my soft voice

Earlier this month, I did an overnight call and around 10pm, a trauma alert was called because a young person was in a car accident and was on her way to the hospital - with a big head injury.  She arrived in the ICU after going directly to the operating room to have a large hole cut in her head to make room for her expanding brain.  We checked her in, noting that she was in decerebrate posture (meaning "without the brain", and that she had a brain injury that was low enough to interfere with her brain's signalling to her spinal cord).

Staring at this young woman, all I could think was: this could so easily be me or any of the young people in their 20s who are in cars that I know and love.  A few hours later, one of the ICU nurses who is about my age came into the ICU, in regular clothing, not scrubs.  We all looked at her and said, "Alison? (*not her real name, obviously) What are you doing here in the middle of the night when you're not working?"  She told us that she heard that her friend (our patient) was at the hospital, in the ICU, but she didn't know what had happened.  She turned to the resident with whom I was working - who was, basically, the first line of the ICU during the patient's admission - and looked at him, questioningly.  He used a soft voice and said, "Alison, her pupils were fixed and dilated in the OR."  At this point, Alison screamed, covered her mouth and crouched down on to the floor, as if she needed all of her energy to bear the news and had none left over for standing.  My resident, for better or worse, kept going and described the situation in grave and great detail, continuing to use his soft voice.  Even though the news was terrifying, there was something about the tone, the volume, and the caliber of his voice that was almost eerily comforting. It seems like an important skill for a doctor to have - this soft voice - because some words are so important, yet so horrifying that they cannot even be said by most people in most voices.

And with that story, so begins my last week of being in the hospital as a medical student.  This Friday I start my TA month (hello sleeping in until 7 and sipping coffee slowly while someone teaches me...yessss) and then I'm finally taking a vacation in March and April.  More on that soon.

~~~~~~~~~~~~~~

"I prefer winter and fall, when you feel the bone structure of the landscape - the loneliness of it, the dead feeling of winter.  Something waits beneath it; the whole story doesn't show."

- Andrew Wyeth

Peacemakers

For a little weekend inspiration, before some more heavy stories from my month in the ICU - 
in hopes that my path is taking me further towards becoming all of these roles

“The plain fact is that the planet does not need more successful people. But it does desperately need more peacemakers, healers, restorers, storytellers, 
and lovers of every kind. 
It needs people who live well in their places. 
It needs people of moral courage willing to join the fight to make the world habitable and humane. And these qualities have little to do with success as we have defined it.” 

-- David W. Orr

the presence of justice

photo source: lisa congdon art and illustration; check out her awesome blog here

two stories

I have a hard time writing about spending time in the intensive care unit, because generally it's not my favorite.  I'm much more of a keep people healthy and make them healthier than looking death in the eye and stopping it in its tracks, or at least holding it off for a while on a daily basis.  I'm glad other people want to go into critical care medicine because I do not.  That said, I want to be able to handle myself in a crisis, as they arise even in people who are pretty healthy.  I also think it's important in medicine to think about the ways in which people die, the process of dying, and learning how to help people confront dying and cope with changes.  This and more is why I chose to spend my January days in the Surgical Intensive Care Unit (also called the SICU), even though it sort of terrifies me.

Today I have two stories for you.  One was recounted to me by my attending this morning on rounds, and the other is about a patient I saw earlier this month.  I'm not sure why, but I want to see them side by side.

Story One.  Katherine is a 99 year old woman who has lived a very satisfying life.  She has four children and 10 grandchildren who live somewhat close by.  She has been generally healthy all of her life and decided when her husband died 20 years ago, to move into an independent living community for older people.  As she has gotten older and frailer, she has moved into a room on a hall with other residents of her community.  Everyone in the community is required to complete most of their activities of daily living (bathroom, eating, bathing, etc) with little to no assistance.  This suits Katherine just fine.  Every day, she wakes up and walks down the hall (using her walker) to breakfast, where she sometimes talks with friends or acquaintances, sometimes gazes out the window at the trees and birds outside.  After breakfast, she usually returns to her room or to a chair in the library to do some reading or knitting.  Then she usually has a small lunch - usually just a soup or salad - and returns to her room for a short nap in the afternoon.  She spends time with family or friends or catches up with them on the phone, attends dinner, takes a shower or bath and goes to bed.  She has noticed that she is less interested in talking with other people and has less of an appetite, but enjoys sitting in quiet and thinking.  One day, she gets up on at her usual hour, heads to breakfast and chats with a few friends over some oatmeal.  She returns to her room and instead of picking up her knitting, she takes a shower, puts on her favorite blue dress, her pearl earrings, and lays down on her bed.   Her daughter finds her later that day when she comes for a surprise visit.  Her daughter says that Katherine looked so peaceful and it felt as if she had just decided her time had come and she was ready to leave this life and move on.

~~~~~ *** ~~~~~

Story Two.  Tracy is an 18 year old young woman who lives with her parents and her younger brothers.  Until today, she has been pretty healthy besides struggling with depression which has led her to experiment with alcohol and marijuana with some friends on a pretty regular basis.  Her parents are very concerned and have tried everything they can to help Tracy.  She regularly sees a psychiatrist who prescribes her medication, and a counselor with whom she talks through some of the struggles in her life.  One day, a few days after Tracy and her boyfriend had gotten into a big fight, and a few days after she had increased her dose of her antidepressant medication, Tracy is having a conversation with her parents and then leaves to go to the bathroom.  After ten minutes, her father starts to wonder if she is okay and decides he is going to go check on her.  He finds her hanging by a belt above the bathtub in a suicide attempt, with vomit on her chest.  He immediately supports her, undoes the belt, and brings her down to the floor.  He screams to his wife to call 911 and begins CPR.  He feels like time goes on forever before the paramedics arrive and take over.  Tracy is taken to the hospital, found to have no serious traumatic neck injuries but very critical hypoxic (from not enough oxygen) brain injuries.  She is comatose and must be put on a ventilator to breathe.  Her parents struggle with the decisions before them - with the doctors saying that it's too soon to tell what Tracy's prognosis will be, but implying that no matter what it is, she won't be the same person she was before.  Her mother asks when they have to make decisions about more invasive measures, like a feeding tube or a tracheostomy (a temporary incision in the neck where a breathing tube can be placed to avoid inhaling vomit).  Her father asks if we need information about the angle of the belt around her neck, because if it would be helpful he could draw it - goodness knows he can't stop picturing it.

~~~~~ *** ~~~~~

I'm still processing these stories and thinking about why I wanted them next to each other.  But I think I also wanted to give you - and probably mostly myself - a sense of what's hard about medicine.  It's not just the long hours inside or the lack of time to eat or see the people I love, it's being confronted with impossible scenarios and the most critical and poignant moments of people's lives on a daily basis.

"but a mountain you're plannin' on climbin' ain't the same as the one you ain't.  

It ain't so pretty, nay"

- David Mitchell, Cloud Atlas

(book review to come)

work I must do

"the best way to predict the future is to create it"

- by one of the doctors at the conference I attended

(I'm going to look up who and correct this soon)

2013 is the year of big decisions and a big transition for me, with the start of residency about half way through the year.  The process of interviewing has been an introspective experience about the doctor I want to become, the service I want to provide, what are the roles I want to emphasize as a physician, and talking with Chris about the best decisions for our life together.

I also had the opportunity this past week to present at a national conference about the medical education of obstetrician-gynecologists.  It was an incredible experience - not just because my presentation was so well received - but also because I was surrounded by people who are really passionate about teaching adults to be phenomenal physicians.  As part of the conference, the participants reflected on the physician they thought they were going to become when they were in medical school and how that compares to their reality.  For me, this was less reflection and more thinking forward about the type of physician I want to become.  In many ways, the writing of a personal statement as part of my application was a laying out of those aspects of the field that are fascinating and compelling to me, but this conference inspired me to be a bit more specific.

Here's the mission statement I've come up with so far.

*To be healer and promoter of health to my patients and in my community

*To be an advocate for women's access to health care and reproductive rights

*To be an educator and mentor, improving how we train the next generation of women's health physicians

*To be a researcher of best practices - determining how to better maintain and restore women's health

I've also been thinking a lot about the environment I train in, and thinking how important it is for me to be surrounded by people who inspire me, who challenge me, and who make me want to be a better doctor and person.

As part of my thinking about how I want to live my life and what's important to include in it, I read about this guy, Scott Dinsmore, and his company, Live Your Legend, on a great blog that I follow.   Check out his Tedtalk about finding your passion and doing the work you love.  It's definitely inspiring.

2013: Let's Go Exploring!

I feel so grateful at the start of this new year 

I got to spend a few days with my family, am almost finished up with my requirements for medical school, am done with travelling for interviews, and rang in the new years with so many wonderful friends.

***

for a few years now, my friends and I have, instead of resolutions, come up with words as themes for the upcoming year.  stay tuned for reflections on last years word, LISTEN.

as well as ideas for my word for the upcoming year: COURAGE.

what's your word for the upcoming year?

~~~~~~~

"Life loves to be taken by the lapel and told: 'I'm with you, kid. Let's go.'"

-Maya Angelou