. 

I love being the resident. How, at the end of the day, everyone else goes home. Case managers and attendings and pharmacists and even nurses, at the end of their shift. But I don’t leave until the work gets done. I beg pharmacies and insurance companies, schedule outpatient appointments, arrange for transportation, talk down stubborn family members, write and rewrite prescriptions, as if by sheer force of will I can heal and protect my patients. I reason and plead and say it matter-of-fact. I am here, at the end of the day, to make sure that what needs to get done is done, to do the dirty work, to explain to an angry family member for the 10th time why the procedure has been delayed, to call with updates, to take a deep breath in and say that even though we did everything we could to avoid it, it’s time for the breathing tube. 

I’m tired. It’s hard to write because my thoughts come sluggish and slow. I forget the grace of language, its liquidity, how to find a feeling and encircle it gently without pinning it down. I don’t know the day of the week anymore, whether its night or day, early morning or late evening. I drift along, all brain and no body, falling into a dead dog sleep when my work is done. 

I fell in love with the idea of being a doctor the summer after college, when I was so full of despair that it was intoxicating to lose myself in someone else’s life. In the ensuing years I’ve created a life for myself that I have no desire to escape from, so this getting-lost feels good but in a different way than it did before. A. tells me to be careful, that the MICU is addicting. There’s nothing to flee, my life overflowing with love, but there’s something about dedicating one’s waking hours to a singular purpose that still quenches a complicated thirst, a long tongue on the salt-lick. 

I wonder if I belong on the face of this aching earth. My heart stays broke. But none of this has ever stopped me before and I’ll be damned if I’m not up early tomorrow, doing my stretches and saying my small and fruitless prayers and putting on my scrubs, swiping my badge and striding into the unit, my sleeves rolled up, ready to do whatever it is that needs to be done. 

#micu nights #post-call

[whitecoatdiaries]

After a week of nights I scramble out into the sunlight. Walking down the sidewalk to the parking deck I’m not sure I recognize the world. I try and remember how many people I’ve pronounced, how many lines I’ve stitched in, how many families I’ve attempted to console. Out on the sidewalk, I worry that somehow people can smell the death on me. I keep seeing blood underneath my fingernails even though it’s not there. I shower in the hottest water possible. My face seems misshapen in the mirror, dark circles settling in under my eyes. There’s no space for me in my head anymore. Just a litany of lab values, chest xrays, blood gases, the culture results. All the dead faces I’ve seen. 

The world feels full of ghosts that crowd out the living. 

#Dark Nights of the Soul #MICU

[whitecoatdiaries]

Work gets hard. I’m put in the position where I truly have to choose: between sleep and staying connected with friends, between exercise and feeding myself and exhaling at the end of a long day. 

It’s hard not to complain, to not get overwhelmed. To not feel crushed by what I see every day. I become aware, now more than ever, of the enormity of medicine, how much there is to know. I feel hopeless that I’ll ever know it. I love this job but worry that I’ll never be good at it. 

The word that I keep returning too, more than anything, is weight. The weight of every day, every piece of bad news I deliver, of each patient of mine that dies. The weight of responsibility. Of second-guessing. Of knowing that someone’s death is coming long before they have accepted it. Of the moment just before you tell a family that they will lose their loved one. What happens to a big heart that breaks, over and over? 

I feel crushed at the end of most days. I try and be like a bug or beetle, flattening and then miraculously scurrying away. I try and surrender my limbs like a starfish or skink, defenseless. I will grow them back on my day off, I say, and then I will let them go again. 

#Dark Nights of the Soul #MICU

[whitecoatdiaries]

This month it’s the solid tumor service. It’s a hard one, because most solid cancers that go well are managed entirely as outpatients. To get admitted for your cancer usually means that things aren’t going well, that your bowel or ureters or esophagus are obstructed by tumor, that your kidney’s are damaged, that your blood, thickened by cancer, clots off in your legs and lungs. It usually means that your death hovers somewhat more ominously on the horizon, whether we admit to it or not. 

Every room I walk into stinks of fear. I go skating out over its surface, asking my questions: what would you want if your heart stopped? what do you know about your disease? I can’t help but linger at the bedside of the terrified, can’t resist my desire to be at least a temporary balm. It wouldn’t be so tempting if it wasn’t in my sights, if I couldn’t see shoulders unknit, feel a body loosen underneath my hand on a shoulder. 

Out on the ice I feel like I could do this work forever. That elusive click of love. Sliding into place. Heart finding its purpose. But other days I know that this ice won’t hold my weight, fear that if I stay in these rooms too long the floor will break under me, that I’ll be swallowed up. 

I have a patient who raises his voice at me every day, just shy of yelling. He acts as if he’s healthy, that it’s his cruel doctors who keep him in the hospital, not his cancer. I reach into the depths of my patience and respond calmly and gently to his accusations. Every day he threatens to leave and then waits, expectantly, for me to beg him to stay.

A. says there’s a cloud in every room in the ICU. You can slice through it but it’s back immediately. It’s so thick you can’t see. It comes at you in waves. I know I can’t run from it. I know I came here for the fog, to breathe it in and not choke, to soak it up and not sink. 

It feels impossible. I want to be porous to it and yet still protected. I want to give myself away and still have something left at the end of the day. I read this passage, again and again, 

“There are two elements at play in worship: the aiming and the aimed at. The aiming itself is hungry but unstable. The aimed at is nameable but evasive. Invested by your aiming with the hope of satisfaction, with the hope of escape and transcendence, the aimed at becomes an idol. ... But, again, your idol can’t meet this expectation. No idol can. The hope that it could is a mirage. And when that idol fails—when it disappoints your aiming and shows itself without transcendence: immanent, disheveled, disenchanted—there will be a moment, perhaps quite brief, when all that remains of worship is a pang of raw aiming. This moment when it looks like your worship has failed is the religious moment. This is the revelation. This moment allows the aiming itself to appear. And it is in the aiming itself, not in the object aimed at, that God is most clearly manifest. This is the epiphany. ... The religious moment is not the moment when—whoosh!—the magic happens and the world seems full of a pantheon of idols able to satisfy. It’s the moment when—fshzzzt—the spell breaks, the credits roll, the lights come back up, and the world must be cared for, again, as just whatever it is.” (Miller, The Gospel According to DFW)

I find this feeling everywhere. My favorite novels work relentlessly at putting into words the moments that escape language, coming close but always failing. How we love each other flagrantly, knowing we’ll fail at that, too. And in my work, especially: we drag our bodies out of bed, work all night, eat crackers for dinner, feel gray hair sprout from our temples, dance intimately with death, one step forward two steps back, trying and aiming, failing, trying and aiming, sliding out over the ice, getting lost in the fog, emerging, heading straight back in. 

#oncology #pity party #saying this is not my grave and climbing out of it #DFW #aiming #God by any name

[whitecoatdiaries]

Already one rotation behind me. I wake up on my first free day off and walk around my apartment like it’s another planet. 

Every night I dream I’m crashing my car. As a teen, this was my anxiety-dream: stuck behind the wheel of a car I couldn’t drive, slowly accelerating down hills and onto highways, my feet never finding the brake. The metaphor was a little on-the-nose even for me then. Now I’m stuck in traffic, distracted, when I glance up just moments before collision. In the morning I’m left most with that feeling right before impact: the involuntary flinch and sinking gut, self-recrimination, regret. 

I met Mr S. when I admit him out of the CICU. He’s got a failing heart that’s mostly ballooned-out scar, weakly pumping, the tissue unable to properly conduct the electrical currents that trigger the lub-dub of a regularly beating heart. He keeps getting aberrant currents, eddies around old scars, that throw him into VTach, a fast, unstable rhythm that usually devolves into no rhythm at all. He has a implanted defibrillator that shocks him out of these rhythms, and comes to our hospital because he’s been shocked 10 times in the last week already. 

I know he’s sick when I see him. He’s pale, his body a mix of old and new bruises from all the blood thinners he’s taking. He looks much older than his age. But he’s sitting up eating breakfast when I see him, making jokes, smiling back at me. On cardiology, I learn each patient’s volume exam. I find fluid hiding in the legs, the lungs, filling up the neck veins that pour into a backed-up right heart. His legs are always swollen, lungs always wet, neck veins bulging even when he’s sitting up. But I examine him every morning, learn dry-for-him, because too little fluid and we start starving his kidneys. I learn his volume exam, his pallor, his bruises, his non-healing wounds. I learn where his ancestors are from, that he is estranged from everyone except his cleaning lady. I learn that he has not always been a good man. Somedays when I lean over him, resting my stethoscope over his ribs to hear that faintly beating heart, he gives me a long wounded look and I can’t tell if he’s about to say something inappropriate or burst into tears.

I have a day off and when I read his chart that night I can tell that he’s getting sicker. In the morning when I see him he’s complaining of being cold, wrapped up in a blanket. I ask him if he’s feeling bad, weak, but he says he just drank something cold with breakfast and is just waiting to warm up. I’m scared when I see him, a feeling I can’t objectively describe in my physical exam, except that even though he’s always cool, always fluid-overloaded, he’s wet and cold. He’s cranky, won’t smile at me, but his blood pressures are okay, we’re still pacing him out of VTach, everyone says he looks better than yesterday. I check a lactate and it’s up. We decided that if the next lactate is higher he’ll go back to the unit. 

There’s not much left for him. Ablations haven’t worked, he’s maxed out on antiarrhythmics, we’re waiting on experts to tell us what, if anything, to do next. I’m in the workroom when his nurse finds me and says: I’m having trouble getting an accurate blood pressure on him? I mean, he’s always so swollen I can’t get it with the cuff, but now even the automatic isn’t working right. 

I’m following her to his room when I heard “ADULT CODE BLUE, ADULT CODE BLUE” and we’re flying to his room even before they say the room number. There he is, eyes open, not breathing, dead in his hospital bed. Days ago he’d assured me: no chest compressions. No CPR. So there’s nothing for me to do except stand stricken in the corner, move to listen to his heart, his lungs, to check his legs for fluid, automatically, to listen to the time we declare him dead, to go get the death certificate that I’ve already learned to fill out. It’s my job now to call his family, to say “your brother died this morning,” to listen mutely to sobs, to feel utterly ineffectual, unprepared. I don’t know how to comfort someone over the phone. 

It’s strange to look at someone and feel real fear, to hover around their room all morning, to feel nauseous in an unfamiliar way, and then to be right. To smell death coming and find it’s footprints. When I’m trying to fall asleep or when I’m in mid-conversation with a friend or when I’m driving home I remember something else, some other figment of a living body now dead. 

The next day I get up and go to work, smudging concealer under my eyes, blush on my cheeks to fake my own color. I walk past his room, another patient moved in within hours. It blows by me. 

#Valley of death #battles lost #intern year

[whitecoatdiaries]

I have 2.5 months off between my last 4th year rotation and when intern year starts.  

I fill it with joy. I spend two weeks on a beach in Mexico, watching the sun set and re-reading my favorite book. I rock my cousin’s two-week-old infant to sleep, explore all the local hiking trails I can find, go on a bunch of dates, do yoga outside, look for god, make mojitos for my parents, check out books from the library, buy all new furniture for my apartment, water my ever-growing garden, see my friends, over and over, and delight in the ordinary things we do together: not -catching up- or -grabbing a quick drink- but letting the day roll out together in front of us, running errands and driving to the beach singing at the top of our lungs and cooking dinner and having meandering, generous conversations. Time becomes my favorite luxury. 

I say goodbye to friends, too, who are moving away. For the first time I’m thankful for the incessant chatter of the icons on my phone, how easy it is to send that text. I hug everyone, say i love you, exhale. 

And then intern year starts. I’m terrified the weeks leading up to it, the same old fears in a different costume. I’m afraid of becoming someone else, exhausted and crumple-faced. Of not Measuring Up. Of having forgotten everything. Of giving up so much of myself to remembering everything that I become the compulsive, anal person I know I can’t love. That this trial of fire will singe me irrevocably. That medicine isn’t what I thought it could be. That This is the End of My Beach-Days, the end of being carefree, of allowing others to grip their lives loosely. That my own grip will tighten on myself and those around me, death-grip. That I will believe again that there is more suffering in the world than love. 

On day 1, I clip my pager onto my scrubs. I’m overwhelmed by all of the patients I have on my list, feel adrift in their labs and vitals and procedures and blood gases and vent settings and meds and venous sats and central line readouts and advance directives. I click through patient after patient on my list, scribbling furiously, trying desperately to build enough of an understand to present on rounds. And then I fly through my patients’ rooms, introducing myself, beaming, my heart in my throat. They are sick but they still smile back. My voice gets the slight southern lilt that it always does when I’m in the hospital. 

One patient., Mr. B, has been in the hospital for over two months. He knows everyone. I’ve been told, many times, “just don’t break him.” During my routine exam, I press on his belly, and he yelps, loudly. My hands fly back and my jaw drops, but before I can even start theorizing about his abdominal pain, he lets out a big belly laugh and says, “Just had to mess with you. I gotta keep things interesting, you know.” I laugh with him, a deep laugh of relief and an even deeper joy, grateful for the reminder than the human spirit is just as resilient as I remember it, that hospital rooms are still bedrooms in their own way, that if this man, who truly never knows what the day will bring, can give me the widest grin at 6am and welcome me to the Cardiac Intensive Care Unit, that my heart’s going to be just fine, too. 

#CICU #mend those broken hearts #intern year #liminal times