Life in Triage

2 months in. Overwhelmed. Don’t feel like I’m improving as fast as I should be. Still too disorganized. Disillusioned and disappointed at how green finished. Hopeful for this month.

-For my own personal notekeeping, I wrote this almost a month ago, but its been sitting around waiting to be published for some reason

Wow, it has been quite some time since I scribbled anything down in here. Things have changed for me. A lot. I’m now living 2,500 miles away from home, thus shattering my previous record of 200. I’m a doctor, which is a fact continually amusing and terrifying to me, and every time I have to answer the phone as Dr. Louis, I feel a twinge of pride mixed with a tidal wave of fear.

I’m absolutely in love with this part of the country. I can’t imagine why the whole population of our great land isn’t actively trying to move here. Granted, its the summer and the weather is amazing, but when I look out a patients room to see a panoramic view of Mt. Hood, Mt. St. Helens, and the Willamette River…its just….well good Lord its majestic. Its difficult–damned difficult–being so far away from the love and support of my family, but I think its good for me. They are now only a skype call away…and I feel like I’m really creating my own life here. Its a good thing, I just miss them so much.

Then, there’s the job. I’m exhausted. Its currently 3:10am, and I’ve been here since 5:30 this morning. And I have almost 9 hours to go before my shift ends. I don’t care who you are…that sucks. And yet, and this is truly astonishing to me, I’ve never been this happy. I’ve never slept this little or worked this much, but I’m absolutely filled with joy every time I wake up in a fog of half-arousal. You people that know me know I’m kind of a bitter old man…but I think that guy might be dead. I’m genuinely happy right now, and I’m going to cling to it as tightly as I can. I had a patient’s family from pediatric surgery send me a letter of encouragement, and it absolutely meant the world to me. I’ll be clinging to that feeling for quite some time.

Pedi surg was…well…not so bad, really. We had a relatively light census, and I feel our team was really strong (Nikki really picked up my slack). I didn’t get to be around Bliss as much as I would have liked, he really is a great teacher and I feel like I missed out on it because I spent the majority of my rotation on nights. Oh well…the time will come again. And now…Green. The bariatric and colorectal service. Taking care of the aches and pains of pre and post operative 400lb people is….well, I guess it should be miserable…and there are parts of it I loathe…but dammit I’m so irrepressibly happy right now. I have an awesome team, and the med students actually really rock, its hard to really get down about having to go change the wound dressings on a 350lb woman with an open abdomen, as truly disgusting as that really is.

I did my very first disimpaction the other day, and boy howdy, was that an experience. If you don’t know what that is, google it. If you do…mourn with me.

The people in my program seem universally…just dang great. I generally don’t like most people, but these folks seem a whole lot of OK. I’ve made some pretty good friends quicker than I usually do, and I can’t help but hope that continues. There’s just so much to do here! Between hiking, going to the coast, snow skiing, beer drinking, bike riding, etc. I doubt I’ll ever have a spare moment to relax. And dang it, that’s a bit of ok by me.

So, I think I’ve decided to stop having some noble goal of cataloging useful information in this journal and will start using it as an actual journal. Not enough people read it to really matter, so off I go

Its 3, the night before we find out if we matched or not. I’m so nervous I can’t sleep and feel like I’m about to vomit. Rationally, I have no real reason to be afraid. I have 10 programs on my list, several of which have been courting me rather vociferously. Granted, they are not my top programs, but at least I have that on which to hold. The odds that I will not match are, I hope, pretty dang minuscule. Even so, the nagging doubts linger at this time of night.

Plus, this stupid P90X thing is absolutely destroying my back. I love it, and I’m taking it even more seriously than I thought I would, but it’s gotten to the point where I am taking 6-8 Advil a day just to keep my back pain in check. If it keeps getting worse I’m going to have to bite the bullet and go back to the doctor. All that to say this: the back pain isn’t helping me sleep either. But my arms, chest, and legs are sore in wonderful ways, so I’m going to keep up the program, in all its masochistic glory.

So, yeah. I’m scared. Hurdle #1 tomorrow, here’s to the next 4 days of elevated blood pressure.

My thought a couple months ago was to sit in my hotel room the night after each interview and record my thoughts on the program, as a way of helping me keep track of how I felt about it at the time. Well, it turns out I’m lazy and just plain old didn’t do it. In retrospect, however, it was probably for the best, as my opinions of each program I’ve been too has been so constantly molded and shaped by the subsequent interviews.

So, here I sit, 9 interviews down, and absolutely no idea what I want or need to do. I have my favorites right now (Portland, Denver, UTSW, and Cornell), but even that list is constantly changing. Its coming to a time where I have to decide what I really want out of life. There are two paths laid before me right now, and I don’t really know how to choose between. I have two primary goals on what I want out of residency: 1) to become a technically proficient and clinically competent surgeon, and 2) to land a fellowship which will allow me to do whatever I want with the rest of my life career-wise.

Now, these two goals don’t necessarily need to be mutually exclusive. In fact, I think any one of my top 4 programs right now will allow me to do both of those things, but there are definitely skews. For example, I will probably do a larger number of more varied cases at a place like Louisville or UTSW, and probably be a better surgeon at the end as a result of it. On the other hand, the fellowships that the residents land coming out of Cornell are among the best in the nation. Not to say that there aren’t great fellowships going to the other schools, there just seem to be more of them going to a place like Cornell.

And then, there are the intangibles, the most prominent of which are the personalities of the residents and the city itself. In the former category, UTSW and Cornell probably win, but it could just be happenstance that I connected with some of the guys there. In the latter, Portland and Denver stomp all over the other cities.

I’m tired. I’m tired of traveling, tired of the interview process, tired of not knowing where I’m going to spend the next 7 years of my life. It really is incredible the humiliation that we subject ourselves to on the path to becoming a doctor. I’m hemorrhaging money that I’m borrowing from someone else, paying someone for the “opportunity” to do some resident’s bitch work and paying to fly my happy ass around the country and paying for my hotel rooms only to show up at 6:45 in some time zone and try to sell myself. Screw this. Ok rant over. Its 3am, I have no idea why I’m awake, and I’m mad at everything

In a zen moment, I’m going to leave this post with a picture of why Portland is awesome

30 minutes away from the hospital...

I originally intended this journal to be a collection of stories that I picked up on the wards. I thought my days would be ripe with stories to tell. Stories of pain, heartache, inspiration, and joy. I am sad to sat that it simply didn’t happen.

I can’t say if it was my own lack of involvement in my patient’s lives, or that simply what happens around the hospital just isn’t all that interesting. All I know is that my moments of connection with patients were few and far between, and moments of inspiration were almost nonexistent.

It seems as though, unfortunately there are really only two kinds of patients (with the rare exception). They are either a) not all that sick, or b) so sick that they have lost the ability to effectively communicate. So, either way, establishing a real connection with a very sick patient is nearly impossible. Sure Ms. Smith who comes in to have her HCTZ refilled is a nice lady, but she’s not sick enough to make her interesting. And Mr. Jones with his end-stage pancreatic cancer is dying, but the drugs we are giving to keep him pain-free eliminate any chance at real communication.

And to top it all off, when the day ends, this turns into a job just like any other job. I come here, I get the things that I need to do done, and I go home. I pray that my M.O. will change once I am a physician and directly involved in the care of my patients, but I can say that while playing doctor as a med student (get ready for that post), I found it unbelievably hard to get really involved.

As this is my second month of pediatrics, and its almost over, I’ll run down the highlights (for my own memory) of the first 7 weeks:

Dr. Cochran (If you haven’t worked with him, you don’t get it, and never will. If you have, smile quietly to yourself and remember your favorite times with him…)

Leaving the ER 4 times over the course of a 12 hour shift to get random things for Dr. Viets

“Acute Gastroenteritis” HA! 9.5/12 sucker.

Height: 5′10″ Weight: 275 Age: 9 freaking years old

Performing a Lumbar Puncture on a 8 moth old kid in status epilepticus.

The first time I was attracted to an attending.

H&P times a million

Being able to confidently tell people what I’m going into…without regrets.

Boredom on the Wardom

Harriet Lane

Having nothing to say to a crying mother watching her child die. Feeling bad about getting annoyed at how much time we spent in the patient’s room.

Feeling, for the first time this year, like one of my residents doesn’t like me.

Musical attendings.

Team Badass/Bad patients. Team Disaster.

Kairi

Landon

Anna Belle

So, my mind is finally made up, I’m going into surgery. Am I going to stay there? Who knows. Going through a surgical internship, even if I decide its not for me, will provide a lot of options of other things I can do with my life.

If I was a betting man, however, my bet is that I’ll stick it out. I like the OR too much to do anything else with my life, I think. I like the whole philosophy of surgery, a get in-get it done-get out way of thinking that suits my ADD just fine.

So, I thought I wanted to be a surgeon. I really, really though I did.

Then, I had a meeting with an interventional cardiologist that I met through family. He has what I want in life. Do I go through the horror of a medicine residency to get there?

Help!

So, we were supposed to write a narrative about medicine from the POV of the patient. Here’s mine:

Blood Pressure. Temperature. Respiratory Rate. Pulse.

“How are you feeling today?”

Ah, the mind-numbing monotony of the ICU. I count the days by the ticker on my watch, but really, what does it matter? I am here to die, and die I shall. Does it matter if it happens on a Tuesday or a Friday? Certainly not to me, possibly to my family (you know, for funeral planning purposes). The concepts of “Tuesday” and “Friday” are ones completely foreign to the place. Even the concepts of day and night die a slow death lying in this mildly uncomfortable bed.

Were my watch to break, I could keep track of the hours of the day based on the visages of the people entering and leaving my room. Short white coat and glazed eyes must mean 5:30 has rolled around. (His shoes squeak softly as he enters the room…maybe its raining outside? It would sure be nice to have a walk…but I am tethered to this bed by plastic tubing as surely as if it were steel chain). This poor kid asks me the same standard questions, only halfway pretending to listen to and care about my answers. I can’t say I blame him; normal people should be happily asleep at this hour. When I was his age….well, let’s just say I don’t envy him.  Now for my least favorite part of the day- he examines me. Unsure hands almost parkinsonian in their clumsiness, I can tell he has absolutely no idea what he’s doing. I play along as to not make him feel bad, I say some vague niceties to ease the palpable tension in the room.

Tired eyes and an unsteady gait, the intern has arrived. I could set clocks by her prompt arrival at 6. When did she last sleep? When did she last have a nice dinner, talk to her family, play with her kids? Oh well, she has a job to do, and she does it relatively well, if a little quickly. I understand, I think. Lots to do and not enough time to do it…the story of American life, no?  Its funny, sitting in this place…I have all the time in the world, yet nothing meaningful to fill it with. Such a funny irony that the last days of my life will be spent in exactly the opposite condition in which most of it was lived.

Ah, 7 o’clock- time for the big wig to roll on by. Such a funny game show they put on when he’s around. The glazed medical student and swollen-eyed intern stand straighter, I swear they each put on an inch or so. The meeting is brisk, but succinct. I’m asked “How are you feeling today” for the third time in the last 90 minutes, and just for a moment I considering answering “Pretty damn bad, I’m dying,” but I shake that urge pretty fast. It wouldn’t make a lick of difference in my treatment, and only cause undue stress on these poor stressed out people. Its funny that I’m the one sitting on my death bed, but I’m the one concerned about hurting their feelings. Very few of them seem to care all that much about mine. I know, they’re busy, but seriously, a comforting smile or touch doesn’t take much time. Oh well, it’s the nature of the beast, I suppose.

The attending fires questions at the medical student- he knows some, he doesn’t know others. Its kind of embarrassing for everyone in the room when he doesn’t know an answer…there’s an uneasy silence as he searches the reaches of his memory- terrified to utter “I don’t know.” I’ve seen my share of medical students during my various tenures in hospitals, its amazing how similar and different they all are. They come in scared and almost helpless, every day they look a little more like doctors. Some know more than others, some are better with patients. Some are bad at both, some good. Hell, I even miss a few of them, I was truly sorry to see them rotate off. Oh well, nature of the beast again, I suppose.

We can fast forward through the hours of 7-3 in this narrative, but I can’t every day, however I much I may wish I could. The time just hangs in the air, but that’s far too boring to be discussed here. The whole charade repeats, in a mildly abbreviated form, around 3. More useless questions, more useless writing. I wish they would just let me sleep. After that…nothing. Sometimes friends and family stop by, but their visits are more depressing than uplifting at this point. I see the sadness in their eyes to see me like this, and it makes me lament my current position all the more. Truth be told, the monotony is better (awful though it is). I used to enjoy reading, but the damned narcotics make everything blurry and incoherent. I no longer have an “attention span.” Even television is hard to follow. The drugs make you just awake enough to realize you’re still existing but annihilate and chance of enjoying it.

And so the hours fade into days, the days into weeks. My slow, outrageously expensive descent into death, surrounded by all these damned beeping machines. It is not a gracious way to exit this world. Fitting that this sterile world was where I entered it as well. I could say something about some circle of life bullshit, but I won’t. Truth be told- this is hell to me, and I’ll be glad to exit in a body bag.

There is nothing glamorous about dying of liver cancer. From the moment the diagnosis is made, the slow, painful degeneration from human being to lifeless cadaver begins. The first victim is cliché, off comes the hair. Sure, the first therapies they have nowadays save it, but as soon as they realize the treatment isn’t working, its off with the top of your head. But that’s really the outward symbol of the inward depersonalization and dehumanization of cancer therapy.  A colonoscopy is thoroughly humiliating, but it hardly holds a candle to the horror that is Chemo. It is not a torture I would wish on the most depraved prisoner of war. Sparing the more horrific details, one can analogically say that it is as if your entire body is at war with itself. It is a battle fought by one army against its own members. Spies exist, insidious members of a hidden enemy. Chemo is seemingly an almost random killing of faceless soldiers, done in the hope that in the end, the spies will be dead with enough soldiers left to rebuild the fort. Its an excruciating experience.  The doctors give you drugs designed to kill your own body- the enemy. Your body does not respond kindly to this. Honestly, I could have hugged the doctor last week when he said the treatment wasn’t working and they were going to stop it (if I had the strength to get out of this God-forsaken bed).

And so I sit, 50 pounds lighter than I should be, in my sterile coffin, waiting to become the corpse I already am. Life slips away under the Goddess that I now consider morphine to be. Not feeling anything at all is good now. Ah, they’re discontinuing PCA, switching to a constant drip….won’t that be nice. Darkness creeps in around the corners of my vision, a very nice sleep peeking around the corner. The beeping of the machines fades away, at least I’ll be away from them for these, my last few moments. And now…all I feel is…peace. Goodnight.

A 13 year old with a BMI in the 30’s and already has signs of Diabetes. Sigh.