Did I Get a Gold Star?

What is success?

I’ve asked myself this question a lot in the last few months as I’ve battled with thoughts of comparison and self-doubt. My performance has been under the microscope as we hastily wrap up our third year of medical school where our grades are mostly determined through individual evaluations by our clinical preceptors. For them it’s a task on their to-do list, but for me these comments have impacts on my future opportunities. That feels like a lot of responsibility for a couple of sentences typed into a box on the internet.

As their words appeared on my screen some of them made me stop to think, “Is this enough to…?” To get the ranking, the membership to some society, the job at that residency program, to get the gold star. I wasn’t sure.

A conversation with a mentor has helped me start to shift my perspective. She validated my feelings, but then went one step further to suggest that perhaps my definition of success could come within. She challenged me to answer the question – what is success?

This past year success has looked like my patients telling me they would want me as their doctor in the future. It’s looked like someone telling me they trust me. Success has been making space for important people in my life outside of medicine. It’s been performance on exams, but it’s also knowing that this information I’ve learned will help me change a life. Success was overcoming my fears, trusting myself and leaning into the difficult and tireless moments. It’s reflection, tears and humanity.

The combination of letters in my evaluations might tell the story that I can take a good history and present it in a clear and concise manner. They might say that I’ve learned the neuro exam and have been a good advocate for my learning. But those are only a piece of the story and they’re missing all of the details.

I had the day before Thanksgiving off, but I had just finished a week on in-patient medicine and one of my patients was still in the hospital. I decided I would go visit her because she seemed so lonely, and I didn’t want her to feel alone around the holiday. We sat and talked about how she was feeling, then she told me about her family and what they normally do for Thanksgiving. As I was getting ready to leave, her eyes filled with tears and she looked at me and said, “Can I ask you to do me a favor?” “Yes, anything” I replied. She said, “Tell your Mom and Dad that they should be proud”.

That’s the gold star. Those are the details worth mentioning.

Equity//Equality

Are we playing at being God when we are forced to choose who gets the single remaining ventilator? When we decide to withdraw care in order to free up scarce resources?

Who will be there to pick up the pieces for these physicians who are making these decisions that no human was meant to face?

So, we create recommendations and positions for people who aren’t involved in direct patient care to decide. It makes it less emotional. We distance ourselves from the humanity of it all to protect ourselves from the trauma.

I have to wonder though…

Do the algorithms and guidelines consider things like unconscious bias when they ask us to decide who will be more likely to survive if a treatment was allocated to them?

They say that the triage protocols are being developed using population data based on several social determinants of health. Consider if you had asthma because your childhood home had mold. Or that your hemoglobin A1c is off the charts because your only access to groceries is the local convenience store. Will these metrics decide that you don’t get the ventilator because your survivability is lower compared to the person who has grown up in a safe, stable household?

What about decades of institutionalized racism? Do the flow sheets account for the reason why a disproportionate number of African American and Hispanic individuals have co-morbidities because of a society that undermines and diminishes their rights as humans?

**this post was originally written on 4/5/2020

We Spin On

**trigger warning**

A family friend shot himself in the head last week.

Is that jarring?

I thought so.

He’s still alive, but probably not for much longer. Going home on hospice care because the ventilators are needed for other people who want to live.

Anger. Sadness. Despair. There is no room for second chances here.

How did we get to this place? Where doctors have to decide who lives and who dies due to a shortage of supplies? Where we desperately use a single mask for a week?

It’s covered in virus.

We have a president who thinks we are okay because this is America and we have been made great again.

Dare I ask, what are we great at? Self-preservation for one as evidenced by empty grocery shelves and stocked cabinets of those who can afford to spend extra at the market.

On the other hand, I’ve witnessed greatness through simple acts of kindness. Humans being humans and looking out for one another. Through individual states who had led the way to protect the vulnerable. The grass that’s beginning to turn green outside my window.

Though it may seem that the world is on pause while the coronavirus wreaks havoc.

The Earth still spins.

24 hours per rotation.

**this post was originally written on 3/29/2020

Who Sets This Curve?

In college, there were always those students who “set the curve”. They did the best on exams and therefore defined how the grading would play out for the rest of the class. We have a different kind of curve on our hands, but we all play a role in how this curve is set. We will all play a role in who will be beneath the curve and how steep or flat it ultimately becomes.

At first, I thought that I was outside this curve. I’m 28, young, healthy and exposed to viruses on a regular basis at the hospital. I had a trip to Paris planned for as soon as I finished third year. We were going to sip on wine and eat baguettes. I didn’t care if I got sick after the trip, as long as I got to go. This was in February, as we were first starting to see flights canceled and the numbers spread. Still, we held onto our trip.

Then, in the beginning of March I participated in a tour of community resources for individuals with intellectual and developmental disabilities. Accompanying me on the tour was a physician who cares specifically for the IDD population and I heard her express concern over how COVID-19 was going to impact this community. What would happen to them if their primary caregivers became sick? What would happen to Day Programs where many people with IDD go during the day if someone who attended became sick and still went?

I grew concerned when I began to see first-hand who was going to be impacted the most.

I still didn’t want to give up my regular schedule. There were only 6 weeks left in my third year and I had patients I was looking forward to seeing back in clinic. I had skills I was looking forward to perfecting. I had surgeries I was looking forward to scrubbing in on. Pausing clinical rotations was a devastating turn of events. But then, I thought about how many people I interacted with on a daily basis when I was working in the clinics. I did the math. At least 25 people in one day. How many others do those 25 contact in a day? I understand now how things go viral.

Maybe I will be outside this curve meaning that I won’t get sick, but that doesn’t mean I don’t have the ability to affect it.

So, I stay home and hope that others do too.

We get to determine how this plays out.

We get to decide to flatten the curve.

There Are Lessons to Be Learned

I sank to the floor and tears rolled down my cheeks when I read the email titled “Pause to Third Year Clerkships”. I was trying to stay calm before this huge decision, but I felt overwhelmed and out of control the moment it was made. Between the stresses of finishing up third year, studying for final exams, choosing a specialty and planning for our fourth year this was the straw to break my camel’s back.

What would happen next for us?

It’s been over one week since the news that brought me to my knees. In the last week, I’ve been on numerous virtual calls while spending a lot of time with my cat. I went to the grocery store and bought a half-dozen eggs because that was all that was left. I learned how to put a phone on hold, transfer calls, and checked on my grandma to make sure she didn’t go to her regular card playing event.

No one knows the answers, but my school has jumped at the chance to use this pandemic as an opportunity to learn, to grow as leaders, to serve our communities in other ways than with direct patient care. We are open to allowing these uncertain times shape and mold us for the better. That being said, it would be dishonest to say that I’m not worried for what will happen next or wonder how this will all pan out.

At the end of the day, I’m incredibly thankful for the lessons I’m learning and the grace that there is for everyone who is just figuring it out as we go. 2020 will be the year of rolling with it and we will come out stronger no matter the course set before us.  

Another Cancellation

COVID-19

This seems to be the word on everyone’s lips. Followed by anxiety, fear, astonishment and uncertainty. We get multiple emails a day with updates but even that doesn’t feel like enough. It’s changing rapidly and now I’m sitting in my apartment for what feels like the 100th hour practicing “social distancing”.

We aren’t canceling events because the virus is incredibly dangerous to the healthy many, but because it poses a threat to those of us who aren’t privileged enough to have strong immune systems. It poses a threat to our capacity as healthcare workers to properly treat and heal, because even though we are the great United States, and we spend almost 18% of our GDP on healthcare, we still have limits. Limits that exist in the form of ICU beds, ventilators, doctors, nurses, and even N95 masks.

This is why we are isolating. It’s not for our own personal benefit, but for the benefit of other humans. Does that make it any easier to swallow?

Even as I sit here, I struggle with the need to do something, the feeling that all will be okay, while also heading the advice of the experts.

On my clinical rotations, I feel like a nuisance. I’m “non-essential staff”, technically they can treat and care for patients without me. I’ve been told not to see patients with fever, cough, or shortness of breath as their chief complaint. We aren’t allowed in the OR’s in order to save masks for those who need them. ED shifts are being canceled and the communication from the medical school administration are too few and too vague. They too don’t know the answers that we all desperately want to have. I feel pushed to the side while the real doctors are overwhelmed with the prospect of pandemic.

This feeling of helplessness when you’ve been training to be the exact opposite is something I’ve struggled with all year. What do we do when we can’t do anymore?

I think the answer is LOVE. We meet people where they are and say, “I’m here with you”.

And while I stand the recommended 6 feet away, we’re in this together.

This isn’t about me, or you, but about us.

Not My Patagonia

I slowed my pace as I walked from the Emergency Department CT scanner back to my computer in Care Unit 1. My shoes briefly disturbed the down that had settled on the floor. Gravity pulled it back to the ground. 

As I passed the recess bay, my eyes turned to where more feathers rested amidst the gloves discarded in haste and drops of blood left behind on the sanitized stage. He was in the hands of the trauma surgeons now with act two listed as a pelvic artery embolization, followed by an appearance in the operating theater. For a moment, the emergency department had returned to calm as the actors dispersed at the end of a rehearsed performance.

He came to us for help after he was struck by a car. The charge nurse told the room as we prepared for his arrival by ambulance, “pedestrian versus motor vehicle”. My preceptor would later draw an image on a sticky note for me; pictured was a car and stick figure as they made contact. One of our learning points for the day would be the classic pattern of injuries seen in these types of situations.

Who was he, our main character? John Doe, a man who happened to be wearing a blue Patagonia jacket when he became the victim of an unfortunate accident. The EMS team wheeled him in and the room sprang to action; a dance unfolded before my eyes. We methodically assessed his airway, breathing and circulation. “Do we have a blood pressure yet?” 80/40. “Let’s get some fluids running.” He shouted in pain when we pressed on his pelvis. We wrapped him in a pelvic binder. Abdominal ultrasound didn’t show any free fluid, but that didn’t mean it wasn’t there. We rushed to the scanner in search of more information. There was a blush down in his pelvis on CT, a sure sign of ongoing bleeding and an explanation for his soft pressures.

It was almost a comical scene as I recalled the feathers marking his path through the hospital, the lead trauma surgeon failing to remove them from his pant leg while we waited for the scans, the suppressed laughter from the staff watching these repeated attempts, the EMT apologizing for creating this mess.

But, what was this mess? Would John have made a different decision on his choice of outerwear had he known that he would later be center stage?

In the wake of John’s appearance in the ED, we lamented the inconvenience of the feathers and commented on how we would continue to find them in various corners of the department for weeks to come. My preceptor and I discussed the sticky note. I wondered how he was doing in the next act. In the midst of this tragedy, I wondered if John would be upset upon finding his down jacket ruined and scattered across the hospital halls? Would he find some humor from the way he entered from stage right? Or would it not matter that his coat was destroyed in the effort to save his life?

It wasn’t my Patagonia, but it’s caused me to pause all the same.

Since that morning in the ED, I’ve had the chance to visit and learn more about who John is. When I told him about the jacket, a knowing smile erupted on his face and his eyes pointed to the cupboard in his hospital room – “It’s in there”.

Hermit Trail

I tried to sleep at the trailhead after parking at 3 am, but all I could think of was whether or not there were mountain lions in the Grand Canyon. Sitting in my car, waiting in the darkness, I remembered that best practice was to never hike alone. I remembered that if you chose to hike alone, then you should let people know when you expect to return, but my people were down in the bottom of the canyon without cell phone service. My thoughts spiraled… this was a bad idea.

Despite these fears, I laced up my hiking boots and hoisted my pack onto my back. I wasn’t going to let these last-minute doubts ruin all the planning and dreaming that had gone into this moment. Walking into the Grand Canyon from the rim it was pitch black except for the tiny beam of light coming from my headlamp. The silence was broken by my shoes crunching rocks, my breath quick. With each step the darkness slowly lifted and soon enough I turned a corner to see the Earth drop away into the depths of the canyon, while the sun grazed the walls rising around me. I continued to hike, following the trail that hugs the canyon wall while slowly descending deeper, and I felt like someone in “Honey, I Shrunk the Kids”; a miniature version of myself picked up and placed on a topographical replica of something imagined.

After hiking for several hours, I began to wonder when I would run into Leah. According to our newest plan (hatched over the spotty satellite phone connection), she would start hiking on Hermit Trail from Granite Camp at 4 am. We would hopefully pass each other on the trail, she climbing out, me climbing in, but I left the keys at the car. Just in case.

The moment I saw Leah approach me was the moment I was first able to breathe deeply, and a weight lifted off my shoulders. Maybe this crazy thing was going to work out all along. We exchanged a hug, some snacks and I checked in about the first part of the trip while Leah checked in about my exam the day before. We snapped a selfie and departed in our own separate ways.

The next big hurdle was meeting the rest of the group at the beach before Hermit Rapids. I arrived around 9:15 and sat down to wait; stripping my shoes off and dipping my toes into the cold, clear Colorado River for the first time. It was hard to relax (I wasn’t quite on river time yet), so I paced, applied sunscreen and checked to see exactly how squished the cupcakes were that I brought with me for Garrett’s upcoming birthday. They were only **slightly** squished. Around 9:45, I spotted a single raft at the bend in the river. Then two, three … four. Okay, now I could relax and it was going to be an FA day.

Ice…And Tequila?

Alternative titles, “The Big Ditch” or “The Grand Canyon”.

Our trip down the Colorado River was years in the making, starting with a dream and a group of men, who were once boys at Colorado Mountain College together. As a kid, I got the chance to go on a couple of raft trips. The first was also on the Colorado River, but where its runs through Westwater Canyon in Utah. I distinctly remember holding onto the front of the raft and watching the wall of water, wave after wave, come towards my face, while screams of joy erupted from within me.

Time passed and a little over two years ago, while I was returning from Thailand, I started reading the book, “The Emerald Mile” by Kevin Fedarko. A beautiful and gripping tale of the fastest run through the 300 miles of river that cuts the Grand Canyon. It tells the history of the canyon, a story of exploration, destruction, bravery, redemption and revitalization. As I read, I felt as if I was racing through the canyon myself and I knew that I was captivated by the beauty, power and awe of this place I barely knew.

Luckily for me, my dad never stopped dreaming about another trip on the Colorado River. I can now safely say that if you ever get the chance to row [or ride] a raft through the Grand Canyon do not hesitate. Drop everything and run to Lee’s Ferry.

I’ve been trying to figure out how to share about this adventure and I think I’ll do a mini-series. So, hang on to your hats and get ready to high-side because as they say on the river, “We’ll run her down the gut”.

Waiting for the rafts to all clear Bedrock Rapid. It looks like you can go right or left at the top, but if you go left you end up in deep trouble. You gotta pull hard right and glide through the rest of the way.

Stuck

July began in the hospital, with my first week on Internal Medicine. IPIM, or in-patient internal medicine, is our chance to learn how to take care of patients who are admitted to the hospital. We have four weeks spread throughout our third year that consist of 6 days each. The hours are long, and its filled with mountains of reading, thinking about and caring for acutely ill patients.

My first patient presented to the emergency department the day before I arrived with shortness of breath. He was recently discharged from the hospital, after more than 100 days for the same chief complaint. He was back because he was unable to refill the proper medication, and so his chronic obstructive pulmonary disease (COPD) worsened. He needed increasing amounts of oxygen to breath, his legs were swelling, his cough worsening, and his mental status deteriorating. By the time I met him, he was receiving steroid therapy, antibiotics, and more oxygen. I listened to his lungs with my stethoscope, and my novice ears heard wheezes for the first time.

Throughout the week, I would have many firsts.

I had my first patient tell me that I was being mean when I went to examine him. I tried to brush it off, because hey, no one enjoys being in the hospital, and no one enjoys being poked and prodded at 7:30 in the morning.

I had my first patient who wouldn’t talk to me.

I had my first patient who refused almost every recommendation we made. We recommended physical therapy, he refused. We recommended eating his meals sitting up, he refused. We recommended breathing treatments for his COPD, he refused.

Eventually, we got him up for a walk (his first time out of bed in 3 days). His lung sounds, and breathing became easier. He ate dinner in the chair. It felt like we were making progress, and I counted these as small wins.

The fourth day, he returned to his “baseline”, requiring only small amounts of oxygen and the daily medication therapy for COPD that was typical for before his hospitalization. We began to discuss discharge from the hospital.

My patient was experiencing homelessness, and part of the reason he stayed in the hospital so long previously was because social work had difficulties finding someone willing to provide long term care for him. He had been denied from all rehab facilities because of behavioral problems. The case manager recommended that we discharge him to a motel, with medication and oxygen.

The fifth day, social work provided him with a list of motels. He refused to call them. He told me, “you guys are pushing me out of here. I need more time to think.”  

It broke my heart to hear him say those words, because what I heard was you don’t care. I worried about whether I was treating him different than my other patients. I worried about if it was true, that I didn’t care. I wondered about what the role the hospital must play in his life. No one likes staying in the hospital, but if it meant a warm bed, food, safety and constant healthcare, then maybe staying in the hospital isn’t so bad.

What is the big picture role of the hospital? As a doctor, I will work to uphold the ethical principle of justice, meaning I will treat individuals fairly, including through equitable allocation of healthcare dollars and resources. By allowing a patient who is medically stable remain in the hospital, am I fairly allocating the resources with which I am entrusted? I struggled to answer this question, because it felt (and still feels) cruel to send someone into a poor living situation, knowing that it most likely won’t go well and they would be back in the hospital again soon. I will also work to uphold the ethical principle of nonmaleficence, or “do no harm”. If I discharged him, would this bring harm to my patient?

On the 6th day, we discharged him, and he was back in the emergency department 3 hours later with shortness of breath.