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.
Tuesday, December 12, 2017
Wednesday, November 22, 2017
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.
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.
Sunday, September 17, 2017
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,
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.
Friday, August 18, 2017
trauma based care
i was just thinking about some things i've seen on social media: white people complaining about being called racists, the apparent "resurgence" of the KKK and neo-nazis, the accusation that the BLM movement is the "same thing." wondering how it all came to this.
i think i get it. it was really hard to take. you do what you do hoping to make a positive difference. all of us are doing our best, navigating a broken system, to provide health for our communities, because we believe it is the right thing to do. we lose sleep, lose touch with our loved ones, get behind on self-care and life in general, because we believe in it so strongly. and then to turn around and get that kind of treatment from the people you are trying to help -- that is difficult to bear.
but, i'm beginning to realize, the moment you make this about yourself, and not the person at hand...you've completely missed the boat.
i have no idea what kind of experiences have led this family to this point today. poverty, emotional and physical trauma, here, abroad, access to care....i have no idea. and even if one of them calmed down enough to talk to me, and even if i had the time to listen, i would still have no idea, never truly understand.
that doesn't mean i stop being their physician, and just dump the case. we all keep trying, morning into afternoon into evening into morning, putting on a pleasant face, providing constructive data and options even though we know they will all get shot down immediately. because there is no other alternative. because we have to keep trying to work as a team. or things will never get better.
i took care of a 60-year-old woman who was found down in the field and near death from DKA. as she came to and an entire team of people began to piece together her history, it because apparently she had a history of psychiatric illness, polysubstance abuse, and was in a poor/dangerous social situation. as she became stable and more with it, as part of a cognition evaluation i half-jokingly asked her if she knew who the president was. "Trump, and i'm glad i voted for him," she said with a smile.
of course, inside i raged, because it was so easy to take personal offense to this. a person for whom it is become more apparent by the day that she is reliant on public resources, proud to defend a man who is by all accounts a sociopath. a man who poses a danger to the very systems she relies on just to live her life. but of course, i have no idea what she's been through to make her feel this way. our systems ARE fundamentally flawed. i've heard the struggles first-hand from the patients i took care of through the county clinic during residency, patients who despite living similar traumas are thoughtful, decent, and making the "right" decisions about their health and well-being.... and are still struggling. the minute i made this about myself, about my own opinions about politics, my own judgements of this woman's life choices, i was blinded by indignant hatred for this lady. and that is not helpful.
i took care of a 60-year-old woman who was found down in the field and near death from DKA. as she came to and an entire team of people began to piece together her history, it because apparently she had a history of psychiatric illness, polysubstance abuse, and was in a poor/dangerous social situation. as she became stable and more with it, as part of a cognition evaluation i half-jokingly asked her if she knew who the president was. "Trump, and i'm glad i voted for him," she said with a smile.
of course, inside i raged, because it was so easy to take personal offense to this. a person for whom it is become more apparent by the day that she is reliant on public resources, proud to defend a man who is by all accounts a sociopath. a man who poses a danger to the very systems she relies on just to live her life. but of course, i have no idea what she's been through to make her feel this way. our systems ARE fundamentally flawed. i've heard the struggles first-hand from the patients i took care of through the county clinic during residency, patients who despite living similar traumas are thoughtful, decent, and making the "right" decisions about their health and well-being.... and are still struggling. the minute i made this about myself, about my own opinions about politics, my own judgements of this woman's life choices, i was blinded by indignant hatred for this lady. and that is not helpful.
when i see some of my dear acquaintances on social media become consumed with their own outrage, despondence, depression about what is going on in this country, unfriending/unfollowing every dissenting opinion, i get it. i want to do the same thing. but, to what end? to take those feelings and turn around and channel them into hostility towards another, what will that accomplish? we have to work as a team. or things will never get better.
Sunday, August 13, 2017
resuscitation
life is motion, right?
many of us live in 2-D. we stand up to awaken, we sit to work, we lay supine to sleep. we hold a hand, one side's fingers interlaced with another. our time is linear. point A to point B.
dr sutherland described the tide, a three-dimensional pulsation bathing our beings, an all-encompassing force greater than the to-and-fro within our vasculature, without which we could not exist. dr jealous described the embryologic zones, a four-dimensional construct enabling him to describe why some of us are born and develop and live and die suffer and thrive the way we do in the physical world over the course of our existence. the motion of development. structure and function. function and structure.
i always thought if i could have a superpower, it would be to fly and experience the world in three dimensions. but on thursday, i discovered i had a different one. it is the ability to experience it all in slow-motion.
i could hear my footsteps echoing much louder than they should for the soft shoes i was wearing, the sounds bouncing through my skull endlessly. i could see in my periphery the bland walls moving by as i ran down the hall. i could feel my heart stop as i saw the crash cart and ten million people in my patient's room. and then i could feel the entire world frozen, breathlessly immobile, as i saw them inside his room, standing over his bed, beating on his chest, yelling at each other, his feet flopping to and fro, keeping time. his belly grotesquely distended. an impossible marionette.
and i saw, one by one, the faces of staff and family, as they crumpled in agonizing pain before all that was unfolding, in shock and disbelief. i could see my patient's face as i remembered him when i saw him last night, wide smile, kind and forgiving eyes shielding his physical pain and the inner pain of the unknown, the known, and the realization he was too late. i could feel the soft warmth of his hand as i shook it for the last time. i could feel the same hand gripping my throat and dragging my spine down into the floor as, after 45 minutes of cpr, he was pronounced.
what have i done. what could i have done for you, P, that i did not have the knowledge or foresight to provide earlier? could i have saved you? could i have bought you precious time during which at least your family could come to your side and say their final goodbye? have i robbed your family of that joy and sorrow and closure?
outside, the clouds moved briskly through the blue sky, and people toiled in the fields, and why am i still here and you are gone?
i feel you at my back. i carry you with me always, as i do the faces of your loved ones. it is heavy. and endless.
many of us live in 2-D. we stand up to awaken, we sit to work, we lay supine to sleep. we hold a hand, one side's fingers interlaced with another. our time is linear. point A to point B.
dr sutherland described the tide, a three-dimensional pulsation bathing our beings, an all-encompassing force greater than the to-and-fro within our vasculature, without which we could not exist. dr jealous described the embryologic zones, a four-dimensional construct enabling him to describe why some of us are born and develop and live and die suffer and thrive the way we do in the physical world over the course of our existence. the motion of development. structure and function. function and structure.
i always thought if i could have a superpower, it would be to fly and experience the world in three dimensions. but on thursday, i discovered i had a different one. it is the ability to experience it all in slow-motion.
i could hear my footsteps echoing much louder than they should for the soft shoes i was wearing, the sounds bouncing through my skull endlessly. i could see in my periphery the bland walls moving by as i ran down the hall. i could feel my heart stop as i saw the crash cart and ten million people in my patient's room. and then i could feel the entire world frozen, breathlessly immobile, as i saw them inside his room, standing over his bed, beating on his chest, yelling at each other, his feet flopping to and fro, keeping time. his belly grotesquely distended. an impossible marionette.
and i saw, one by one, the faces of staff and family, as they crumpled in agonizing pain before all that was unfolding, in shock and disbelief. i could see my patient's face as i remembered him when i saw him last night, wide smile, kind and forgiving eyes shielding his physical pain and the inner pain of the unknown, the known, and the realization he was too late. i could feel the soft warmth of his hand as i shook it for the last time. i could feel the same hand gripping my throat and dragging my spine down into the floor as, after 45 minutes of cpr, he was pronounced.
what have i done. what could i have done for you, P, that i did not have the knowledge or foresight to provide earlier? could i have saved you? could i have bought you precious time during which at least your family could come to your side and say their final goodbye? have i robbed your family of that joy and sorrow and closure?
outside, the clouds moved briskly through the blue sky, and people toiled in the fields, and why am i still here and you are gone?
i feel you at my back. i carry you with me always, as i do the faces of your loved ones. it is heavy. and endless.
Sunday, November 27, 2016
running
i stepped out of that cave of a dance studio around dusk. the air was heavy and cool. the clouds were backlit with brilliant yellows and pinks, and with smokey greys. i hadn't heard anything out of the ordinary, as i was concentrating on stepping around the deep pools of water in the parking lot to not get my shoes wet. then i noticed nails on the pavement. and suddenly, there it was. short hair, caramel, long pointed nose. lean, with mouth open and tongue lolling about. uncollared. unafraid.
it looked me in the eye, then trotted towards another dancer walking to her car, as if it belonged to her. i was startled, but i figured someone just let it off its leash. i turned and got in my car. as i was backing out of my space, i saw it dart across my front, then out of my line of sight. i was irritated. the last thing i wanted to do was to kill a dog on accident after dance class. i braked and rolled slowly to avoid crushing it, if it was still there. then, i saw it loping away from my car in my rearview mirror. relieved. went down the driveway.
as i started picking up speed down the street, i suddenly saw her again in my rearview, running after my car and going into a full on sprint. it was not the face of a rabid dog, nor a playful one. her eyes were piercing and dark. as if to say, i am running too. take me with you.
it looked me in the eye, then trotted towards another dancer walking to her car, as if it belonged to her. i was startled, but i figured someone just let it off its leash. i turned and got in my car. as i was backing out of my space, i saw it dart across my front, then out of my line of sight. i was irritated. the last thing i wanted to do was to kill a dog on accident after dance class. i braked and rolled slowly to avoid crushing it, if it was still there. then, i saw it loping away from my car in my rearview mirror. relieved. went down the driveway.
as i started picking up speed down the street, i suddenly saw her again in my rearview, running after my car and going into a full on sprint. it was not the face of a rabid dog, nor a playful one. her eyes were piercing and dark. as if to say, i am running too. take me with you.
Sunday, November 13, 2016
swing state
I have been thinking about my grieving process. What constitutes healthy, mature reactions? How do I prevent unhealthy reactions?
My lack of resilience gives me great anxiety, ironically.
But I think this time will be different.
I am nearly crossing the line over which women are designated "advanced maternal age." Aside from my inconceivably crushing debt, I have nothing holding me back - house payments, children, involvement in politics. Though I am sure the future ramifications are far more serious than I imagine them now...how can I stay silent through these times?
During morning report last week, the director felt it was appropriate to comment on the election. He said something to the effect of, "so, all those minorities who are saying they are scared for their lives, they should quit their bitchin and moanin, because that isn't really a thing."
Right then, right in that moment I saw my shackles, my shame. Because as I knew instantaneously I should say something, I saw my future fellowship taken away from me, my name slandered from ever practicing in the area...career ruin.
If I could go back in time, I would say something. Anything. Just, something to let the room know that this is not right. This is not okay. This is the type of attitude that should be a crime to perpetuate amongst future healthcare providers. This is a gentleman who is so completely ignorant of his bias that he can't see any other worldview than his own. We CAN'T let this be normalized for doctors in training.
See something, say something. See something, say something.
What do I have to lose?
Everything.
Say something.
My lack of resilience gives me great anxiety, ironically.
But I think this time will be different.
I am nearly crossing the line over which women are designated "advanced maternal age." Aside from my inconceivably crushing debt, I have nothing holding me back - house payments, children, involvement in politics. Though I am sure the future ramifications are far more serious than I imagine them now...how can I stay silent through these times?
During morning report last week, the director felt it was appropriate to comment on the election. He said something to the effect of, "so, all those minorities who are saying they are scared for their lives, they should quit their bitchin and moanin, because that isn't really a thing."
Right then, right in that moment I saw my shackles, my shame. Because as I knew instantaneously I should say something, I saw my future fellowship taken away from me, my name slandered from ever practicing in the area...career ruin.
If I could go back in time, I would say something. Anything. Just, something to let the room know that this is not right. This is not okay. This is the type of attitude that should be a crime to perpetuate amongst future healthcare providers. This is a gentleman who is so completely ignorant of his bias that he can't see any other worldview than his own. We CAN'T let this be normalized for doctors in training.
See something, say something. See something, say something.
What do I have to lose?
Everything.
Say something.
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