On aging

When I do complete these years of residency, these long, seemingly endless hours in the hospital, medicine will have aged me. Filled in gentle wrinkles around the lips, placed faint circles beneath the eyes. It is not just the hours that do this, but the very nature of the work. But I will also emerge from this residency with perspective, and with an unparalleled appreciation for life. You only begin to appreciate it when you watch as it is taken away from those around you, one after another after another. You begin to value it when you realize – and see with your own eyes – what the alternative is. I walk out of the emergency department each day thankful that I can inhale deeply, break into a slow jog towards my car, feel my muscles tense and stretch with each stride. These are the things life is made of. They make each day worthwhile. And I love medicine for revealing this to me, over and over again.

I also love children. Working in the pediatric emergency department makes me happier than anything else in the world. Time flies. More so than on the floors, where time drags while we are waiting, making phone calls, filling out paperwork, and caring for children who are sicker than we would like them to be. My shift this evening was delightful. I am finally starting to teach – I walked a PA student through sewing up a fingertip laceration on a 7-year-old boy. Teaching is another highlight of medicine, and I have only reached the tip of the iceberg in that regard.

On difficult access

So the last hour and a half of my shift today was spent trying to get access on a patient. What a term – get access. It the world of medical lingo, this simply means “to successfully stick a vein, or artery, to obtain necessary blood work and to place a line.” My access today was the femoral artery. Numb up the area with lidocaine first, then stick your needle in and go for the gold – or, in this case, the red. There is something immensely satisfying about getting access; as physicians, we are always there to get access on the difficult patients, or to get central access on the sickest patients. These lines are some of the initial “monsters” of intern year – they take up your time, you fail at them over and over again, and eventually you come out on the other end being fairly decent and fairly timely at doing them.

While all the other gray areas of medicine – there is even very little evidence for one of the simplest things: the two or three medications we give during a cardiac resuscitation – are something we stumble through from day to day, barely able to justify with hard evidence, getting access on a patient is black or white. It stands in a class of its own. You get the blood work, you get the line, or you don’t. And after getting it, no matter how long it takes, you feel a grand sense of accomplishment. What did I do today? I got blood. A virtual vampire. Success. Instantaneous results. I am a champion.

Over the course of intern year, I have felt more satisfied – and more fulfilled – by getting access than I have by doing anything else. Talking with patients and their families is often tedious and depressing, and it makes me want to walk away immediately – this instinct is a kind reminder as to why I chose emergency medicine in the first place. So I can walk away. Not deal with these chronic medical issues, these slow, treacherous journies to the end of life. Furthermore, treating patients is something I often feel ambiguous about, because treatments have risks and benefits, and there are many patients whom we treat regardless of whether or not the risks outweigh the benefits.

Case in point: a woman with metastatic breast cancer, who continues to come in and out of the hospital, over and over again, for fluid accumulation in her legs, her body, and her lungs which is making her more and more uncomfortable. Should we admit this lady to the hospital, stick her multiple times for blood work, and continue her chemotherapy? Is this really how she wants to spend her remaining days, under the circumstances? And why has her oncologist not had this discussion with her? When I bring it up, her daughters are in tears, asking me all kinds of questions about how much time she has left and if this is the right thing to do – as if no one has ever talked about these things with them before. The only reason I can be candid – and, in doing so, remain true to myself – is because I know I will not have to face them tomorrow. Or the next day. Or the day after that. But in this moment, I can tell them what I believe, and I can also make sure they understand that the future is not rose-colored. They deserve this, and so does the patient.

And so it goes

I am writing early today because it is a Wednesday – long hours of class immediately followed by an ED shift. I am quite disenchanted with medicine at the current moment. I can hardly be excited about vacation when I know that I will be postponing an ATLS course until later this year because of it, and that I will be returning to one month in the MICU. I have had trepidation about the MICU since I was a medical student. I cancelled my medical school rotation at the last minute to fly to London instead – not a decision I regret, but nonetheless…

As far as I can tell, residents drown in the MICU with work weeks totaling over 100 hours, far too many admissions of critically ill patients, and minimal rewards. It is here that families suffer, that patients pass away, that all the lines and tubes of medicine are utilized to their maximum in heroic attempts to save lives, at hundreds of thousands of dollars a day. This is the superior, high-level care which epitomizes the American medical system. Any invasive measure, at any cost, to save a life. This is the unit in the hospital where people do not ask three important questions:

What is quality of life? Why are we prolonging life? What is a death with dignity, and can it ever happen in this country?

Rather than addressing these questions, we build these MICUs and perfect our medical skills and enhance our medical knowledge, to the point where we can no longer recognize what is beneficial and what is detrimental to the patient and their family.

One Day Away from the Hospital…

And I have been on hold with my loan processor for over 30 minutes. Medical school has become such a financial sacrifice, I can hardly believe anyone is willing to apply. With over $200,000 of loans hanging over my head through the next three years of residency, and with the new laws which no longer allow us to defer our loans, I have been jumping through hoops with Sallie Mae for the last 2 years. If I totaled my phone time with this company, it has eaten away at 3 weeks of my life – and that is a gross underestimation.

As usual, my day off is spent negotiating loan repayments and trying to prevent myself from drowning in a financial hole over the next 3 years. On a salary of approximately $10 an hour, this is a difficult feat.

And Obama, and the rest of the world, wonder why it is that more medical students are not going into primary care. I felt so pressured by this financial burden that I wasn’t even able to let myself consider it – it would require me to be indebted to the US government, and to continue repaying my loans to them, through the entire next decade of my life.

If we want to have more primary care physicians, and better physicians overall, then the government should decrease the financial burden of medical school and residency. This is the least lucrative career one could hope for in their 20s – and as a result medicine is attracting less qualified people to its ranks.

Post-Call Addendum

I am post-call and ready for some sleep. This marks the end of my only month of floor pediatrics in residency. A reminder for the future is not to start patients with acute chest on ceftriaxone due to the risk of sludging – cefotaxime is preferred. The next time I take care of children, I will be in the PICU as a second year resident. It is hard to believe that time is flying by so quickly.

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