Monthly Archives: December 2024

Hello 2025

Posted on by

The Red Wheelbarrow

By William Carlos Williams

so much depends

upon

a red wheel

barrow

glazed with rain

water

beside the white

chickens

~

2024 was a toilsome year interspersed with joy and success. My themes were quietness, pause, and connectivity. It was the first calendar year spent 100% in residency: the lack of time off, no control over my schedule, and too many hours worked made me weary. Yet, despite these challenges, my year was fulfilling. I took several amazing vacations – a highlight was going to Costa Rica which included a 4-day trek in the mountains. I’ve enjoyed camping, sharing moments with family and friends, and completing my first half-marathon since I started medical school. I added back a few non-medical activities I’d put on hold when I started residency because (back then) I didn’t have the bandwidth for them. It’s exciting to have tangibly more time simply because I’m more efficient than I was in the beginning of residency (hard work paying off). This year I’ve seen my ability as a doctor grow and am proud of my progress. I feel more confident in my clinical decisions and more able to help my patients than ever before. I’ve also started to envision my career after residency – I can’t wait to be an attending physician.

2025 will be the second (and last) complete calendar year of residency. I’ll be halfway through residency on January 1, 2025. On December 31, 2025, I’ll only have 6 months left. 2025 will be a practical year for me. I’m hoping to solidify my medical knowledge and my abilities so I’m ready for residency graduation. By the time I write a post welcoming 2026 it’s highly possible I’ll have a job lined up – amazing how time flies. Yet, while I’ll focus on professional development in 2025, I’ll also work to maximize my life outside of work. On the nonwork side, my focus will be cultivating time with loved ones, embracing non-medical pursuits, and spending as much time outdoors as possible. My themes for 2025 are curiosity, resilience, and gratitude.

Curiosity

Now that I’m settled in Richmond, residency, and my 30s I’ve found that I’ve fallen into a routine of familiarity. This year I’d like to shake up that routine by jumpstarting curiosity. I’d like to see things through new eyes and challenge myself to answer questions I’ve brushed aside because they aren’t central to my daily trudge. I’d like to dig deeper and challenge myself to learn and do new things.

Resilience

Residency is hard and I feel worn down. Further, I find the negative aspects of healthcare sit heavily –examples are healthcare’s money focus and its inequity. When I’m baseline tired because of work I find it hard to flourish in non-professional aspects of life. I think 2025 is a good year to acknowledge how hard residency is and find ways to turn its challenges into strengths. While I don’t have the energy or time to do everything I’d like – I have so many opportunities. I think working as a doctor is a privilege because it allows me to touch people’s lives. I’d like to take 2025 to emphasize the good things residency offers. These good things won’t make up for the negatives but focusing on the good will help me remember that incredible growth occurs during challenging times.

Gratitude

In 2025 I’d like to take more time to be grateful. I’ve achieved my dream – I’m a doctor. I have an amazing husband, a lovely home, and a sunny place to be. It’s easy to forget to be grateful when I’m busy. I’m looking forward to carving out time for it this year.

The Hospital in the Forest

Posted on by

Looking at the one-story entrance, the building appeared too small to be hospital. To get there, I drove down a neighborhood street. Tall trees lined the final stretch up the hill and then there were several small buildings with several small parking lots. Tall trees stood between the industrial features. The whole hospital was about the size of a city clinic. Tiny but mighty – people could get CT images, surgery, and life-saving medications within the hospital’s walls. There weren’t many specialists available and none on the weekends, but the basics were strong. There was “Emergency Department” in glowing letters on one side and there were hospital beds for patients who needed to be admitted. Though not meeting criteria to be a critical access hospital, this hospital in the forest was the only access to healthcare some people had. It was not as remote as the most desolate places in New Mexico, but the hospital in the forest illustrated the scale of healthcare available to many (most?) rural Americans.

The patients were brave and grateful for care. A large portion of the patients were also frustrating because they didn’t see doctors and didn’t take medications outside of emergencies – thanks to the stoicism of rural people and a lack of access to health resources. The full-time workers at the hospital were a blend of devotion and mediocrity – strengthened by being the only healthcare around while limited by the hospital’s small infrastructure and many slow days on the job. I found myself out of place on one hand, having come from a hospital almost 30 times this hospital’s size. While feeling at home on the other hand, having grown up in rural America.

The hospital also reminded me of the hospitals and clinics of Paraguay. The scale was more in-line with the hospitals of the world. The limited access to specialists also reflected my experiences in Latin America and growing up in rural Vermont. I found myself more interested in the functioning of the hospital in the forest than I thought I would be. When I applied to residency, I limited my search to programs at hospital that had 350 or more beds; this hospital had about 30 beds (a critical access hospital has 25 or less). At larger hospitals there are more patients, more specialists (including medical specialties and surgeons), and more treatment options. In a small hospital like the one in the forest, there is some access to cutting-edge technology but more than anything there is creativity because one must find solutions for problems with fewer resources.

As I settled into taking care of patients at the hospital in the forest, I found myself challenged in a different way than when I was at the large hospital where I spent most of my time. Caring for patients in a low-resource hospital forced me to use the full range of my training. If patients started to decompensate it was on me to figure out why and to what to do about it. If the hospital in the forest didn’t have the treatment that my patient needed, then it was my job to pitch their story and get them accepted to a bigger hospital with more capabilities. If I couldn’t transfer a patient who needed something I didn’t have to a hospital that had what they needed, they’d get worse and maybe die. So, while most days at the hospital in the forest were filled with the bread and butter of medicine (the basic, simple cases), complicated cases required more thought than they did at a large hospital where any treatment my patients needed was at my fingertips.

I felt the ebb and flow of the hospital in the forest. Many days were calm and straight forward. Those days I had so much extra time I progressed rapidly through my non-work to-do list. These lulls made up for the days of insanity when the patient list grew with lightening speed (admission after admission) and my patients were all trying to die at once. The flow was more like that of my days in the emergency room – boomeranging between busy and slow.

When my time at the hospital in the forest ended, I was grateful for the experience. Perhaps the greatest lesson was realizing that I could be happy working at a small hospital. While such a realization may seem trivial, a willingness to work at a small hospital opens the door of possibility. There are so many small hospitals in the US and the world. Knowing rural medicine is interesting to me means that there are now 1000s of miles where I could live that I couldn’t live if I wanted to work at a hospital with 350 beds or more. What a funny thing that I spent years jostling to train in an urban center to realize that rural life has its own set of challenges and joys. I can see myself being happy in either setting in the future. Big, busy hospitals are ideal for learning but now I know they aren’t the only interesting places to work in medicine. As I think about the next steps, the hospital in the forest sits laughing in my mind. It’s laughing because life has a way of sending me to places that I never expected to go.

Lost in Delirium

Posted on by

The patient was sick. On death’s door kind of sick. They were a nice person – treating all the hospital staff with respect. Saying “please” and “thank you.” Cracking jokes even though they were ill. They were articulate. Earlier in their hospital stay we’d discussed God. They believed strongly in the power of God. The patient explained that they were at peace with their life and were ready to join God whenever he called.

Then one night the nurse found the patient completely naked in their room. At that time, the patient couldn’t remember their name. The nurse was able to redirect them, remind them of their name, and put them back to bed. They were embarrassed by the events the next morning. In the morning, they seemed to still understand what was happening around them.

The next night they became confused again. But, this time, they weren’t better by morning. As the days unfolded, they were usually able to tell me their name. They’d lost track of why they were in the hospital or what the plan for the day was. They didn’t know the month or the year. At times they seemed more lucid and at other times they were so confused that they believed they were on a business trip. Occasionally they were angry. But, more often, they looked scared. They were easily frightened because they didn’t know where they were or what was happening to them.

This patient was a classic example of delirium. Delirium is a state of confusion that waxes and wanes. It occurs because of the unfamiliarity of the hospital setting, the disruptive nature of hospital activity, and the stress of being ill.  Every patient in the hospital is at risk of developing delirium during their stay. Some people are at greater risk of delirium – elderly people, severely ill people, and people with underlying brain illness.

Delirium is complex from a medical standpoint. We try to prevent it but everything about the hospital promotes delirium – from frequent sleep disruptions to the unfamiliar setting and faces of the hospital. Preventing delirium involves encouraging family members to visit, minimizing overnight wake ups for medical care (vitals, blood draws, meds, etc.), and frequently reminding patients of where they are and the date. We try hard to ensure lights are off at night and lights are on during the day (and window shades open). Despite precautions, delirium can still develop. The challenge is that we have no good treatment for it. Overcoming delirium involves the same strategies as preventing it and treating the illness that brought patients to the hospital in the first place. Another difficult aspect of delirium is managing it when it causes patients to become agitated.

When patients are lost in delirium they don’t act as they normally would. They are in a state of confusion. They may scream and cry not because they are in physical distress but because they don’t understand what is happening. They might fight hospital staff or try to run away. They might become dangerous to staff or other patients. They might refuse the medical care they need to get better. Sometimes to keep a delirious patient and staff safe we need to use sedating medications. But sedating medications can prolong delirium. It’s a tricky situation.

Delirium is one of those conditions that takes up a lot of my time as a physician and consumes nursing time but is little-known among people who don’t work in healthcare. In the short term, it can negatively impact patients by making it difficult to care for them. In the long term, it may impact patients’ cognition.  

Everyone should know about delirium because the best way to prevent delirium has nothing to do with medicine. Delirium is most successfully prevented by having family/friends at bedside. Patients who have frequent family/friend visits (ideally daily for multiple hours) while in the hospital are less likely to develop delirium. The reason family/friends are so important is that they are familiar faces. They can help patients keep track of night and day. Family/friends help keep patients’ minds engaged in conversation, games, and other shared activities. Engaging the mind helps keep it from getting lost in delirium.

In the US, it is fascinating how many patients don’t have family members or friends visit while they’re in the hospital. There are many reasons for this, but two important ones are the American focus on independence and our geographic distance from relatives. Many Americans can’t help that they live hours from their family (and even their friends). But, in an era of electronic connectivity, don’t forget that your loved ones need you. Try a voice or video call. Call or visit even if your loved one says they’re fine. Your support might be the reason your loved one remembers their name the entire time they’re in the hospital. And that, though seemingly small, might make a world of difference in their recovery.