week 2

this last week has been a lot of waiting. a lot of the initial fear and nerves are, well, not gone, but in the background. taking it day by day. ear to the news - getting called in, might be 24 hrs notice.
turning inward. small stuff. petty stuff. on one hand it's been a relief getting this gift of time to finish things in the office - reviewing charts, ie. but on the other hand, just a growing sense of dread for what will happen once people start coming to the office again.

week 1

things were relatively quiet in terms of the outpt world. a lot of time spent getting oriented to working in the urgent care/green zone setting, inpatient setting. nothing remarkable happened, except for a day where there was drama with one of the MAs and she threatened to quit.

the isolation is not helping much. i appreciate my girlfriends so much, letting me express my views and fears and doubts about what is going on. with my dance acquaintances it's pretty apparent that i don't fit in when physical presence is not required. i am making a choice to try to continue to insert myself in this group of people but ultimately they have no idea what i do, nor do they really care.

even though we are given this precious gift of time to prepare, instead of being very motivated and productive i find myself drawing more and more inward. i think i've already established my fear is not so much for myself. i think i am more afraid of causing more harm than good. i also fear for what the rest of my life is going to look like. if it is short, how will i spend this time? instead of plunging into work and work and work - should i be taking a different approach? instead of trying desperately to leave a footprint in others lives, should i just focus on "being" and becoming individually satiated?

I was trying to handwrite a will the other day. it is difficult.

the crown

in the last few weeks, i have thought nightly, in between burying my conscious brain in the sewage of youtube and social media, about my own mortality.
who could have predicted this reckoning? a plague, people are calling it.

i recently started talking to a complete stranger via video and phone. i disclosed to him, how unafraid i feel towards death. that i would rather die doing something meaningful than nothing at all. he was taken aback. he is only a couple years younger than me. "i don't want to die." neither do i (today) (dumbass), but if i were faced with it - well, i should like to think that i have been exposed to it enough to tamp down the insane fear of it. that is: if i were dying for a cause...i would go quite gently into that good night. i have an idea of what that journey entails.
until then, yes, i am terrified. terrified i will do a bad job. that i will harm, instead of help.

a new resolution. to blog something daily. to leave some trace of myself during this time. even if my physical body remains, i suspect this type of fire will leave me and everyone around me changed forever.

i think i would like to continue documenting the bad cases. as well as the good. the outpatient world has been rather mundane, with several notable exceptions. reading my old posts from the inpatient days (what a gift to myself, to have documented some - like a goldfish, i would never have been able to recall any of it), it really does seem like i made the right choice. wasn't cut out for it. and yet, here i am. on the precipice of being called back in to war. and suddenly i wish quite deeply for the mundane again.

some beautiful moments: on march 30, national doctor's day, someone bought ten pizzas for the entire clinic.
every other patient i talk or email to expresses their thanks, gratitude, and empathy for those of us in healthcare. i remind myself, i get the privilege of taking care of some of the most wonderful people in the world. (i also get the dubious honor of taking care of some of the worst people in the world, but never mind this for now)

tomorrow, training begins.

post-dc

i am appreciating clinic for its low key nature. it has bothered me at times, the feeling that i need to prove myself to a specialist, just to seem competent.  that never feels fun.  i know that overall i am vaguely competent.  but not excellent. that does bother me.
the rest of my life is such as mess that it feels overwhelming to strive for that excellence.  and what does that mean, anyway?  that i have to be on call essentially, available 24/7 for my patients, most of whom are about as privileged and well as i am?
i wish it was more clear from day to day if i am doing the right thing by these people.  of course real life is never as clear cut as a board exam.
day to day i also ruminate on my secondary boarding -- where do i want to go from here?  there isn't anything that i am doing that necessarily is above and beyond something a fourth year osteopathic student would do.  long gone are the days of shared meditations with my patients, working in the fluid, the ether, the embryonic zones.  a part of me scoffs, easily, at those times -- the idealism of an ignoramus.  the feeling is like a past lover.  you wonder how you could have been so silly.
but also, here i am willing to shell out hundreds of dollars for that treatment for myself.  i'm not sure what this represents for me and my journey in health and as a healer but i hope that someday it will lead to something good for the world.

A jumble

sometimes it feels like everything is scrambling, scrambling, scrambling, on low heat.  if you're gordon ramsay, then also with tons of butter.
today was just a jumble of cases.  i don't think i felt good about any of my discharges.
every day makes me glad that i wont be doing this anymore.
jaime tries really hard to make me feel better about the work here.  he inspires me sometimes to be more likeable.  always, until i realize i will never be likeable.
another holiday season working. alone.
here we go again!

i am definitely listening to the DMX/reading rainbow remix on repeat.

another one i guess

so yesterday, it was deja vu all over again.

i can't help but think it was the exact same thing.  patient with cancer, liver. unclear etiology. presenting with abd pain, nuasea, vomiting, distension.  she'd already been treated with NGT.  surgery'd already signed off.  and yet things turned from bad to worse.  she coded.  i was present, standing in the corner, impotent as the code leader, looking towards the intensivist who was already in the process of intubating her as i arrived.  and today, she died in the ICU.  i heard the wails of her daughter at the other end of the unit.

i wonder if i shouldn't have dropped an NGT tube.  I wonder if i should have been more persistent in getting surgery to come back.  i wonder i wonder i wonder.

part of the reason i feel i am not fit for inpatient is just this.  the tendency to ruminate.  i could have done all those things and the outcome would not have changed; this woman was fragile, a cirrhotic from drinking so many years.  and yet, i can't let go of the what-ifs.  and certainly, i am not the first person that this (sudden and rapid outcome) has happened to (arguably this has not "happened" to me, but i am choosing to put myself in the center of this scenario). but i can't help but feel ashamed, a little disgusted at myself, scared, angry.  like, an unwitting murderer.

one thing that bothers me about this case is how unaffected i feel, in comparison to patrick.  his death devastated me.  and i had only known him for less than a day.  i had been rounding on this lady for a couple days at this point.  i am not sure what the difference is.  maybe after the first couple deaths, one starts to get "used to it?"

if that is the case, then i surely am in the wrong field.  i don't want to get "used to it."  i don't want to be so jaded (as a defense mechanism) that i stop caring about the human side, the family side, the meaningful side. 

her death, i will carry.  as i have patrick's.  even though my shoulders are around my ears as i'm hunched over the computer, stressed, walking down the hallways as if trying to make myself like a mouse, like a ghost...their deaths weigh on my neck like elephants.  reminding me with every breath, that for some reason i am here and they are not.

horrifying

i forgot who i was talking to, but someone mentioned that for terrible/interesting cases, one should document it for posterity and future reflection.

yesterday i admitted a 28 year old man with past history of alcoholic pancreatitis, complicated by a pseudocyst.  his belly was soft and not particularly distended.  i thought this would be a quick few days of managing his pancreatitis and withdrawal and sending him on his way.
today i get a call from the radiologist, that on the follow-up CT i ordered he was noted to have a 12x10x14cm complex mass where his previous pseudocyst was, with possible solid components, hemorrhagic components, and intraperitoneal hemorrhage/ascites.  that morning, his hemoglobin had dropped from 11 to 6 without hematemesis, hematochezia, or melena.

it was so completely overwhelming.  i was just thinking, well i have to get surg, IR.  then i couldn't reach IR, the operator had the wrong number.  i was so despondent by the fact that this guy could potentially bleed out into his stomach and die, and it would be because i couldn't find someone smarter than me to handle the situation.

i think i will be forever grateful for the GI specialist.  he gave me some reassurance about the case.  he even told me that he himself reached out to a surgeon he knew at a nearby hospital for advice! and ended with some feedback to always call him with this type of complication.  he didn't think the patient was actively bleeding into the pseudocyst, that it was old, and that urgent imaging/IR/transfer was probably not warranted right now.


i remember my first really memorable case working here.  an elderly japanese-american woman coming in with AMS.  the next day, i happened to be there the same time as the ID doc.  he had enough gumption to roll the patient over, which i did not do.  and lo and behold, along her midline lumbosacral area following a dermatome, she had a vesicular rash.  her csf later tested positive for VZV.  my first zoster meningitis.

i remember a near-miss.  a lady with history of renal transplant, then subsequent colon AND lung cancers.  coming in with UTI.  i was about to send her home on her regular home meds when the renal specialist noted her pancytopenia and said, you have to call her transplant team before you let her go.  and that's how i learned that transplant medications should be changed depending on certain situations.  oh boy, i was so angry with myself that i didn't know even the basics of transplant medicine.

and another near-miss!  an older man with history of renal transplant, with ESBL UTI whom i had to send home on meropenem, forgetting that i had to discuss with his nephrologist prior to putting in a PICC.


oftentimes, i feel that i am not cut out for inpatient medicine.  compared to where i trained, the cases at this institution are so complex, and then i've never done inpatient onc in my life, and it seems like every other person in this goddamned town has cancer.  this week alone i had three patients with brain masses.
this has been an important learning experience.  sometimes, i justify quitting, telling myself "it's my personality, i take things too hard, too much to heart, as opposed to thinking through them in a calculating fashion."  or, "i am just too stupid to do this."  there was a click-bait article that i clicked on, "amateurs vs professionals."  one of the items on the list is,

• Amateurs give up at the first sign of trouble and assume they’re failures. Professionals see failure as part of the path to growth and mastery.

i sure hope this is what a natural path feels like.