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.

On winter solstice, or becoming real

December 2011. X marks the spot. In exactly 18 months, this journey will be complete. But now is the time that I begin to get nervous. Residency is easy, relatively speaking. Easy, you may ask? After these blog posts about grieving, hardship, long hours, and sacrifice? But how?

Ah, my friends, I have painted the picture too grimly. It is only with time that my lens has cleared and reveals…life in the real world. Residency offers us much protection. We have strict hours restrictions. We still go to school, and get paid to do it. We always have an attending to call on for help. We always have the excuse that we are “still in training” when there is something we do not know. We are protected from much of the litigation that floods the world of medicine today.

It is the life of an attending that is difficult. As emergency physicians, we bear the weight of people’s lives on our shoulders – and we do it alone. And, in some sense, we harbor responsibility for each bad outcome that happens on our watch, in our department. And – if we are good – we ask ourselves, again and again, “Was this something I could have prevented, if I had acted quicker, smarter, better?” And we ask, “Was there something I missed?” And we ask, “What if?”

There is a quote from a children’s story that I will cite here…

“What is real?” asked the Rabbit one day.

“Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you.”

“Does it hurt?” asked the Rabbit.

“Sometimes,” said the Skin Horse, for he was always truthful. “When you are Real you don’t mind being hurt.”

“Does it happen all at once, like being wound up,” he asked, “or bit by bit?”

“It doesn’t happen all at once,” said the Skin Horse. “You become. It takes a long time. That’s why it doesn’t happen often to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in your joints and very shabby. But these things don’t matter at all, because once you are Real you can’t be ugly, except to people who don’t understand.”

- Velveteen Rabbit, Margery Williams

Residency is all about the process of becoming real, of walking farther along the path to “doctor-hood” – the path to adulthood. The path to making one’s own decisions and standing by them, come hell or high water. But you realize that this journey to “real” has happened only after it is complete, all finished, in the blink of an eye. Real creeps up on you that way, nice and quietly, and then it is there forever.

But, as I look back, the Skin Horse was right – Real is a process, bit by bit, day by day. Over the years, residency has taken its toll, the wrinkles are there, my hair has been loved off, and the memories of all of my patients – through life, death, and everything in between – are present in me, subconsciously affecting my decisions at each critical turn. And real hurts, too – more than you would imagine. No one ever said it would be easy. It is scary sometimes. Sad sometimes, too.

But it is real, after all.

I still remember when one of the bravest attendings I know told me that she had hoped, in those first few years after residency while driving to her single-coverage overnight shifts at the hospital, that she might get into a minor car accident just so that she could have a reason to call out that night, not go. She is one of the bravest people I know. And even she had a hard time becoming real, in the beginning.

People ask me what I want to be when I grow up, now that I will be graduating in 18 months and interviewing for jobs in less than a year, and I look at them, perplexed. I know what I do not want to be when I grow up – a medical resident. That is for sure. But what do I want to be? Maybe a real doctor, maybe not. Maybe a writer, but that will never pay off my monstrous loans. Maybe a teacher, I have always loved to teach. Or maybe I just want to be me for a while, and be free for a while, not a slave to my occupation.

I always used to have an answer to this question. In high school, I wanted to go to college to be pre-med. In college, I wanted to be pre-med to go to medical school. In medical school, I wanted to go to residency. And somehow, after all these years of a nice, clean and cut path to success, I find my feet faltering at this next step. Part of me is hesitating, does not want to venture on anymore.

The more time passes, the farther I travel, the less I know. But maybe this is all part of the process…I am not real yet, after all.

Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

Another day, another summer…

Heat rises from the sidewalks of the city. Backyard grills appear again. Sun dresses, outside tables, kites, picnic baskets, bike riding. The world welcomes us to summer. In the hospital, it is a time of great change. All of us – residents, fellows, medical students – are moving on in our journey. Over a period of a few weeks, we will be “promoted” to new positions in the hospital. Some of us – those who have completed their training – will be leaving, to become attending physicians at last.

The emergency room, windowless and air-conditioned, feels the heat of summer in our patients. Sunburns, carbon monoxide exposure from boats, firework injuries, fractures from playing sports, dehydration, heat exhaustion, and the list of summer maladies goes on. And so it is with the seasons of emergency medicine.

Here are some important words of advice, for those of us want to enjoy our summers and avoid the emergency department.

1. Wear sunscreen. This applies to people of all ages. Do not let the urge to get a beautiful tan quickly take over here. Use at least SPF 15, preferably 30 to 45. Wear baseball caps and sunglasses. Protect yourself from those rays which will wrinkle your skin, penetrate the epithelial layer, damage cells, and increase your risk of skin cancer.

2. Drink water. Lots. And look for signs that you may need more water – darkened urine, decreased urine output, increased thirst, decreased skin turgor, dry mouth, light-headedness, or lethargy.

3. Be aware of running boats, and avoid swimming in these areas. Refer to a CDC report from 2004 for more information, Carbon Monoxide Poisonings Resulting from Open Air Exposures to Operating Motorboats.

4. Do not operate equipment while drinking alcohol. This includes boats, lawn mowers, grills. Some studies have estimated that 6 to 45% of injuries that present to the emergency department are alcohol-related cases. Refer to a World Health Organization project website, Alcohol and injuries, for more information.

5. If you ride a motorcycle, wear a helmet at all times. Wear protective gear. Do not ride after drinking alcohol. Be careful on the roads. Do not ride in the dark if at all possible.

6. In the summer heat, invest in air conditioning. Approximately 400 people die in the United States per year of heat stroke, which is defined as a core body temperature that rises above 40C. Refer to an excellent review article published in the New England Journal of Medicine in 2002 , Heat Stroke.

These tips only touch the surface – but they are related to some of the most common, and devastating, injuries that we see in the emergency department. So cool off, be responsible, enjoy the summer, and avoid the emergency department if you can!

For the residents…

Only today did I realize that after almost two full years of residency, I have not yet acknowledged one of my greatest sources of support – my co-residents. They have stumbled along this path, by my side, step by step, over the years. They have celebrated, and grieved, and learned alongside me. They are the pillars that hold me up when I am ready to fall. They have demonstrated to me, time and time again, that if they can do it, so can I. They have scaled this mountain with me, pulling me along when I began to lag. Without co-residents, this journey would be impossible. They inspire me to be a better doctor, a better teacher, a better student – every day. And I go to my limits for them – work-up a patient at the end of the shift only so that it will be easier for them when they come on, call a consult so that they will not have to deal with the inconvenience.

Residency is about caring for patients, but it is also about caring for one another – volunteering to work extra time when a colleague’s baby is sick, or when someone needs to get to a graduation or a wedding on time. I cannot imagine this journey without them. And as I venture into year three, when we will be transferring patient care from our hands into the hands of one of our co-residents, this bond only becomes stronger.

More on trauma tomorrow, but for today, a thank you to the residents – my support, my vitality, and my strength through this minefield of residency.

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