As I begin to round the bend on my last lap – year four of residency – my view of the world has opened. My tunnel vision is beginning to subside. I take in my surroundings – the rooms of my emergency room, the closets, the counters, these cold, hard tiles. This chair and counter, where I have spent countless days and nights, working, racing, learning. Even these will be gone soon. It is the simple things – the distinct sound of the black phone ringing next to me, begging to be heard as I stubbornly ignore it. Room Number 5 where, for the first time, my attending turned to me and said, “You saved someone’s life today.” I see the ghosts of patients in each bed – how many I have cared for. I wonder if they still remember me.

I realized today that residency is not static. The people who have come on this journey with me – we have traveled through residency together, but we have also traveled through life together. Some have balded, others have given birth. All have cried and laughed and struggled. Some have suffered through their own illnesses during this time, or the loss of loved ones. And our attendings – they too have aged. Four years is not an insignificant amount of time in life.

I had hoped that time would freeze during these last four years – and that somehow I could it win back. I deserved it – after all that I have sacrificed. But time – life – does not work this way. These years have passed…and I have let them pass by simply waiting for the end. Looking back, I realize how much has been lost, swept away, missed. Life has happened during these years of tunnel vision, sleepless nights, and overwhelming hardships.

I feel my feet on the pavement – there is a calm that comes with rounding the bend on lap three. Deep breaths, fresh air – I am finding my stride as a physician. My pace is steady now – the finish line is close enough that I can sense it right there, just beyond my reach. My shifts ebb and flow, all with the knowledge that the river has run its course and I am almost there. The ease with which I now do central lines, arterial lines, intubations, lumbar punctures, calms me. There is a peace that comes with lap three. I will take this time I have left to look around, to remember, and to think about all that has happened on this journey.

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.

The day passed as many days have passed in the intensive care unit – extubating one patient, intubating another, placing one or two central lines, and being present with families in a time of crisis and even in the face of death. It is a charged atmosphere. At one point, our hospital raised the Donate Life flag in honor of a young gentleman who had died and donated his organs to patients in need across the country. At another point, we gathered round in a patient’s room with family and chaplain to offer the only piece of caring we still could offer her – empathy, compassion, and prayers.

The families and patients in this unit have reminded me, over the past few weeks, of the primary reason I chose to become a doctor: to care for my patients. Patients roll into this unit on stretchers, many with breathing tubes in place, many so confused or sedated that their memories of this visit will merely be a vague sense – blurred brush strokes across canvas, lacking definition or purpose. But perhaps it is better that they do not remember – it serves as a survival mechanism, if they ever make it out of here.

All too soon, however, reality will hit. Some of these patients will be paralyzed for the rest of their lives. Others will never be able to eat or lie flat again, because they are at such a high risk for aspiration . Still others may never speak again because of malignant masses occluding their vocal cords. Hard to imagine, really, but it happens here every day.

Even with these tragedies, though, some patients will make it out of the ICU in good health, at least in a medical sense. But even they must struggle to overcome the effects of their prolonged hospital stay – weakness, anxiety, fear. Many of them will need rehabilitation, both mental and physical, for extended periods of time.

“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?

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!

As I glance out the windows at a stone garden where a little girl in a hospital gown throws a ball to her father, I wonder if residency is a process that will encourage me to close the doors of the hospital, inch by inch, never to return again, or if it is a process that will allow me to re-open the doors, ever so slowly, as I recover from the hours that I have spent here healing patients.

The sun shines bright, and rain pours down outside. Clouds linger in the distance. The rain is gray but sparkles. The greatest paradox. A beaming smile curled with doubt at the edges. Eyes wide and bright through tears. Hope high in the midst of devastation. Expect the worse, hope for the best. Residency is not unlike a downpour in sunshine – and I, drenched but warm, through it all, have reached the peak of this mountain and am now ready to trek down the other side. Unchartered territory, slippery at times, but less daunting – and less exhausting – than the ascent. This I can do.

We are entering into a transition time in the hospital. As July approaches, the new interns – with fear and enthusiasm that now amaze me, although I was one of them only 24 months ago – are entering the realm of the hospital for the first time as doctors. A momentous occasion. But as I gaze at them, I realize that an insurmountable barrier has formed between us. How can I tell them what to expect? How can I explain to them how they will change in these coming years, how they will be challenged, and how hard they will be pushed – emotionally, physically, and intellectually? No words or experiences will do this journey justice. It is very much an individual journey – shaped by our unique encounters with patients, physicians, and one another.

Earlier this year, I used to approach my drive to the hospital with dread. But now I approach my drive to the hospital with a sense of wonder. I understand, sadly, that I will not be able to save everyone who rolls through the doors. But I am confident that I will be able to make a difference in the lives of my patients. I am confident that I will work to help people heal – and even to alter the course of their lives.

The sun shines on a downpour. Tears, regrets, the past trickle down into the drains. The grayness of the world is lessened by these rays, which boldly penetrate a place where they are unexpected, but where their warmth – and persistence – are always welcome.

And the cure? Well, as with so many things in medicine, there is none. There are several laymen’s approaches to arresting hiccups that are often used by patients before seeking medical care, some of which rely on pharyngeal stimulation or interference with the normal respiratory cycle. These include: sipping ice water, gargling with water, biting a lemon, drinking water upside down, drinking water from the far side of a glass, a teaspoon of vinegar, a teaspoon of honey, and holding one’s breath. The list goes on. A letter to the editor, Granulated Sugar as Treatment for Hiccups in Conscious Patients, published in 1971 in the New England Journal of Medicine advocated for the use of one teaspoon of white granulated sugar, swallowed “dry.”

The medical anecdotes are not well-studied, but chlorpromazine - an antipsychotic – is perhaps the most widely accepted agent for the treatment of persistent hiccups. Metaclopramide may also demonstrate some benefit.

For patients with persistent hiccups, the inconvenience – and annoyance – can become unbearable. Hiccups can ultimately lead to weight loss or difficulty sleeping and thus have an impact on people’s lives. As we continue to advance our medical knowledge and skills, perhaps we should look back at one of the simple, familiar, age-old problem which remains very much a medical mystery.

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.

A young girl, without a seatbelt, drives into a tree and is now unable to move her legs. An older gentleman, riding a motorcycle without a helmet, no longer remembers what year it is. A high school athlete, driving drunk in the middle of the night, now lies in the hospital incapacitated – three of his limbs splinted, immobile. A pedestrian, in a moment of impulse, runs across the street and is hit head-on by an oncoming car. He does not survive.

Trauma. It strikes at all hours of the day and night. It happens in the blink of an eye, and the world shifts permanently.

Do not drive drunk. Wear your helmet. Do not get distracted by the moth in your car. Do not text while driving. Do not eat while driving. Do not let your anger get the best of you – pull over, cool off, then continue on. Do not let anyone interfere with your concentration. Do not get in the car with an unsafe driver. Do not take your seatbelt off 30 seconds before the car is parked.

Always, always wear your seatbelt. Never, never let your eyes leave the road. Do not take this 5 minute trip home for granted. Do not assume that you will be saved. Be safe. Take care of this fragile, precious vessel – the human body. It is not as durable as you might imagine, or wish.

Perhaps we do not educate children enough about the importance of these messages. Perhaps it would not make a difference.

We will never have the chance to exchange our bodies for another one . The spinal cord does not fix itself. The brain does not heal so easily. Our eyes – they are our once chance at vision on this earth. Do not forget these things. Remember them, act on them, before it is too late. There is no second chance.

The idea that writing is therapeutic, and can even improve performance, is not a new one. It has been utilized effectively in poetry therapy for centuries. The first known poetry therapist was Soranus, a Roman physician who lived in the 1st century A.D. And the same concept is now being implemented in medical schools, as discussed in a recent article in The Wall Street Journal, Poetry, Painting to Earn an M.D..

The process of writing has much to offer all kinds of people – physicians, patients, bloggers, novelists, musicians, engineers. To pick up a pen and express how we feel is a momentous step in the process of self-discovery and personal growth. Perhaps incorporating writing more into the daily life of physicians and patients could be an effective way to improve communication, reduce stress and anxiety, and develop closer relationships in the hospital setting. From a practical standpoint, this becomes difficult when there is simply not enough time to take a step back from things and write. But if a brief amount of time were allotted each day – even 15 minutes – to writing, that might provide a source of relief for weary minds and downtrodden souls.

The concept of narrative medicine has taken hold at some university hospitals, with Columbia University at the forefront of this movement. The idea behind narrative medicine, at least in part, is to hurt and to heal through writing. The process of taking a blank page and beginning to express all of the grief, life, death, pain, hope, and fear that lives and breathes in the walls of the hospital is a formidable one. It is almost overwhelming. There are so many stories to tell, so many plights to share. But this could bring into the world of academic medicine a fresh breath of air – and a new source of healing.