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.

This Too Shall Pass

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.

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?

Coming to a close…

As the first half of residency nears an end, I recall this year – with all of its trials and tribulations. There were days when I walked through the ominous double doors of the hospital’s front entrance and wondered if I would ever emerge from them again – and if I did, how changed I might be. There were days when I was so frustrated to look down at my pale blue uniform and realize that the blueness had penetrated me, coursed through my veins, made me sad. There were days when I was angry to be in the hospital and not home. And there were days I was grateful to be here, honored to care for my patients with compassion and concern. This place has grown on me, and it has challenged my perspectives on healing, illness, and hope.

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.