Another day, another dollar

The clouds hang in the sky as I drive home on the highway, headed east towards a horizon splattered with gold streaks. My head nods, time and time again. I can barely keep my eyes open. Over the last 52 days, I have completed 30 night shifts and 4 day shifts. I finished multiple certification courses, 4 days in total. Over the last 17 days, I have worked 16 shifts – 13 of which were nights. I did not know, before now, that this would be humanly possible. And, in fact, I still do not know. I have been pushed far beyond my limits. I do not know what has kept me going. Stubbornness, I suppose. Some internal drive. Quit now, or forever hold your peace.

I always knew that residency would be difficult. But I never quite imagined… I did not know it would be this difficult. Day in, day out. My face has become important during this trek. My face can hide me and shield me from the outside world. And so I spend all of my extra hours on my face – creams, exfoliators, moisturizers. As I walk through those hospital doors every day, I transform into the face of a physician. The rest of me has crumpled into a non-physician. And so I wait, patiently, for a reprieve.

I have a newfound respect for anyone who has made it through this journey – for anyone who is a physician. Even if I make it through, I will have done so stumbling and tripping along the way – anything but smoothly. And I will have done so with little, if any, energy left to continue along this path.

A list of gratitude seems hardly possible at this point, but I will give it my best effort.

1. I am not the patient. It is always easy to take this for granted. After working there every day for so many months, the hospital becomes a place of work rather than a place of illness. It seems run of the mill to witness pain, disease, and suffering in others. I see it every day. But it is not.

2. I have a job. The pay may be minimal and the hours grueling, but I have a job and a paycheck. It would take a grand effort for me to lose this job, even for me not to advance in it. A mixed blessing, I suppose.

3. I have the opportunity to serve others each day. This is another thing I take for granted. I go home at the end of a shift with the knowledge that I have helped several people in concrete ways.

4. I get free graham crackers, saltines, and peanut butter at work. I have no idea what it is about these foods that makes them omnipresent – in the OR’s lounge area, the pediatric floors, and the emergency department. I get sick of them from time to time, but they are always no more than a minute away – sustenance in those times of utter exhaustion or internal collapse.

5. I have the privilege of listening to countless stories over the course of a day, and I can learn something from each patient. The emergency department has a plethora of stories.

6. I can wear scrubs and flats to work. No fancy suits, high heels, uncomfortable skirts. I only need 15 seconds to get ready each morning, and I can be comfortable in pajama substitutes throughout the day.

7. I have decision-making capabilities and authority. As my attending stepped out of the emergency department for a break last night, one of the nurses turned to me and said, “Are you running this joint?” Yes. And in only a few short years I will have the opportunity to run it on a regular basis.

8. I still get to go to class. Even though residency is a job, it is also a training program. I can spend one morning a week at class and several months later down the road on various electives.

9. I get to take a huge chunk of vacation without any ramifications. One week, two weeks, three weeks – I can choose to divide it exactly how I please, with no work or projects carried over during that time.

10. And lastly, the best aspect of emergency medicine – the end of a shift is the end of a shift. No worries or work to bring home, no long-term projects, no stress in between work hours, and – that’s right – no beeper. I can relax and release all my memories of the day as I drive towards the sun, windows open, music blaring. Another day, another dollar – and another life saved.

Grand Rounds, Volume 7, Number 4: Uplifting Moments in Medicine

Good morning! Thank you for all the submissions which have flooded my inbox over the past week. They kept me going through a stretch of countless overnight shifts in the emergency department, which seemed never-ending and darker than a moonless night. In the midst of stunning fall foliage this October, the vibrant colors of this week’s Grand Rounds reach towards the sky. Take a moment out of the day to live in the present. Listen to the sounds around you, whatever they may be – leaves rustling in the wind, blaring sirens, constant monitors. Sit back, relax, take a long, deep breath and a sip of your favorite morning drink. Take in the flying kites, subtle music, and silver linings of today’s indulgence: Uplifting Moments in Medicine.

Autumn Sugar Maples, by John Eastcott and Yva Momatiuk. Vermont's outstanding array of fall foliage is highlighted by the colorful sugar maple. Broadleaf plants shed their leaves each year in preparation for winter, but variable temperatures and moisture determine how spectacular each annual show will be.

We begin with a story of redemption in Copiapó, Chile: the rescue of 33 miners who had been trapped after the collapse of a mine on August 5. The miners spent 69 days underground. In the first days after the collapse, they set off explosives and burned tires in an effort to communicate with the outside world. Shift boss Luis Urzúa rationed milk, crackers, peaches, and canned tuna for his entire crew over 17 days, before the world knew that the men remained alive 2000 feet underground. When their reserves of bottled water dwindled to only 10 liters, they began drinking water tainted with motor oil from metal drums. By the evening of October 13, all 33 men had been successfully recused and reunited with their families. The spirit which kept them alive through 69 days of darkness is awe-inspiring. The miners worked with each other and with the doctors, scientists, and support groups above ground in order to survive. Gómez, the eldest miner, served as a religious leader and worked with psychologists to support the team’s spiritual health. Yonni Barrios served as the medic for the group; he monitored their health, administered vaccinations, and provided reports for doctors on the surface. Sepúlveda organized the miners’ video journals, and Ticona worked to maintain the underground portion of the telephone and videoconferencing systems. The story highlights the best of medicine, science, and humanity. Watch all 33 rescues online at CNN. Elaine Schattner supplements this with a wonderful post, Copiapó Dreaming – The Copper Miners’ Tale, about the uplifting aspects of their story.

Luis Urzúa, the last miner to be rescued, celebrated with President Sebastián Piñera of Chile.

Along the same theme, we must remember and reflect on the brave men and women who put themselves in danger in the line of duty – fire fighters, police officers, EMTs, and medics. Some even choose this calling without the prospect of compensation. In Michelle Wood’s post, The Volunteer EMS, she recounts the story of her parents who worked as volunteer EMTs in a small town. She mentions a site with poetry dedicated to volunteer EMS personnel.

Moving on to more practical but still uplifting stories, David Harlow interviews Massachusetts State Representative Ruth Balser on the success of Massachusetts health care reform – the state has successfully achieved 97% health care coverage in just a few years. Massachusetts takes the lead again in patient-centered health care with new legislation. On October 1, 2010, it became the first state to require that all hospitals have a Patient Family Advisory Council. Read more at Bedside Manner in the post Leading the Way on Patient Centered Care. On a more personal level, in An Educator by Chance, medical librarian at Laika’s MedLibLog discusses the development and implementation of training modules for medical students and residents who are learning how to navigate the vast world of technology and medical information.

Rescuers applaud the rescue of a firefighter rescued at site of World Trade Center.

And that brings us to the life of the physician. The first Grand Rounds of the year, at Doctor Grumpy in the House, served as a humorous and disgruntled reflection on medicine. Today’s edition serves as a nice juxtaposition to this. Jill of All Trades, MD, writes about the positive aspects of being a physician in Practice Perks. She cites an article by Abigail Beckel in Physicians PracticeTop 10 Reasons to Be Happy You’re a Doctor. For all the physicians, residents, and medical students who are having a difficult time, enjoy these small reminders that our contribution does matter. Despite our endless complaints, grievances, and hardships, remember that the grass is always greener on the other side.

And now we move along to our patients, who are our greatest source of hope. Mattie Stepanek said it best, “While we are living in the present, we must celebrate life everyday, knowing that we are becoming history with every work, every action, every deed.” Bongi, a general surgeon in South Africa, writes about a fulfilling relationship with his patient in the gift. Spice Island Queen, who will be hosting Grand Rounds next week, writes about her experiences at “the best place on earth,” a Camp for Teens with Multiple Sclerosis.

Boy in Mid-Flight, Jodhpur, India in 2007. Photograph by Steve McCurry.

Happiness is not always straightforward. Although countless studies have examined what makes people happy, we have not yet come up with a formula that provides a clean-cut answer. But perhaps there are a few basic principles which can guide us along our path. A psychiatrist at How To Cope With Pain discusses some of these in Are Banana Split Jelly Bellies The Key To Happiness? No – But Here’s What Is (Even Despite Your Pain!). And to end with an uplifting note of laughter – the Happy Hospitalist shares with us a video about a comical interaction between a doctor and a neurologist.

I hope you all leave this morning’s Grand Rounds with a little hop in your step and flutter in your heart. Thank you for stopping by! Please be sure to check out Grand Rounds on Twitter and Facebook.

Grand Rounds: Uplifting Moments in Medicine

I am looking forward to hosting my first Grand Rounds next week! There are many things about medicine and health that are frustrating, angering, and even depressing. I have vented about some of them lately, as I complete a long string of shifts in the emergency department. But for the week of October 19, let’s take the “glass is half full” approach.

The theme: Uplifting Moments in Medicine.

The theme is broad-based, and I encourage all of you to use your imagination and think big. Uplifting moments can include anything about health, hospitals, health care providers, family, friends, dreams, life goals – anything and everything that has given you some sense of hope and enlightenment.

The words of Mattie Stepanek explain it best, in his poem below. Mattie, born with a rare form of muscular dystrophy known as dysautonomic mitcochondrial myopathy, was a writer and an optimist. Mattie began writing poetry at the age of three in order to cope with the death of his older brother. He published six collections of poetry and one collection of peace essays, all of which were New York Times bestsellers. Sadly, he passed away in 2004, three weeks before his 14th birthday. But his legacy – and his love for life – live on in his poems.

On Being a Champion

A Champion is a winner,
A hero…
Someone who never gives up
Even when the going gets rough.
A champion is a member of
A winning team…
Someone who overcomes challenges
Even when it requires creative solutions.
A champion is an optimist,
A hopeful spirit…
Someone who plays the game,
Even when the game is called life.
There can be a champion in each of us,
If we live as a winner,
If we live as a member of the team,
If we live with a hopeful spirit,
For Life.

Search for a hero, a slice of optimism, a diamond in the rough, a silver lining. Or anything else which suits your fancy. When you find it, send it along to idiopathicmedicine at gmail dot com. I look forward to reading your entries!

Abridged Version
Please submit entries for Grand Rounds by Sunday, October 17, at 6PM to idiopathicmedicine at gmail dot com.

Welcome to the Hotel

There are nights when being a physician in the emergency department is like working as a hotel manager on an event weekend. Tonight was one of those nights. Rather than saying, “My name is Dr. ___, and I will be taking care of you. What brings you into the emergency department today?” A much more fitting opening for most of last night’s shenanigans would have been, “Welcome to Motel 9. We have a beautiful ground-floor view of a drunk man stripping his clothes off just beyond that half-opened curtain. On the other side of the building, we have a free live music performance – a patient clucking continuously for all to appreciate. In the corner we have a young woman and an elderly man arguing over who will get to have their c-collar taken off first – that is, which one of them will be sober first. Pick your poison. This is a full-service operation, 24-7. The customer is always right!”

We aim to please.
“Doctor, I need a sandwich.”
“Doctor, I’m cold right now. I need more blankets.”
“Doctor, I really need to go to the bathroom. Now.”
“Doctor, you can’t let me go home. I’m not sure if I can get into my house.”
Yes, right after I take care of one or two dying people, I’ll get right on it. Full-service motel. We wouldn’t want any of you to go without a sandwich for more than two hours in the emergency department. That would be pure sacrilege.

And so I am drained. Ready for a reprieve from constant service, constant sacrifice, constant work. In time.

Nature, Nurture, and The Uterine Environment

An article published by Nicholas Kristof in The New York Times, At Risk From the Womb, discusses the mounting evidence that the uterine environment – rather than genes or environment alone – has an important impact on development. Several new studies have demonstrated that the mother’s health directly affects the long-term mental and physical health of the developing fetus. A recent article discusses new evidence that women who gain more weight during pregnancy tend to have larger-than-average babies who are prone to childhood obesity (see Gain in Pregnancy Is Linked to Weight Problems in Children). Evidence is mounting that maternal stress – which causes the release of cortisol in the bloodstream – can have negative effects on childhood development.

As this new field of research expands, it is important to keep in mind that for many of these studies – especially those which measure psychological health, intellectual development, and social interactions as outcomes – the multitude of confounding factors makes it difficult to tease out which factor – genes, environment, or uterine environment – were the primary cause in each case. All three of these influences are likely important in different ways – but how important, and how they interact with one another, are more difficult questions.

The impact of this recent news on young mothers, pregnant woman, and woman who have had a miscarriage can be devastating. I have seen several women who, after reading these articles, are wondering if it is their fault that their fetuses and children have health problems. Maybe if they had been thinner, or less stressed, or had eaten better during their pregnancy…things would be different. The new evidence is giving them concrete reasons to feel guilty – and even these feelings of guilt may have an impact on the health of their baby, thus the vicious cycle goes on.

So for the women who are asking themselves these questions, remember that it is a combination of factors – genes, environment, and uterine environment – which come together to influence the health of a baby. We can alter these to some extent, but not completely. And in the end, there is no scientific formula which guarantees that we are optimizing all conditions for a child. During pregnancy, the main tenets of success are relatively basic, and include (1) eating a healthy diet, both before and after the baby is born, to give them the nutrients they need and to reinforce important lifestyle habits for later down the road (2) maintaining a balance in life and finding ways to relieve stress – exercise, yoga, walking, and the list goes on (3) keeping regular appointments with your doctor, to check how you and the baby are doing, to get all of your questions answered, and to make any adjustments to your lifestyle that may be necessary.

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