Category Archives: Medicine

Notes from a post-call Sunday

Snow always looks prettier when you’re watching it from a warm, dry place. Even more enticing if you’re looking out at it from the hallway at the hospital where you’ve spent the last 28 hours.

When you are on call and you know it’s going to snow overnight, wearing open-top shoes are probably not a good idea, because there are only so many snowplows and a lot of sidewalk.

And if you are wearing shoes which do not cover the tops of your feet, and you are walking through unplowed parking lots, it’s helpful to remember where you parked. This saves you not just time but also helps head off a post-call meltdown.

Prairie Home Companion is probably the best thing on the radio. Particularly when you’re really tired and heading home to your family. Love it.

The only thing better than a post-call nap is a post-call nap with a two and half year old wearing the same Batman jammies he’s had on for the past 36 hours, and who smells like the peanut butter sandwich he just finished eating for lunch.

Sometimes pepperoni, cheese, crackers and apple slices are just enough for dinner. Especially eaten on the couch next to the same two and a half year old (wearing the same Batman jammies) while watching football.

Sleep is good. Time at home with my family is better.

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Flashback

“What branch of the service were you in?” I asked him, as I always do when admitting a new patient at the VA.

“The Marine Corps.” he replied. Oh God, I thought to myself, he has seen some shit.

“Where did you serve?” I asked, again as I always do.

He paused just a second. “Iwo Jima” he said, and I saw his eyes get shiny with tears. I gripped his hand.

“Thank you,” I said, “thank you for your service”.
***********************************************************
Mr R didn’t stay long, he recovered quickly and was ready to get back to splitting wood on his farm in a few days. Like most of the WWII vets, though, he grew on me. When he was getting ready to be discharged, I sat down with him to go over his medications and instructions for follow-up. When we were done, I stood up and shook his hand. “It’s been a pleasure,” I said, “you take care of yourself.”

He got misty-eyed again and said “Well, this is a better place than where I was 63 years ago.” I sat down again and took his hand. “I’m glad you’re here now Mr R, I’m glad you made it.” He smiled and said he was glad too.

“Just one story” he said a little sheepishly, asking me to indulge him. I was happy to.

“Well, my best friend in the service got wounded when we were landing at Iwo Jima. He was a skinny little guy, and he took a piece of shrapnel in the shoulder. I made him stop and I bandaged it up as best as I could and we kept on going. A few days later, he told me that wound was starting to hurt pretty bad. We got the corpsman to look at it and he told my buddy he needed to go out to the hospital ship because he was right on the edge of blood poisoning. So my friend went out to the ship to get treated, and the next morning our sergeant asked where had my friend gone. I told him he had gone out to the hospital ship. Well the sergeant took that to mean he had died, and filed a report saying he had been killed in action.

Meanwhile, my friend was getting treated on the ship but wanted to come back and help us out, because he knew how bad we were getting it. So he told the doctor he wanted to leave, and even though the doctor didn’t want him to go, he let him. Before he left the ship he wrote a letter to his family letting them know he had been wounded but that he was okay. His family, who had been told he was dead, got a letter from him written from the hospital ship, dated after he had supposedly died. Now, his father called the Red Cross and asked them to sort it out, and it took them over a month to figure out what had happened, but then eventually realized that it had all been a mistake.

Well he and I stayed pretty good friends, and after the war he moved to San Antonio, Texas and had a beef ranch. He died at the beginning of this past winter, and a reporter called me up to interview me about his life. I told him this story, and the reporter and my friend’s granddaughter decided to do some research about it. It turns out that the mistake never got fixed in Washington, and so my friend has two death certificates!”

He laughed, remembering his young skinny friend who left the hospital ship to help his friends. He smiled a little self-deprecatingly at me and apologized for taking up my time with his story. I assured him sincerely that I love hearing veterans’ stories and that this was a great story to tell. We said goodbye and I walked out of the room marveling that 63 years ago he was on a pile of rock in the Pacific Ocean seeing and doing things no one should ever have to. He came home to his very small town, raised dairy cattle, sold insurance, and raised a family. He continued to attend Iwo Jima reunions and kept in touch with the men who had seen and done those horrible things too. And in his standard issue VA pajamas, this great-grandfather had more dignity and strength of character than most well-dressed executives. The term “Greatest Generation” doesn’t even come close.

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Lone traveler

I’ve been needing something to jumpstart my blogging recently. The biggest problem I have is really that I have so many things I want to say, I’m having a hard time condensing into something coherent and meaningful. So I’m going to start with Sunday Scribblings this week, we’ll see how it turns out. The prompt this week is: “Fellow Travelers”

When my son was born, I was in medical school and slogging through my last year of clinical rotations. There were several of us who had babies that year, and I was the lucky recipient of commiseration, advice, and general moral support from my fellow travelers on the motherhood and medicine pathway. We pumped breast milk together in the call rooms, we traded tips about baby food, and all used the same babysitter. It was a wonderful thing, to have friends who knew, really knew what it was like.

Now that I’m a resident, I’m the only intern with a child, and actually one of the few women in my class who is even married. Most of the women in my intern class are single, stick-thin marathon runners who are into going out post-call and singing karaoke. They tell me, “I don’t know how you do it”, and the truth is, I don’t either. I have no one who gets this. My mother is nearby and God love her, is tremendously supportive, but only in the general sense of offering desperately needed encouragement and occasional help with laundry. At work, I feel like I’m a world apart. From a career standpoint, I’m just starting out and I am so far down the ladder sometimes I’m not sure I’m even standing on the bottom rung. But from a social standpoint, I’ve been married almost five years, I have an amazing little boy, and I wish there was someone who I could see in the hallway at 2am and trade a knowing smile with.

But there isn’t. And it’s okay, most of the time. I’m thinking of myself as a trailblazer. So what if I’m different than everyone I’m working with? I love my life, I love my job, and I adore my family. At home I’m mama and wife: chief tickler and bath-giver, and head-scratcher extraordinaire. At work, I’m an intern: order-writer, scut-monkey, shaker of hands and caffeine queen. For now at least, I’m a lone traveler.

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Compassion

It’s been a bad night. I’m on the night float service which means I cover the general medicine teams from 5:30pm- 7:30am. Tonight when getting my sign-out, one of my co-interns warned about their new admission. He was “sick” my coworker said, meaning not just the kind of sick that lands you in the hospital, but the kind of sick that makes your heart beat a little faster every-time the pager goes off because you just know that things are going to get worse before they got better. This patient, Mr A, had an infected joint and was septic from it, causing his blood pressure to be low. He had gotten a lot of IV fluids to try to raise his BP which worked nicely, he was getting antibiotics, and the surgeons were planning to take him to the OR tonight to wash out the infection. I stopped by to see him soon after coming in and he looked okay, better than I thought he was going to, and I felt like things were moving in the right direction.

About an hour later I got a call that he was having a hard time breathing, so I hustled over to his room, where I found him working hard to catch his breath and with decreased oxygen levels. Mr A had a DNR order in place, meaning that if his heart were to stop or if he were to have extreme difficulty breathing, he would not want to be resuscitated. He had discussed this with his family, and he understood that his condition was quite serious and there was a chance he could die. When I came to his room, we increased his oxygen and gave him a breathing treatment. We also gave him medicine to get rid of some of the fluid from his lungs, a consequence of all the fluids he got to maintain his BP. He was agitated, panicking because he couldn’t breathe well. “I’m dying”, he said, “I’m going to die”. His nurse and I reassured him, “we’re right here, you’re doing okay”, we said, holding his hand and encouraging him to take nice deep breaths. His oxygen levels kept dropping. And then I realized he wasn’t fighting anymore, that his eyes were open and staring at the ceiling.

“Mr A”, I bellowed into his ear, “Mr A, look over here at me”. Nothing. My interior panic alarm went off. I asked the nurse to call my senior resident. The nurses and I looked at each other, silently asking what we could do. With his DNR order in place, there wasn’t much left. I felt for a pulse in his wrist and couldn’t find one. I went to his other side, where there was no pulse. I felt in his groin for a pulse, and found nothing on either side. His heart was still beating on the monitor, but not strong enough to pump any blood. “Well”, I said to the nurses, “can anyone think of something we haven’t done?” We all agreed that without formal CPR or intubation, we had done all we could. I went to call his wife to let her know that things weren’t going well, to give her a warning shot for the inevitable final phone call. I returned to the room, where we stood, silently, while this man’s oxygen levels decreased, and his heart rate decreased. His nurse held his hand and stroked his hair, and told him I had called his wife, and she was praying for him and sending her love. He never responded, he never moved again. Thirty-five minutes after the nurse first called me, he died. I called his wife and told her that her husband had just died; predictably, she completely fell apart. I told her how sorry I was for her loss, and felt not for the first time how inadequate those words really are. But what else is there to say?

This story is somehow about compassion. Mr A died quickly, relatively peacefully, with a kind nurse holding his hand and stroking his forehead. Such a small act of kindness, to really attend to a dying patient, to comfort and care for him even when he can’t respond to your attention. And his wife, who came to see his body, said he had been ill for some time, and that she was glad he didn’t have a lingering death. She was grateful for that. And me, after I hid in my call room and cried a little bit, and called my husband to tell him I love him, had to attend to a host of pager calls; fevers, nausea, rapid heart rates, and the problems of the living. The nurses rallied around me, telling me how sorry they were that my patient died, asking how the family was, asking how I was doing. That empathy, maybe undeserved but badly needed, was unexpected and humbling. Death touches us all, and while I could never grieve as much as his family, you can’t watch a man die and be unmoved. At times like this, what else is left but compassion?

For Mama Says Om.

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Grand Rounds!

Grand Rounds is up and I am thrilled to have my post Match Day mentioned! Thanks to Blog, MD for including me and for doing a lovely job with this week’s best from medical bloggers!

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Match Day

March 15 was a big day. I had been anticipating it with something akin to mania for weeks, with butterflies in my stomach and a tendency towards twitching a little when I thought of it. Match Day is the day when the majority of fourth year medical students find out where they are going for residency. The day when I would find out where I am uprooting my family to, and in which unfamiliar hospital I’ll to be hopelessly lost in about three months. My rank list was submitted weeks ago, but I hadn’t been able to stop thinking about whether or not I made the right choice, was my first choice as good as I thought it was, did I really want to live there, on and on. On Thursday, it was a relief to know that the suspense would soon be lifted and for better or worse, I would be committed to a residency program by the end of the day.

At my medical school, the ritual of openingdsc02877.JPG our match letters is carried out in the lobby of the school administration building, which is attached to the main hospital. We each have student mailboxes in the lobby, which is where we get our grades and other school-related correspondence, and where we can have packages delivered when we’re on those rotations when we never see the sun. On Match Day, we assembled in the lobby beginning at 11:30 in the morning. Some were dressed nicely, reflecting the import of the news we were about to recieve, while others wore jeans and flip-flops, maybe trying to convince themselves that they felt as casual as they were dressed. We milled around, with spouses, children, parents and friends, making anxious small talk (mostly complaining about having to wait so long) and trying not to check our watches too obviously. Some third year medical students stood at the edge of the crowd, just watching, with arms crossed and curious expressions on their faces. Professors and deans circulated throughout, offering words of encouragement and congratulations. By 11:57, a friend and I had migrated to the edge of the crowd nearest the mailboxes, leaving our spouses and children at the back of the crowd. At noon exactly, the Dean of Student Services gestured to us that we could come back toward the boxes and get our letters.

My friend and I were the first ones to start back, we started at a walk but our pace rapidly increased until we were nearly running. We found our mailboxes propped open, an unexpected blessing because at that moment I couldn’t have told you my birthday much less the combination to my mailbox. The hospital photographer hovered over us, snapping pictures as we snatched our letters from the boxes, along with a letter opener that had been included. At the moment I thought it was just a nice touch. But by the time I made my way back to my husband, my hands were shaking so badly that without that opener I would have ripped the letter itself in trying to open the envelope. I had started to cry already, I have no idea why except that the moment was so unexpectedly emotional I was just caught up in it. I got the envelope open with letter intact, and through my tears saw my first choice listed. The relief that flooded through me was truly profound, and the tears began in earnest.

dsc02876.JPGThe next half hour was spent in total chaos, with nearly my entire class running around finding their friends, shouting congratulations, hugging joyfully and sometimes in consolation. It was a moment of sheer joy that yes we had survived medical school, yes we had matched, yes we are going to be residents. A validation of the last four (and more) years of our lives. Finally, sooner rather than later, we will be doctors.

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selling myself

I interviewed today at my home institution, and it went really well. I really got the feeling they want me to stay here, and truthfully, if location was not a factor, I would stay in a second. As it is, I’m thinking pretty hard about it. There is something to be said for not having to pack up my house, find a new place to live, move there, find the grocery store and post office, find childcare, and that is not even taking into account my husband finding a job. Big decisions loom ahead.

One of the things the program director said to me in my interview with him was that he was really moved by my personal statement, and that my statement stood out from others he had read. I worked really hard on it so I was very pleased to get that piece of feedback. I thought I would share it here with a few minor revisions. I think it gets to the core of what kind of physician I want to be, which is really the goal of a personal statement, isn’t it? I’d love to hear what you all think.

Personal Statement for Internal Medicine

I was fifteen when I decided I wanted to be a doctor. I was learning for the first time about organic molecules, and I was completely fascinated by their complex interactions. It seems almost mundane now but at the time the relationships between nucleic acids, proteins, and enzymes were the most amazing things I had ever encountered. I had always wanted to enter a profession in which I could make a difference in people’s lives, and medicine seemed to combine that desire along with the science I had newly discovered. My love for biology and the intricacy of life was reinforced immeasurably in college with my advanced biology courses, and I couldn’t wait to get to medical school and learn the ways in which all those courses applied to the human body.

Eleven years later, I am a fourth year medical student on my emergency medicine rotation. A man is brought into our emergency department with a self-inflicted gunshot wound to the head. He had been airlifted from a rural county and had no identification on him. I watched as he was stripped, examined, and scanned, and I thought about how sad and alone he must have felt to do such a thing. Forty minutes after entering our doors, he died in a room full of strangers with tubes sprouting from his body and monitors beeping. At some point, someone called out “Do we know this guy’s name yet?” Someone answered in the affirmative, and said he had just been discharged a few weeks ago from our hospital. They said his name, and I can honestly say it was one of the greatest shocks I have experienced. It was a man who had been on my service during my month-long general medicine acting internship. Afterwards, I studied his face, looking for something familiar, but among the swelling and blood I saw only a hint of the man I had known.

It took me days to realize why I was so upset about this man’s death, above and beyond the sad circumstances surrounding it. In our team’s interactions with this patient, we had never suspected he was capable of such an act. I wondered if there was anything we could have said or done differently to uncover his desperation while he was under our care. This got me thinking about the original reasons I wanted to go into medicine, primarily my desire to make a difference in people’s lives. I wondered about the many patients I have taken care of over the last few years, and what effect I had on them, or if I had any effect at all. My experience in the emergency department made me realize why internal medicine is the ideal choice of specialty for me. Along with the chance to study and manage disease processes affecting all organ systems and facets of a patient’s life, I will have the chance to build strong relationships with my patients and perhaps make a crucial difference in their lives. I don’t know if there was anything that could have been done to prevent our patient from ending his own life, but witnessing his death reinforced my determination to always make the effort to reach out to my patients and consider the state of their emotional as well as physical health.

As a third year medical student, I had a lot of time to spend with patients. I always made an effort to make sure the people I was taking care of understood their illness and felt confident in their treatment, and spending time with my patients in that context was immensely satisfying to me. I believe that my interactions with my patients are as important as the prescriptions I write for them. For me, internal medicine provides the opportunity to serve as a physician trained to manage all aspects of medical care in adults, and who can also establish a strong personal relationship with patients. I find it as rewarding to improve a patient’s blood sugar control as it is to help them manage their stress, and I hope to do both equally well in my practice.

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