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.

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!

Thanksgiving in the Hospital

I press on the gas, lean back against the head rest, rest one elbow on the consul, and glide along vacant lanes of highway. Speed, and the absence of traffic, is almost exhilarating at 6AM in the morning, as gold rays pierce through a lattice of cloud cover. One more day in the hospital, in this long string of days. As I walk through the tunnels to the entrance, weary faces pass in the other direction – worn but polished with morning light. Ready to leave. Comforted to be going home, even if only to crash on a pillow. I have a fleeting wish to turn in the other direction, but I suppress it, keep walking, pretend I don’t notice the lump building in my throat. Just another day.

A boy playing in a marketplace with a strutting old gobbler entertains Chichicastenango visitors by doing the son, a dance popular throughout Guatemala. Luis Marden, National Geographic.

Inside the hospital, it is not Thanksgiving. Small, lonely reminders of what is missing – a turkey poster on a wall, the festive sweater of a passerby,  a holiday song playing faintly in the cafeteria – make for a somber backdrop to the day. It would almost be better if there were nothing at all. It is not Thanksgiving inside these walls. It is on the calendar, if one were to look, but in here it is only a shadow, an echo, a memory reverberating through the sterility and the sadness. It is a day to remember – even to long for – all of the better, healthier Thanksgivings before this one. The ones to be thankful for.

The families in the hospital are quiet. Sadder today, if that is possible. One father, rubbing his eyes and rising from a hospital cot as I enter the room, says to me, “I’m with my little girl today. That’s all that matters. That is Thanksgiving.” Another anxious mother raises her eyebrows, “Do you think my son will be able to go home today? It is Thanksgiving, after all.” A grandmother greets me with her new plan, “We are going to reschedule Thanksgiving this year. Thanksgiving will be when my baby comes home. Then we will have a turkey to celebrate. Yes, Lord, we will.” A five-year-old boy begins the day by singing in his room. He ends the day in tears – no one in his family came to visit like they promised.

Holidays in the hospital are some of the saddest times I have experienced. Families, patients, and even nurses and physicians – their yearning for home becomes more poignant. An anxious longing to be elsewhere pervades the building. But we are all resigned. We imagine Thanksgiving beyond the windows. The empty roads are the only sign that something else, something better than this, might be happening in other places. But try not to think of this. Instead, think of it as just another Thursday. Another day in a string of days. The time to celebrate will come, but not today.

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.

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.

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