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.

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?

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.

Trauma

It is the title of this month’s rotation. In practice, it is more than that. It is lives changing in an instant. It is the careless slip of the wheel beneath a distracted driver’s hands, the slightest swerve of a motorcycle to avoid a bump in the road. It is lives that will never be the same again. In the hustle and bustle of daily life, it is easy to forget how quickly the world spins into catastrophe.

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.

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