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.

Suction, please

I arrived at the hospital as the sun was rising, the sleep slowly wearing off and the coffee ran through my veins. I planned to sit down at a computer in the office to start reviewing my patients charts before going to see them, but the morning had other plans for me. My doc walked in moments after me saying, “There’s a patient in the ED trying to die on us”. My sleepy brain registered the labs he’s relayed to me – pH of 6.9, base deficit of -10, possible dead gut.

If you didn’t know, now you know, a pH of 6.9 is bad. It’s a measure of how acidic your blood is and normal is ~7.4. When the blood becomes acidic it’s a sign that lactic acid is building up, a sign that there are tissues that are not getting any oxygen.

She needed to go to the OR, stat. He showed me the scans and we took the stairs to the emergency department. There our patient was writhing in pain, conscious, but barely able to answer our questions. I’ve never seen anyone as sick as her and she was sick. My doc was saying she might die, but would she? I wondered how I would handle another patient death so early in my third year. Would it be like the patient before?

There was no time to ponder these questions as we wheeled her to the operating room, scrubbed our hands clean and approached the sterile field. This was going to be quick my doc told me. We were going to open her belly, see what was going on and get out as soon as possible.

That’s what we did. The first cuts through the abdominal wall revealed dead gut, revealed a stench, revealed a new life for this woman. Black tissue popped free the moment we broke through the fat into her abdomen. It was her colon and small intestine that were causing the problem. We removed them both, leaving healthy small intestine behind.

Her abdomen left open and she was transferred to the ICU in order to receive fluids and blood products. She was alive.

We took her back to the OR the next day for another operation. She was still alive.

She would go back to the OR again another day. She is still alive.


The opportunity to save this woman’s life does not escape me. We didn’t really do that much, but what we did do will change the course of her story. It allows her story to continue. It allows her grandchildren to know her more fully, for her family to spend more days with her. Life, it’s a beautiful thing.

Surgery was on my list of possible specialties going into my third year. It’s been at the back of my mind since I was an undergraduate performing surgery on rats, and I suppose since I was a child. My grandma recently reminded me of when I was younger and determined to be an orthopedic surgeon.

I learned this week that my left hand is uncoordinated. I learned that dead intestine smells horrible. I learned that six laparoscopic cholecystectomies can all be different, but every patient will be grateful for the removal of their gallbladder. I learned the three keys to success in surgery –

1. Eat when you can

2. Sleep when you can

3. Don’t touch the pancreas.

I learned that being in the OR is exhilarating and I learned that surgery is definitely staying on my list.

Three Words.

Courage, Patience and Connection, these are my words of 2019. I chose them when I was reflecting on 2018 and I was thinking about what my hopes and dreams are for this trip around the sun. One didn’t fit without the other and I think I’m only just beginning the ways that they weave together.

I chose courage because the second half, of the second year of medical school is notoriously one of the most difficult, all because of this little blip in April. It’s called the USMLE Step 1 and is the first of board certifying exams. Basically, it’s a multiple-choice test in clinical vignette style based on the first 2 years of medical school. Each question goes a little something like this:

A 35-year-old woman presents to the emergency department with acute onset shortness of breath. She states that she recently returned to the United States from a trip overseas when she started having pain in her left calf. She has a 10-pack year smoking history and takes oral contraception. Her labs show…. Which of the following possible risk factors is most responsible for her symptoms?

Do you know the answer? It’s okay if you don’t!


I seek courage to face each day and to look inward at my own strengths. I’m an Enneagram Type 1 and basically that means that I’m constantly striving for perfection. I know that’s an unrealistic expectation, but that’s where courage comes in. I’m looking for courage to make mistakes and to stumble from time to time this year.

I seek patience to trust that the plan I have is the best one I can come up with and that the rest is held safely in the hands of God. Today, I had my first test in the Infectious Disease block. It didn’t go as well as I hoped, and as I looked at my score, I felt this deep sense of frustration that I wasn’t good enough, or that somehow, I’m doing this whole thing wrong. I looked at the average and my mind went to all of the ways that I didn’t measure up compared to them. This comparison game is one of my biggest enemies, so I’m seeking patience to trust in my own learning and in the cycles of ups and downs.

Connection is my final word because I want to hold tightly onto human connection. A few years ago I read this article but it still feels relevant. All of her sentiments ring true and leave me feeling convicted of living life in distraction. I’m seeking to connect deeply this year, with friends, family, patients, the world around me.

Courage, patience and connection. Those are the words of 2019 and I guess I’m a perfectionist that tries to see the world as a glass half full of cabernet sauvignon, full bodied and savory.

Do you have a word? Or two, or three?

October in Review

October in review, for all of the things that I’ve wanted to say this month but haven’t had the time or energy to channel them out into the world wide web.

Maybe it’s better this way. I’m not sure. I’m still trying to figure out how to keep this blog going while in medical school.

October was a challenging month. It started with the end of the neuro block, 8-weeks of grueling coursework in the nervous system. With all of our exams on Monday mornings, it makes it really challenging to take a guilt-free weekend off from studying. By the time we got to the end of neuro I was tired and beaten down, but we picked ourselves back up to start the GI tract the next day. The rest of October passed in a blur of brown-tinged jokes and complaints of abdominal pain. What causes diarrhea you ask? It feels like a million things.

My patience was tested. My focus was tested. My ability to find that elusive balance was tested.

On October 1st, I saw a beating heart. In a human body.

On October 1st, I got the opportunity to shadow a cardiothoracic surgeon while he did an open repair of someone’s ascending aorta. Those are basically all fancy words for the tube that comes off of your heart and sends blood to all of the different organs in your body. It’s pretty important that it is strong and sturdy, but sometimes they become stretched too thin and that’s when we worry about them breaking. So, this surgeon went in and replaced a piece of this man’s aorta with a manufactured tube. It was incredible and exhilarating and humbling, all at the same time. I was also terrified of the possibility of tripping and falling onto the patient the whole surgery. My mantra for the day, “do not fall, do not fall”.

On October 8th, we finished neuro and promptly ate our weight in Denver Biscuit Company.

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On October 10th, it snowed.

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On October 12th, my friends and I went to the ballet, Sleeping Beauty. We put on our fancy dresses, I put on some new lipstick and we pretended to not be medical students for one night. Which was actually pretty difficult because we went to the ballet with the CU School of Medicine Alumni Association… Also, I may or may not have rested my eyes during the first act.

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On October 27th, my 2011 MacBook Pro was considered to be a “vintage machine”. I don’t think they understand what the word “vintage” means, but I bought a new computer anyways.

I had been thinking this month about some of the things I was thankful for because my cousin Katie was running a series on her blog about resistance and gratitude. I sent her 5 things, but I left out one. I’m really thankful for student loans because without them I wouldn’t be able to get through medical school. So, while I have to pay them back eventually, at this moment in time I am able to focus on becoming the best doctor I can be, while not having to worry about where my next meal, rent check or gas money will come from. Because of student loans, I can purchase a new computer. This is a privilege.

All through October, we studied a lot, making tables and graphs of the diseases of the GI tract, and having a little bit of fun along the way. Now here we are, on the edge of November.

This month I was challenged to be faithful; to trust in what is coming and what I cannot yet see. To trust that this hard work will pay off and that the season will change. I am encouraged.

How has October been for you?

 

 

Keep Going

We’ve been on a road of neurons and the connections their axons make. A road filled with the cranial nerves, stroke consequences, brain tumors, and psychiatric disorders.

Everything brain.

A rhythmic pulse of a beating heart.

A rise and fall of expanding lungs.

Tears of joy, ecstasy, sorrow.

A decision to choose. To say yes or no.

These are all things brain. The axons are highways and side roads that traverse through our bodies. They cross in predictable places and they carry predictable information. They are critically important, yet fragile all the same. Learning the mystery of the brain has been both rich and exhausting, and if you’ll have me, then I’d like to tell you a story.

It starts with a man and is a story of resilience in the face of hopelessness.

Resilience is the ability to spring back, to adapt to change, to grow out of the dust of defeat and to keep going when everything else around you is yelling for you to get down. 


This man came to us as part of our psychiatry course. This is how it works:

  • The school puts out a call for volunteers to be interviewed by students.
  • A volunteer shows up on the prescribed day and enters a room full of 8 medical students and two facilitators, 1 psychiatrist, and 1 psychologist.
  • The volunteer is asked questions about their experiences with Depression, Anxiety, Psychosis, Autism Spectrum Disorder, PTSD, Substance Use to name a few examples.
  • After the volunteer leaves, we discuss their stories as a group with our facilitators.

This man, he entered the room, carrying a cup of coffee and wearing a hat with the words “Resist”. His wide eyes sagged like he hadn’t been sleeping well and he told us a story of assault, depression, and anxiety. This story had twists and turns, frustrations and sorrow. He told us that he attempted suicide, twice. Sleeping two hours a night gave him the dark circles under his eyes and panic grabs hold when he thinks about what his life will be like when his loved ones are gone.

As I listened to him share his story I felt sadness and despair. I thought to myself that this man knows what it’s like to be pushed down and told not to get back up.

When I asked him, “What motivates you to choose to continue living?”, he said my family, my grandchildren. He said, today my depression doesn’t feel that bad. Today is not as dark as yesterday. This man picks himself up and he chooses to brush the dirt out of his scrapes to try again. As I was reflecting on his story and our interview with him I thought to myself, if he can keep going then so should I.

Sometimes I forget how lucky I am to be given the opportunity to be in medical school. Lately, when I feel defeated and beaten down by the number of things there are to learn and the amount of time I have to learn them, I try to remind myself of all the people that are anxiously waiting to hear about an interview. I try to remind myself of the privilege that I am given because, one day, I am going to be a doctor. In moments of doubt and uncertainty, I try to remind myself if he can keep going then so should I.

So, we build resilience. Every time we fall, stand up, rub the dirt out of our scrapes and try again.

“The phoenix must burn to emerge” – Janet Fitch

A Story

Once a month, at the Swallow Hill Music Hall in Denver there is a gathering of people. To listen to strangers share their fears, accomplishments, comedy, sadness, and adventure. It’s beautiful to watch someone walk up on stage, brave enough to speak out loud some of the most vulnerable details of their lives. This is the Moth story slam.

10 stories. Five minutes. Three judging teams. One slide whistle. One winner and a theme.

I’ve been to the Moth a few times now and listened to people share narratives about love, dirt, collaboration, and control. You never know where the evening will end up. You might find yourself in a backyard while a man gains the trust of a wild dog, or with a couple as they race down a mountain trail while lightning strikes all around them. Each one unique and captivating.

In Bob Goff’s latest book, Everybody Always, he talks about the power of extravagant love and excessive grace. It makes me a little sad because when I look around, I see that we have too little of this. We have too little compassion and empathy for one another.

It’s all about ourselves; how can we be better, how can we make more money, how can we climb the ladder a little higher. We are so tired from the constant focus on self-improvement that somehow we don’t even have enough grace for ourselves.

In medical school, we talk a lot about becoming compassionate and empathic doctors. We have communications sessions where we “practice” talking to patients. These are supposed to help us refine our language to include open-ended questions, to demonstrate empathy, and to learn to listen to the patient’s concerns, think of how all their symptoms come together and know what comes next. I struggle with this a little bit because we can practice saying the words, “that must have been difficult for you” instead of “I’m sorry”, but as much as we practice, it won’t help us be authentic when we find ourselves in a patient room. In order to do that, we need to pull from within our own experiences of hardship or loss, celebration or joy.

This is where our stories come in, as they shape our identities and our actions. They allow us to relate to one another, to stretch our minds to consider another person’s point of view, and to be true to our hearts when we speak.

There’s something so powerful in the words “Me Too”. They say I hear you, I see you, and I know you. In “Me Too” there is an overflow of extravagant love and an abundance of grace, but we can’t get there is we don’t know our own stories first.