Care from cradle to grave…or the other way around.

baby_feetI love my job. The reason I know I love it, is because I come into your room in the dark of the night to take care of you. I take care of you and yours when my own need taken care. I set aside the recitals, the school programs, and the PTA events to be with strangers at their time of need. I stand beside the gurney in the ER and discuss the risks and benefits of continuing your care. I discuss how aggressive you want me to be in your hour of need. Then, I follow you to the floor. I check in on your nurse to make sure that I’ve not forgotten the small details of care – like whether or not you have a diet ordered so you can have breakfast in a few hours. You may be feeling better or you may be worsening. I evaluate my treatment plan and worry and pine over you. Your job is to get well. My job is to worry. I do my job very well. The nurse pages me and your condition has deteriorated further. I stand with you as your soul leaves your body. I comfort your family after you have gone. We tell each other that you are in a better place. And my pager erupts. Someone else needs me. I think, as I take the stairwell, running over your last few hours. Is there a sign I missed? Did I do everything I could have or should have done? The next page is a new life entering the world.


I’m not the doctor. I’m the mom.

IMG_0603She grasps her chest dramatically and falls to the floor. Her eyes flutter as she tries to hold them closed. Her one arm across her chest the other flailed in theatrical fashion to her side. She’s dead. Her heart is broken. The other jumps from the bed, and after landing, reports her leg is broken. She hops about the room, unable to use the leg and there are no crutches or small wheel chair for her to use.

“Sweetie, are you okay?” “Mom, mom! Mom!!” “I’m not dead. I’m okay.” This last sentence in addition to the frantic “moms” break the trance that the chart-grind has induced. “What?!” I start. “I’m not talking to you. I’m talking to her.” She replies. This is number three discussing number two.   I realize the pretend play now. The doctor kit is scattered over the floor. Stethoscopes are draped from both necks. The pager hangs from one pajama dress. They rotate quickly back and forth who is the doctor who is the patient. So I join in, to number three, “are you taking care of her?” “Yes.” I smile, brushing the curls from her sweet forehead, “You’re such a great doctor.” “I’m not the doctor. I’m the mom.”

I watch in amazement as the two littles easily rotate roles. Why is this a difficult task for me? As I near the end of the second month of my practice, I realize over the last month, I have plunged beneath the seas of work and have not surfaced for life. The balance is off. I have the sensation immediately of being hit by another wave before I have gotten my breath. I can’t help but be distracted by the freedom with which they “practice” their craft. Magic Band-Aids are applied over broken hearts. The otoscope is used to evaluate the broken bone. The blood pressure cuff is applied to the ankle as a cast of sorts once the diagnosis has been confirmed. IMG_0641

Turning back to the computer, I stare at the work-list with charts, results, documents, and tasks taunting me. “You cannot complete me.” It’s like building a sandcastle at the edge of the sea. You may get the first towers built. You may insulate the castle with a moat. However, the tide is coming. And the work you complete will shortly be washed away. This is one of the most difficult lessons to learn as a new doctor. However, I am bound and determined to build. I will build a practice, but I will also build a life. It will be another long night. There are only a few times that there is this type of carefree play. The charts will wait. The broken hearts and legs I have seen through the day can have their notes finished after bedtime. Right now, I have two little girls that need a story and a cuddle, and I need a lesson in multitasking.


Burger (or Attending) Expectations

Let’s talk about expectations. And I’m talking the Dickens’ kind. When you watch television, the food flaunts itself before you. Tempting you with golden buns and perfectly placed pickles. The models eating those perfectly styled burgers are the same – airbrushed to perfection. Most often, limbs are stretched to unrealistic proportions and curves are molded and erased to fit someone’s view of beauty.

When someone first takes the baby steps to venture into medicine, they expect to find the cure for cancer. They expect to heal the sick and raise the dead. However, all is not as it seems.

The hamburger, and I’m not just attacking hamburgers – but that’s what’s on the menu tonight, is perfectly stacked and delicious appearing. However, when photographed from the back reveals the T-pins, sponges, and wax to make it so. So much more is revealed when the actual food itself is discovered to not be food at all but some substance that takes a better photo. Those ads sell because they appeal to the your (and my) mind’s eye.

pinkMedicine, when photographed from the back-if you could do that, reveals the red tape of unrealistic processes and procedures, coding complications, and the reality of the EMR. The delusional that enter medicine only see the styled front. We see patients. We see disease processes that can be treated. We see magic.

Who among us has not given “the talk” – I’m sorry your loved one is dying – only to see them make a full recovery. Later, they return so you can bang your head against another wall convincing them controlling their diabetes and hypertension could help ward off another heart attack. Who has not seen a patient survive a fatal congenital anomaly to later tempt fate with smoking, drug use, or some other equally destructive behavior?

But the dang ads are so tempting…everyone looks so happy. Not in the cigarette or drug commercials (I already told you those were fake…pay attention) – but the ads that are our experience. Ads that convince us this path is ours. Physicians, innocently, but deceptively coax students into deciding their specialty is the right one. Often, one preceptor can change the entire direction of a student. Recruit them to the dark side – because we have cookies or ice cream – or give them such a strong aversion to the field they determine then and there they will never practice in that specialty.

It is so difficult to then leave that daydream with perfectly proportioned everything and enter reality. Although they have seen some tarnishing of some their ideals, most residents graduate with a fire to still heal the sick and raise the dead. In the first years (let’s be honest weeks) of practice, it’s hard to see the magic. It’s hard to remember that even though the burger is not as pretty as the ad, it is still pretty damn tasty.


Birthdays.

Birthdays are special days. The day you became you. The culmination of your parents’ genes into what is uniquely you. “Today you are you! That is truer than true! There is no one alive who is you-er than you!”1 I have had a truly remarkable year. This time last year I was beginning the final year of residency.   I was at the top of the food chain. The senior walking through the halls. The short-timer.

The hubs and I spent a wonderful weekend away. We went to our old haunts to eat, drink, and celebrate. Celebrate the survival of another year. But oh, we have done more than survived this year.

steve-jobs-quoteBut what about those that haven’t? The day prior to our whirlwind celebration Katroo-style, I had a full clinic afternoon. I was on the verge of celebrating a year that has past and a year about to come when I was smacked with a patient in the afternoon whose years have now turned to months. She reminded me of how just mere months ago, she was diagnosed in her own whirlwind. In the blink of an eye, she went from an 80-hour a weeker for the local university to a patient with cancer. Every day is about the next appointment. The next time to take medication. The next symptom. On leaving, she told me she was just glad to have survived this long and wanted a hug, in case. She was weeks past her original deadline. There will likely not be another birthday for her.

The next day brought the stark contrast. Giggles. Singing. Dancing. The happiest of birthdays.  I am so incredibly blessed.

Then, from the top of the mountain we were thrust to the valley. Knocked from our swirling glitter to the cold black and white of a multi-trauma MVA on the side of the highway. Thank God for a complete training that helped us help those in need as we were witnesses and first responders. I should’ve paid more attention during the wilderness medicine afternoons, though. The side of the road is neither an office nor a hospital.

After, when we were both coated in the blood of the fallen, it’s difficult to find that light. Where did the sun go? How did the clouds and darkness move in so quickly? How do you celebrate life when you find yourself surrounded in death? It was a long ride in silence followed by a longer hot shower. Then, true to medical form, you discuss. You dwell. You share with people who both understand, and who wish they understood, (but secretly are glad that they don’t).

PSA: Wear your freaking seatbdr-seusselts people. And hug your loved ones.

We found the light, it eventually always comes back, and enjoyed the opportunity to celebrate another year, another milestone, one another.


1Theodore Seuss Geisel


Happy regardless.

One month behind me, I have a feeling of euphoria – and it’s not because I was kissed square on the mouth by a complete stranger. No lie. Well, I don’t suppose he was a complete stranger. I had taken care of him for two days. In the bargaining process for discharge, had I known that was what his hand held, I would’ve made my play from the other side of the room.

Apart from that, it was an interesting last week of my first month. This month, I was voluntold* to be a hospitalist. This was in addition to my expected duties of family medicine previously planned – outpatient, inpatient, obstetrics.

For you that don’t know the difference between a hospitalist and a doctor that visits the hospital, let me paint you a picture. The doctor that continues to do hospital work sees their patients in the hospital. Simply put, you’re sick; your doctor takes care of you. (A dying breed as mentioned previously.) The doctor has medical records, has rapport with the patient, and has the important history-medical and social.

This is drastically different than the hospitalist doctor. The hospitalist meets the patient for the first time at his or her worst. The patient is frustrated that they do not have “their doctor”. The hospitalist is frustrated with the limited amount of information available (or is not frustrated-and that’s even worse). I’m not sure how that is the hospitalist’s fault-however they take the brunt of the punishment.

And it is punishment.20578-happiness

I have grown so over the last week. TS Eliot said, “Only those who will risk going too far can possibly find out how far one can go.” I have had quite a few moments possibly going too far. The line between what was residency and what is becoming practice is quickly blurring-along with so many other lines.

Starting a practice has not been everything I had dreamed, but it also has not been the nightmare I feared. I have had a lot of help. I did miss the first day of first grade. I did drown a bit on rounds. But, I’m euphoric simply because I did survive. 264 months left.

*Deputy Adam

voluntold (v.): past-tense of voluntell; volunteered for something you didn’t want to do and have had no choice in.

 


Duck! He has a bat.*

Hospital medicine and outpatient medicine are two very different practices. At SMA, we try to blur those lines and bridge the gap. Who doesn’t want to see their family doctor when they’re the most sick? It is a dying art, and we know it. This week, I’ve been an obstetrician, a rural family practice doctor, a hospital doctor, an attending, and a hospitalist. It was a busy week, and all of my personalities are tired.

I delivered my first post-resident baby. By section. At 10. At night. The mix of fear, loathing, and excitement left me with a serious case of heartburn. She was beautiful, though. And mom and baby did well, despite the complications along the way. You know the feeling you get right before you bungee-jump? I want to go. I don’t want to go. AHHHH! Yeah. It was like that.

It’s the same, isn’t it?! I was just practicing medicine and delivering babies in June. Why all of a sudden is it so different?

In the office, we are busy. We have a full schedule. What. In. The. World?! Most docs fresh out get a break. They get an easing into their schedule. It’s the natural order. People have to find you. They have to fill out paper work. They get put into your schedule. And slowly. Surely. You build a practice. Why didn’t my schedule get the memo? Must’ve been the ad in the sports section!? Maybe it’s the referrals, (keep ‘em coming). I’m not complaining, really. I’m just trying not to drown. I think I needed a few more lessons before deciding to do an open ocean swim.

The hospital service for SLFP was completely reasonable for a new attending. I had an awesome group of slaves, I mean, residents who are perfectly capable. One of the many selling points of SLFP residency is that it does train residents to be doctors not residents. I feel the need to regurgitate the lessons and lectures I have just learned, myself, so few months ago, to the new doctors in training. I find myself, when asked a question, looking around like “Are you talkin’ to me?!”Babyduck

But in all seriousness, instead on the hospitalist service, you almost wish you had a gun that was holstered. You might need it! Some patients arrive armed. It may only be an index finger, thumb, and a paper bag. Or it may be the arm of a chair that has been disassembled and is now a bat for a minor-leaguer. So, duck if they have a bat. Because, after seeing 21 or more patients in 12-13hrs in a 72 and fluorescent environment, maybe it’s better your holster was empty. As 30 seconds to learn a lifetime of past medical that brought the poor soul in front of you is not long enough to know whether you should fight back or just get their coffee. Maybe I won’t be a barista after all.

 

*Teresa, local CM comedienne.


Deer daughters…

The oldest is reading now. I gave her Homer’s Odyssey for some light summer reading. She looked at me confused. Instead, I gave her Don Quixote de La Mancha. After all, she did start Spanimirrorsh last year in primer. I’m not sure why she can’t leap into reading these texts. They’re the basics, right? The middle duck is now writing letters. On good days, she can copy her name. However, she refuses to scribe for me to help with the new overabundance of charts. Slacker. Finally, the Biz is starting to color within the lines. We are overjoyed. I have put in her application to Julliard, but they have not yet responded.

Surely at this point you’re thinking to yourself how ridiculous this sounds. It sounds ridiculous, because it is just that, ridiculous. I don’t expect the divas to learn something one day and be experts in the field the next. Why do we expect residents to become attendings overnight?

I stand in the dawn of my practice ready to face the day with some trepidation, some excitement, and a whole lot of fear of the unknown. The funny thing is, I know these people. I know this place. I know the computer system. And I know where to find the bathroom. Everyone knows the most important thing in starting a new job is to find the bathroom. However, as I open the doors on the next chapter of this great adventure, I feel myself wanting to hide in the bathroom.

deerTomorrow will be just like the last day of residency. The only difference is that there will be no one to sign off the charts. No one to sign out to after the work is done. The office will be the same. The medical record will be the same. And there is a great likelihood that the patients will also be the same.

The difference is, it’s now my license. The difference is, my nurse and I will have our patients. We will not have patients that we inherit (if we haven’t already). I will not have restrictions on duty hours. There is no next rotation. This is our life. So like a deer in the road, I stand staring into the headlights that threaten to run me down. I do not plan to be road kill. And all those that wanted venison tonight for dinner, will just have to starve.


Good friends and golden weekends.

It’s a golden weekend.  Two days.  No work.  All play.  Golden Weekend!  Those are like unicorns or leprechauns.  To those in residency, the golden weekend is mythical.  Because, in reality, who has two days that they don’t fill with work?  Normally, in residency your every day work-list builds up while you are in the confines of your 72 and fluorescent environment.  You may finish all of your charts, review all of the laboratory values, sign the documents, but there is still work to be done. 

Typically, at SL we have more than our share of golden weekends.  Some may say we have it easy.  (Don’t admit it to the GME, but we do!)  We usually average two golden weekends a month.  Sometimes more.  Say it ain’t so!  However, as third year comes to a close, I find myself spending golden weekends moonlighting, reviewing for boards, and preparing presentations.  There is a point that medicine actually became my life.  I’m not sure when that happened, because the things appeared at onset to be independent.  The swirling of ice creams that has now melted into…one…big…mess.  Venn

In medical school, the kids, (you know, the single-party until 5am-sit through exam day-and still survive med-school), always wished they had my life.  The life of having a regular someone to come home and share in your struggles or successes, in addition to having a baby with her own struggles and successes.  It was a Venn-diagram with me being the only common link.  Slowly, as I have progressed through and am now at the precipice of beginning life as a REAL doctor, there are very few things that lie outside of center. 

This golden weekend, I’m coloring outside of the lines.  I have turned off my pager and left it in the car.  I logged out of Citrix, as the notes can wait until Monday.  The questions for board review will still be there after the weekend.  The presentation can be finished next week.  This weekend, I have a dear friend coming into town that I have not seen in forever.  At least it feels like forever.  The last time we had a visit was sometime in the blur of intern year.

This golden weekend, I will drink wine and monster energy drinks.  I will eat carrots and peanut butter.  I will laugh at our silly mnemonics that saved our butts on Neurology exams.  I will broaden the blue with memories, paint, music, and food.  I will share the divas with their favorite shoe-loving aunt.  It’s definitely a golden weekend.

If you have more than enough, you have too much.
Unless it’s love. Or shoes.  ~NW

 


Snow days = MORE!

South Carolina snoIMG_8510w days consist of a dusting of snow, bare grocery shelves, and the ever present, “be safe on the roads…they’re terrible”.  Okay, granted for the majority of the state, we do not have snowplows, snow tires equipped with chains, or the army of sand trucks.  However, have you been outside?  The most dangerous thing I faced today was a 2-year old going up and down brick steps dusted with fresh powder in cowgirl boots so she could use her sidewalk chalk on the patio.  Uh, what? tumblr_m70a6qnzcS1rnjxnao1_500

While many of my friends have been placed on lockdown by their hospitals, most-definitely violating their 30-hour work rules, I’m at home in my pajamas (most-definitely NOT violating the work rule).  Coffee in hand, I have a snow day.  SMA closed the office for the morning, and our conference was on-site.  Depending on the site, residents learned how to treat frostbite from tiny fingers, how to treat indigestion from eating too many “snow snacks”, and how to treat bruised egos from sledding mishaps.  One of the many reasons SL is the place to train.  I’m certain that my fellow residents are seeing some amazing fractures and dislocations, that the drop in barometric pressure is wrecking havoc on the pregnant population, and that I could use the board review time that conference was suppose to bring.  However, I’m also certain that I have enjoyed…every…single…minute…of my snow day.  There is more to life than a days’ work.  Today, we get to enjoy more.


Care killed the cat.

We have a new bedtime routine.  After our usual evening activities, and she is tucked into her bed under her favorite blankie like a burrito, number three takes her chubby hand and places it next to my cheek.  She then gently presses my head onto her chest.  Sitting there, kneeling next to her bed, I hear the rhythmic beating of her gentle heart.  I try to escape, there’s so much work still to be done, but as I raise my head she presses gently so I give in, and rest my head back on her chest.  This time, she strokes my hair.  I believe she is hoping I will fall asleep and she will have a bed-buddy for the night.  There are times I find myself starting to drift, and as her hand and breathing become heavy, I sneak away from the cuddliest creature on earth.  Charts to be done, presentations to be reviewed, and articles to study.  Tonight I stayed a little longer than most nights.

It was a hard day.  I spent the day moonlighting.  The work is not so different than most everyday with an added bonus of an extra paycheck.  The difference is, I do not know the history.  Likely, I will never see these patients again.  That is so difficult for me.  I need to know what happened.  Did the patient lose her finger, from a necrotic abscess I discovered; was the abdominal pain in the 80-year-old just because of a urinary tract infection, or something more ominous?  That’s one of the many reasons I chose family medicine over the many other specialties.  But, did you hear? Curiosity killed the cat.Screen Shot 2014-01-26 at 9.31.12 PM

In addition to the 80-year-old with abdominal pain, the lady with the possibly necrotic finger, the lacerations, and the countless strep and flu patients I saw today, I saw a 12-month-old with a fractured tibia.  Apart from the pain-seekers, this is my most despised type of patient to see.  The parents are unable to form a consensus on the story, but no matter, the injury doesn’t match anything they’re spinning.  As professionally as I can, and it takes a whole freaking lot, I tell them the “injury pattern is not consistent with the history”.   A report is made, but we are advised that a home visit will be made at a later date – unless we have other reasons to believe this sweet babe should not be in the care, and I use that word loosely, of her parents, she will be discharged home with them.  What reason do you need?  Our system is broken.

Everyday, we face tumblr_m70a6qnzcS1rnjxnao1_500challenges that at times seem insurmountable.  We surmise the training we have received, the medications we can use, and the tools we have available will cure what ails you.  But it can’t always.  No matter how many times you succeed, it’s the ones you don’t save that stick with you.  “Care killed the Cat. It is said that a cat has nine lives, but care would wear them all out.”1

Tonight everyone got an extra squeeze and mooch.  This story, is one I’ll spare them.

1Brewer’s Dictionary of Phrase and Fable