A Palindrome Birthday

The sun sparkles in my windows and alights on the forest of plants I nurture in my apartment. I’m recovering from a whirlwind trip to Oregon to celebrate the wedding of a long-time, dear friend. I stepped away from reading about acid-base disorders, electrolyte abnormalities, and the general unruliness of the kidney to write this post. Residency programs started reviewing applications yesterday; I wait for interview invites to trickle in. By this time next year, I’ll be in the throes of residency and I’m sure medical school will feel like a distant memory. But today, a few days before my 33rd birthday, I’m still in medical school.

Looking at the blue sky and the trees with leaves that are turning red, orange, and yellow, I’m reminded of the mountains that are hidden beyond the horizon of buildings that I see. The mountains are quiet from a distance, but hum with streams, wind, and birds when I embark on their paths. I’ve done 57 hikes (not all in the mountains and some trotting more than walking) since my last birthday.

This has been a long year filled with joy and determination. The number of hikes I’ve done reflects finding a balance between those two forces. Medicine consumes. Yet, since starting my last academic year of medical school, the harrowing nature of academia has dampened and the delight of caring for patients, solving medical mysteries, and contriving medical plans have returned to my lived experience. As I begin my residency interview season, I find myself thinking about life beyond school again. It’s a relief to be nearing graduation.

This year marked a big change; I got married. It’s interesting to shift from plotting my activities and setting goals to stepping back and thinking about sharing my life’s journey with another person who has their own activities and goals. To balance the individuals and the team who form a marriage is a daily endeavor. Of course, my partner and I have been unified for some time now, but something about making our union official and forever makes our collaboration seem more central to daily life.

Birthdays are my favorite time for reflection because they mark my personal new year. I looked back at the previous birthdays I’ve written about – 30 (happy and grateful), 28 (excited), 26 (seize the moment), and 25 (goal oriented). Thinking about their themes, what’s this birthday about?

When I walk along a ridge gazing out at the sky on either side or down a woodland path, I find myself quiet. Quiet in the sense of calm and content and, also, in the literal sense that there is less noise in the natural world than in the cityscape. I hope to hold the quiet I find on the hiking trail in my soul no matter what activity I’m undertaking. The hospital bustles with a din and the street outside my window screams with activity. Yet, I believe coexistence of noise without and quiet within can always be achieved; the way, however, seems as varied as the trails I’ve explored this year. Varied by person and varied by situation.

It’s fitting to focus on quiet movement as I wait to start a new life chapter, the chapter where I close the door to official school (potentially and likely forever) and open the door to learning from a new job. I love new chapters with that accentuated first letter, hopefully a quote, the foreshadowing of the chapter that just ended, and the delights hidden behind crisp pages. I can’t wait to see what this palindrome year brings. At the very least, I know it will bring change, for which, I’m grateful.

Windows to the Soul

I looked into the eyes of a patient for brief moments when they opened their eyelids before falling asleep again. Their eyes were like wells, but there was no sparkle in them like there is in a healthy person. The patient had a bacterial infection of the blood that had attacked their heart resulting in a large vegetation (collection of bacteria and other gunk) on one of their heart valves. Pieces broke off this vegetation, traveled through the blood vessels, and seeded infected clots in the patient’s lungs and spleen. That wasn’t all though. Their body was so inflamed some of the proteins in their blood were destroyed, consumed, or their production reduced. At first, the patient needed transfusions of red blood cells and platelets to survive.

In other words, the patient was sick. They were not just sick, their chance of death within 30 days increased by 16% each day their blood had bacteria in it according to one study.1 Their chance of death was about 40% by another estimate.2 It took us about a week of antibiotics to clear the infection from the patient’s blood, but that wasn’t the end of the patient’s need for antibiotics because of their heart infection and septic clots. They would need at least 6 weeks of antibiotics and likely several procedures and surgery to fix their heart.

I looked into the patient’s eyes each day, hoping to see a sparkle there that would suggest they were awakening from the depths of illness. I hoped and yearned to meet them rather than just examine their feverishness. I was rooting for them. I root for all my patients, but this patient’s eyes were so empty I knew they needed my thoughts more than the other patients I was caring for at the time.

It would take over a week, but one day the patient’s eyes shone with the flame that I think of as the soul, that spark of life. The patient was here with me. They could tell me their name and what was going on. They were awake! How the weeks ahead would unfold could not be predicted. In medicine, we don’t have a crystal ball that tells the future any better than a meteorologist can forecast the weather 10 days out.

My rotation would end before the patient was close to healthy enough to leave the hospital. They were sleepy when I last saw them because they were recovering from their first heart procedure. I touched their shoulder briefly and looked into their eyes. They were so strong and so brave. I reminded them of this and of how much they’d healed since we met. I told them to hang in there. It wasn’t much, I knew, but it was the best I could offer as I prepared to join a different medical team.

In the hospital, we often meet people at the worst crossroads of their lives. We do our best to help them navigate to a destination of better health, but we often don’t get to see where our patients end up after we care for them. We must be comfortable with unfinished odysseys. So, to conclude my telling of this patient’s story, the last time I saw the patient with the wells for eyes, their eyes shown with the brilliance of victory. I will remember them by that brilliance.  

References:

1. Minejima E, Mai N, Bui N, et al. Defining the Breakpoint Duration of Staphylococcus aureus Bacteremia Predictive of Poor Outcomes. Clin Infect Dis. 2020;70(4):566-573. doi:10.1093/cid/ciz257

2. Kuehl R, Morata L, Boeing C, et al. Defining persistent Staphylococcus aureus bacteraemia: secondary analysis of a prospective cohort study. Lancet Infect Dis. 2020;20(12):1409-1417. doi:10.1016/S1473-3099(20)30447-3

Joy

I most remember his rosy cheeks. The humidity and mosquitos hummed around us. We held hands under the shade of widely spaced trees in ferns as tall as our waists beside a beaver pond. There would be many moments I’d attempt to remember from our wedding day – etching them into my memory, writing them down play-by-play in my Spanish journal, and waiting giddily for our photographer to finally send us our photos. But, in those moments between words, I thought about how warm my cheeks felt and how rosy his cheeks were and how it was likely that my cheeks were rosy too.

I was joyful. Some cry when they’re overwhelmed with happiness, but that’s never been me. Happiness spreads across my skin like sinking into a warm swimming hole. The warmth then soaks into my core whereby settling my heart and obscuring all the things that normally zoom through my mind. Happiness is quiet. Contentment. Nothing but his rosy cheeks and my rosy cheeks on our wedding day.

The bright sunlight flickered through the canopy above alighting on my sister, who was our officiant, and our guests. The guests sat amongst the ferns as you might imagine in a scene from A Midsummer Night’s Dream. It seemed fitting that the cupcake shelves hanging from a birdfeeder hook and the brightly colored attire of the wedding guests would float across my mind like a scene from a play. As I gazed at the ferns, I realized that this was my midsummer dream. To make official what my partner and I already knew. These moments would give our relationship a label society understood. But despite the label, he and I knew that no one could truly understand what we meant because every relationship is its own unique product of its unique makers.

Which brings me back to his rosy cheeks. He was wearing his finest suit and the fanciest shoes you’ve possibly ever seen.  The paisley on his shoes and the paisley on his tie had nothing but their name in common, but they each worked well with the stripes of his suit. His tufty blond hair curled above his sparkling eyes and his cheeks were flushed because we were outside, because we had walked through the forest to get here, and because it was a hot midsummer day.

I thought briefly about our guests, the witnesses to the words we were saying. They were the people who had played the biggest roles in our lives since we became a couple. I listened to the words my sister said, then he said, and then I said. We had all thought about, written down, and practiced what we were going to say. Yet, it seemed more improv than rehearsed lines. How could any of us have imagined exactly how this moment would be? We couldn’t. There’s delight in comfortable spontaneity. As I replay those moments now, the rosiness returns. The memory is one of the clearest definitions I have of joy.

Anticipation

I live across from a café that is also as an event venue. The other weekend, I glanced out my window when music uncommon to my neighborhood wiggled through my window screens. My gaze fell upon empty tables perfectly spaced with little plant centerpieces, lawn games in the parking lot, a grill, and green cones outlining the event space. The event organizers meandered around arranged things, chatting, and smiling. Soon the guests would arrive; the evening would unfold. There was no predicting exactly how it would go, but everything was carefully planned with the hope that good things would come.  

I found myself amused by the scene across the street from my home. I’d seen it so many times before, not only in my personal life, but also in a past job when I was an event planner. I’d seen many physical set ups like this one and, perhaps more often, I’d experienced setups and waiting for nontangible events to unfold. The metaphor for my current state of being was obvious. My wedding will be in less than a month (the planning is done). I apply to residency programs the rest of the year (it’s a long process, please don’t ask). My soon-to-be husband is about to move to Connecticut and start his first job as a nurse. Those are the major events soon to unfold; of course, there are zillions of little events where the music is just about to start too.

Life is full of wind ups, waits, activity, clean up, and recovery on repeat. Some versions of these relentless series take more effort and planning than others. Some have more ways they could go wrong. Some events are set up and then no one shows up. Some events last longer than expected. Some events turn out better than you imagined. That’s life. Having gone through these actions over and over again, I believe waiting is the worst. Clean up is also hard, but waiting is the hardest. While my neighbors wait for the food they prepared to disappear into hungry mouths and the games they set up to spark laughter; I find myself waiting for other things that took many more moments (years actually) than cones, tables, and food to set up.

Neurocysticercosis

Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original here.

Recently, I treated a patient with neurocysticercosis. While infection with Taenia solium is not common in the US, neurocysticercosis is not a zebra in Danbury, Connecticut because many patients are originally from countries where Taenia infection is a threat. The patient I saw was young and presented after having a seizure. Though they had received their diagnosis several years earlier at another US hospital, the disease course had started long before. Initially after their diagnosis, antiseizure medications were effective. The latest seizure occurred after a series of unfortunate events caused the patient to stop the medications.

The CT scan showed speckled calcifications throughout the brain. MRI revealed several enhancing lesions convincing us there was a need for antiparasitic and steroid treatment. The patient did well after treatment initiation and was discharged home to complete their albendazole and steroid course with a plan to follow-up with neurology. Their case lingered in my mind. It lingered not because of sadness or complexity, but because it reminded me of how connected our global population is and because the patient had impressed me with their calmness.

COVID-19 has highlighted how easily communicable diseases can travel and how important the health of the global community is for the health of our local communities. And while Taenia solium is an infectious disease, it does not spread like COVID-19. My chances of infection with Taenia solium are meager while living in Danbury, CT. Yet, we have patients with neurocysticercosis because people are mobile. I find it fascinating that the mix of diseases that are the most common in a particular hospital is not only dependent on the vectors and circumstance of life in the hospital region, but also the experiences and diseases prevalent in the places from which the people who make up the community around the hospital came.

As I contemplated our connectedness, the patient impressed me with their politeness and trust. Here was a person who was sick and did not speak English, yet they had complete faith that we could help them. I found myself humbled remembering that patients rely on us, the medical community, to guide them to better health when disease strikes. The patient’s calmness spread to anyone who spoke with them. There is something impressive about patients who can impart positive feelings on those around them despite being sick. I thought about the patient’s history and all the roads they had traveled so that our paths crossed during my medical training. Mobility is an amazing feature of the human experience. It both connects and separates us.

Learning to See

Before I moved to me latest city, the people I talked to about the city during my travels through medical school rotations didn’t have anything good to say about it. One person said there weren’t any good food. Others said there wasn’t much to do. When I moved here, someone went as far as to tell me it was dangerous. And, while I listened carefully because I knew little about the city myself, I had a suspicion they were wrong.

When I was a child, I learned to see the trees and birds around me. I learned to name them. I could tell a white pine from a red pine or a sugar maple from a red maple. I could tell you the sound of the chickadee and the hermit thrush. I knew the difference between a red wing blackbird and an oriole or a bluebird and an indigo bunting. This type of seeing was the outcome of growing up in the middle of nowhere while surrounded by women who knew these things and shared them with me.

Early on, I learned to tell the difference between real wood and fake wood. I could identify sloppy joints and beautifully joined boards. I judged furniture and house finishings based on their joints. I could tell you how sheetrock differed from plaster. I understood these things because my father had taught me to notice them. My mom taught me to see colors and how they might be paired. I still notice boldly paired colors and they bring me joy regardless of if I find them in a painting or on someone’s clothes.

As a I grew, I learned to name the flowers in people’s gardens because I worked in a greenhouse. I was trained to tell the difference between a rose and a lily, for example. My parents taught me to notice architecture. What makes a classic New England home look as such and how that differs from an adobe house. I came to understand what a well-built house is.

When I moved to DC, I learned how to see a street for what it was. A pathway to somewhere. I learned how to chart my course and tell if I was safe on a particular path within moments. I learned to see the places, like underpasses, I should avoid at night and the places that were filled with architecture, trees, and flowers. I learned this out of necessity and because I have a savage passion for walking and walking and walking.

When I moved to Paraguay, I learned to see what someone was trying to say because I couldn’t always understand their words. I learned to see if they were lying, or friendly, or joking. I learned to see why some people might follow God. I started to understand why life in Paraguay is different from life in the United States. And I learned to see that difference as both beautiful and challenging.

In medical school I’ve spent years learning to see exactly what a normal breath is and how stretchy skin should be. I’ve learned to see how the heart and abdomen are when all is well and what an infection looks like. I’ve learned to understand almost every part of the body and to see when it is healthy.

All this learning about how to see I carry with me always. And, when I moved to my latest home, I applied my seeing to understand what this city was. I learned that there is a lot to say about Danbury. I found the trails (there are numerous) where I can run and walk among the trees, birds, and flowers. I’ve noted the buildings with outstanding architecture. I found half a dozen murals with beautifully blended colors. I’m mapping out the good eateries—so far, I have a recommendation for every meal of the day plus elevenses and snacks. Much like Paraguay, Danbury is filled with people who don’t look or speak like me. But, when I took the time to observe my neighbors; it became apparent that they are a bunch of people trying to carve out a little space to work, eat, and be merry. I came to understand they were just like me in many ways. And, noticing our similarities, I understood that this city suits me. Seeing is something that takes practice. But once you learn to see you can begin to understand.

The Moments We Have Together

I would think of her often after we met as I hurried down the hospital walls. I always hurry down the hospital halls…rarely because I needed to hurry, usually just because it’s nice to stretch my legs. Sometimes the memory of her bright eyes would shoot across my mind as I opened the electronic health record system to work on different patients.

She had come to the hospital with a stroke. I followed her during the few weeks after she was diagnosed, during her acute recovery in the hospital. I met her on the medicine floor and then wandered the hospital until I found the rehabilitation center wing where she was moved one night.

After the first day when I conducted a thorough history and assessment of the patient, my visits were just “social visits” – the term for checking in with a patient or their family for the singular purpose of offering support rather than providing a medical update. She hated the hospital and visiting hours started late in the morning. I’d visit her before her family could be with her to help pass some time until they came.

Strokes cause a range of outcomes. Her outcome was good; long-term she was a little weak and a little off balance but still sharp as a tack. Strokes are injuries to the brain. In the first week I followed her, she was very depressed. Strokes can do that. I sat with her in the morning as she described her terrible dreams. Flashbacks to her childhood. She had been a Jewish child in Nazi territory. She described hard times. Her husband had also been in that situation – he had lost his whole family in the concentration camps.

As our days together continued, the patient talked less about WWII and more about her family in the US. She talked about how wonderful her children were. How hard it was now that she was old and her friends were dying. When you get old and people start dying, she told me through her stories, there are fewer people who remember your life experiences. Fewer people who truly know the world you knew.

We chatted about the hospital food. The boredom of sitting in a hospital bed. How playing cards with her children was nice, but barely passed the time. As I got up to go, she’d say, “Come back tomorrow.”

I went back until my school schedule sent me to clinics rather than the hospital. Medicine and the hospital are busy. Healthcare is frustrating and terrible sometimes, even often. When I find myself falling into the pit of work that is any job but especially a job that involves dealing with people and clunky systems all day, I push myself to pause and remember why I went into medicine. The weeks this patient was in the hospital she was my light. I like to think I also helped take the edge off her hospital stay. Seeing patients through sickness is the highlight of medicine in my opinion. Not all stories end as well as hers, but all hospital stays can be made better by our shared moments.   

Remembering Her This Mother’s Day

This week I lost a kindred spirit. I met her in college, over 10 years ago now, when I visited a college friend’s home over winter break. She was his mom. And in the decade since I graduated, I lost touch with the friend but never his mother. It was her efforts that kept us connected. In my life she was a cheerleader, frequently offering support and sending messages of encouragement.

In the last decade, she was brave – divorcing, taking on new jobs, moving across the country, and entering seminary – all while being a mom and a middle-aged woman with all the challenges that come with those realities. She was a loud advocate for many people including women and people with disabilities. She was a staunch supporter of her sports teams.

Her death was unexpected. This week my thoughts have been with her children who are without her this Mother’s Day. I have also spent the week reflecting on the positive force she was in my life. I admired her for her fiery spirit and her devotion to the people she loved. As she was a dedicated reader of my blog, I wanted to write a post in her honor.

She believed strongly in God. If the world is what we believe it to be, then she is with her God watching over her children and the others she took under her wing from a new vantage point. May she rest in peace.

The Night Chef

Overnight, the hospital halls are quiet; all the administrative areas are closed. There seems to be endless dark ends of corridors where no one is. There is the constant beeping of heart monitors and other hospital machines. The night shift’s laugher periodically fills the space – the nurses and others making sure patients get what they need overnight. Of course, if you’re a patient and trying to sleep it seems loud and it’s annoying because you’re woken frequently for vital signs checks and other things.

Some folks chose night shift. Some folks like the autonomy that a less full hospital affords. Some do nights so they can be with their kids during the day. Some do it for the higher pay. Others are just night owls. I do night shift out of necessity – either when the budget requires it or there’s no way out of it. And that is how I found myself in the hospital when I met the night chef. I was on a rotation that had a week of night shifts.

The night chef is the man who runs the grill of the only cafeteria open overnight at the hospital where I train. When your shift is overnight there’s not much to be done but have lunch at midnight. If you’re like me and prefer to be asleep well before midnight, midnight lunch is daunting. On my first night of nights, one of the residents I was working with reassured me that the night chef was one of the best things about night shift. I was curious what she meant.

The night chef can make anything. He’s gregarious and happy despite working at odd hours of the morning. When I met him, I could not understand why he was working in the cafeteria. He is one of those people who could sell anything. You know, one of those lively talkers who connects with anyone. Why had he chosen to be a hospital chef at night?

He welcomed me and the resident I was with when we entered the cafeteria. He listed the delicacies he had imagined that evening. And despite the terrible hour of day, I found myself smiling and feeling only a little guilty for turning down the pizza with gobs of meat he gloated about for a different option.

During my first week of nights, it became routine to visit the night chef at some point. I never bought his most creative dishes, but I did enjoy his cheer.

Eventually my stretch of nights ended. On my last night, I stopped by the cafeteria on my way home. “Will I see you again tomorrow?” the night chef asked.

“No, I’m going back to days.”

“Ugh, too bad,” he said. “But… I understand.”

I went on my merry way wondering if I’d see him again. And, of course, I did soon thereafter because I started my day shift before his night shift ended. He was jolly as ever, even at 6 in the morning after having cooked all night. “Where have you been?” he said the first time I saw him again. “Nice to see you.”

“Nice to see you again too!” I said. I meant it. It doesn’t take much to make someone’s day and his happy greeting made mine that day. The night chef is a master at brightening his customers’ shifts. Perhaps that is why he had chosen to be the hospital night chef. Night shift at the hospital needs him most.

Echoes from the Third of Medical School

The click-click and rickety wheeze of plastic jarred me back to the present from my thoughts about what I wanted to say about finishing my third year of medical school. Even though it’d been 3 years since I operated an ambulance stretcher, I knew that sound like I knew my own voice. The stretcher sound was among the many I’d learned in the past years.

The third year of medical school was a robot period. A term coined by my sister back in our college years. A robot period is a time when you just do as if you were a robot because sometimes you just must get to where you’re going.

I’d ended my third year of medical school learning that the squeak of premature infants is distinct from the wails of infants born on time. I also learned that the cry if a one-year-old is different from the tears that well silently and then exposed loudly before a 5-year-old boy gets a shot.

Before the crying nuggets served by pediatrics were the perfect one-two, one-two sounds of the hearts I heard in family medicine. Or the easy wooshes of lungs moving air happily. In outpatient internal medicine, I discovered the crackling stiffness of arthritic knees.

Before that there was the more forceful woosh of the ventilator in the intensive care unit. Pushing air into the lungs of someone who was silent. That same person had once been a DJ. How odd it was to see them existing quietly when they’d been mixing beats and filling dancefloors for most of their life. Neurology is a dark specialty.

And there was the sizzle sound and burning flesh smell of the electric scalpel in the operating room. The sound of metal tools on metal trays. The snap of putting on rubber gloves and the crinkling of paper gowns as everyone took their assigned places for the operation.

On internal medicine, there were the patients yelling for help. Some of them knew they were yelling. Some were just trying to reconnect with their minds which were lost in the fog of being sick. The beep of heart monitors. The dull sound of lungs full of junk. Oxygen monitors and bed alarms dinging, dinging, dinging.

Before all that, were the screams of women in labor. Of babies announcing their successful arrival with a gurgle-cry. The patter of footsteps as nurses and doctors ran because a baby was coming faster than everyone thought it would.

And that brings us all the way back to the beginning of the year. To psychiatry, where adult tears fell to the sound of congested voices. Or flat voices trudging along telling the stories of visions that no one else could see.

All those sounds are behind me. Today, I find myself listening to bachata and reggaeton. The traffic hums outside of my window. I’m studying for another huge exam. Exams are old news, but this is my penultimate of medical school. It’s the final countdown at long last. It’s been such a noisy year.

Just before I finished the year, I pulled out my violin. I hadn’t played it for almost as long as I hadn’t operated an ambulance stretcher. The songs that were like oxygen in my teens came back slowly. My fingers were awkward on the strings and bow but the jig I’d always loved most bounced around the room just the same. If you do something enough, you don’t forget. If you practice, you get better. Third year of medical school is about practicing. And the best part of practice is not practice, but what you’ve learned after doing it. That’s where I am now. Really glad to have done the year while also certain I’d prefer to never do it again. I’m grateful for the things I learned and the people I met. But, mostly, I’m excited to move on to the next phase of the doctorhood quest.