The pains of Monday, the gray of growing

In the emergency room, Monday is the worst. There’s no way around it. People hold off coming in during the weekend; they hope their symptoms will get better, figure they can hold off just a little longer. And this sentiment begets the Monday afternoon flood of patients – inevitable, painful, never ending. There are some days when things are simply off – today was one of those. My rhythm was broken – in part by an extra person in my critical care area, in part by the patient volume. And so I limped along, feeling as though I was missing something on every patient. There are days like this, I have come to realize. There are days when I find my rhythm easily, get in the groove of things, and then there are days when this breaks down and frustration builds. Unhappy patients who have been waiting hours to be seen does not help the situation. It breeds a highly tense environment, where I feel that I need to first calm people down, then need to care for them properly, and – lastly – to calm myself down. Easier said than done.

The light at the end of the tunnel is here, though. Tomorrow will be my last shift in the emergency department as a third year resident. Hard to believe, really. Only seven more months to go in the coming year, and I will be an attending physician. My blog post on On winter solstice, or becoming real is ever present in my mind and my heart. This is really it. I am savoring every moment left I have with an attending shepherding me, offering his or her insight. And at the same time, I feel as though I am ready – more than ever – to fly. For my patients, I have a strong, growing desire to execute my own plans rather than those of my supervisor. I am ready to be their doctor.

Hues of Gray, Marsha Heiken

I used to believe that residency was a mountain I needed to climb, and that as soon as I reached the summit, things would become clear. But residency is just a small part of a much larger journey – an uphill climb – continuing to learn, continuing to improve my skills, continuing to question myself. Becoming a doctor is a lifelong process. It requires constant questioning, self-reflection, and yes – even self doubt. To become a good physician is to continue working and learning, day in, day out, year after year.

Because no patient is ever black and white. Each one is gray, with subtleties to their stories that can trick you, trap you, mislead you. The skill and art lies in finessing your skills in interpreting each and every shade of gray, in considering each subtlety, each shadow of doubt that crosses your mind. It lies in continuing, no matter how many years of experience you have, to harbor that fine element of uncertainty, of imperceptible fear, that keeps you on your toes, that keeps you wondering. We doctors will never have all the answers. Thoroughness, experience, compassion, and most of all humility are the best we can offer our patients.

Maybe…

To know that even one life has breathed easier because you have lived. This is to have succeeded. -Ralph Waldo Emerson

Easter Sunday, another chaotic shift. I held a woman’s head gently as she vomited into a bucket, while her 80-year-old mother pulled her hair back from her face. I watched a family weep for not one but two losses, a mother and her daughter. The emergency room was packed. And tragedies always seem even sadder on a holiday.

In light of all this, I realize that I have reached a different vantage point this month. First was the climb, which began slowly in year one. Then I began to climb faster, and faster still, covering more and more mileage in year two. Efficiency, skills, technique – these I have developed and polished over the last three years. But now I have reached another, entirely new vantage point – the higher I climb, the more I see as I look out below me. The emergency room lies in a valley, and I watch the ever-changing landscape with vigilance, calm, and still a slight bit of fear – fear out of respect for what I know can happen here. I envision my patients all there in the valley, and surrounding each of them in my mind’s eye are their illnesses, their perils, and the possible paths that we may tread down together over the next few hours.

The metaphor may seem abstract, but it is not. Each patient occupies a distinct territory in my mind  – and the physical equipment surrounding each of them pertains to what I perceive their needs to be in the next few hours. The people around each of them are families and friends. And the boundaries separating these patients are minimal – mere curtains between one and the next. These patients and their families, strangers outside these walls – here, in this landscape, they have become neighbors. They hear and view the suffering of one another. They share a common path today.

As the guardian over this landscape, I watch my ever-changing valley over the course of my shift; I watch these patients’ stories unfold. I can smell forest fires and hear distant thunder from miles away, and sometimes I can even predict their exact location and nature before they occur. Other times I am caught off guard, but only for a fraction of a second until I compose myself and begin to react. And although these are my grounds, I too – like my patients – have become part of the landscape.

My patients’ suffering, the pathophysiology of disease, the hope of their families, and the waiting – all of these realities are entwined together in my mind as I watch this landscape unfold before me. It is a breathing, living being. And I am watching it all, but also sculpting it in my very palms – trying to change people’s paths, trying to readjust things to make for a better picture, trying to create health from sickness. Trying to help people live. And I am doing this with the nurses, the technicians, the chaplains, the social workers. We are all doing it together. Creating and recreating a landscape. Trying to paint a more beautiful picture.

We only have a small hand in this, though. We can only offer our intellect, our sweat, our compassion, and our skills. But even this – how much does it really change people’s paths? Less than we might hope.

Even so, I still hope. Maybe my presence, or spirit, or efforts – maybe they will make the difference. Maybe they will be just enough to change one destiny, to paint one or two strokes on this landscape that lies below me, to leave one sculpted mark on this world. Maybe one frail mother will keep her petals a little longer in the wind with my palm shielding her. Maybe the umbrella I cast beneath the clouds will save one small boy who lost his raincoat.

Maybe not. But maybe…. And it is the maybe that makes me keep coming back. It is this maybe that makes me not want to give up, in spite of how difficult and trying this journey has been. It is this maybe that makes me want, more than anything, to be an emergency room doctor.

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