Update from Labor and Delivery: Non-Surgical Edition

We worked to the rhythm of the fetal heartbeat, ticking along at 140 beats per minute.  We hadn’t met the baby yet, but the baby was getting ready to come out and greet our world.

The soon-to-be-mom wasn’t in as much pain as she had been last time I saw her. The epidural took the edge off her contractions. She could talk to us again and was even happy (albeit also tired).

The team got ready to start pushing. The contractions were the right distance apart and strong. The cervix was dilated to 10 centimeters. We explained the process of pushing the baby out – for each contraction she’d push 3 times, each for 10 seconds. While pushing she’d pull her knees out and back toward her ears because that opens up the pelvis and helps the baby fit through. The first contraction we practiced. Not many laboring humans get the pushing thing perfect on their first try. But, it didn’t take this soon-to-be-mom long to learn what to do.

Birth is trepidatious, exciting, and boring all at the same time. First there is a lot of wondering about how the whole process will go. Then there’s a lot of wondering what the baby will be like. Parents are excited to meet their child for the first time. From the health care perspective, there’s a lot of standing around. A lot of blood and mucus and other types of goop. The work comes in waves, as the contractions come and go. Between contractions the laboring human rests and the rest of us wait. It’s really all about the laboring human. The rest of us are just accessories and moral support. On this occasion, the soon-to-be-dad was a great team member. He was encouraging without being overbearing. He was engaged without hovering. The support people the laboring human brings with them aren’t always that good, but you’d be stressed too if your partner was doing all the work and all you could do was stand by waiting.   

This soon-to-be-mom tapped her tummy and sang to her baby in between contractions. She had made up a song for the baby that involved the baby’s name. She told us she had spoken to the baby throughout her pregnancy. She explained that she had told the baby when they were eating. She told us that the baby knew that they ate yogurt every day at 2:30 pm.

The soon-to-be-mom worked hard when the contractions came. The baby moved down the birth canal. As the baby came closer to meeting us, the soon-to-be-mom became more uncomfortable. If you’ve had a baby via vaginal birth you might know what the pressure of a baby’s head is like as it makes its way out – the rest of us can just imagine. The soon-to-be-mom had a good epidural, but it didn’t’ take away the pressure of the baby’s head. It didn’t take away the pain that came with tissues stretching.

We saw the baby’s hair for many minutes before we saw the baby’s head. Head then shoulders and then the rest. I helped deliver the placenta – best described as a warm squishy sac.

The baby cried upon entering our world, a sign of lungs waking up. The baby started covered in white wax and slightly gray, but soon turned pink. The baby snuggled up on the mom’s chest. The baby was perfect, as all babies are. All babies are both perfect and look like aliens if you ask me. Regardless of babies’ alienness, you still tell the parents congratulations on having their baby (this is very important).

Mom rested. She then sang the baby’s song. Once the placenta came out, we made sure the bleeding stopped. We made sure any tears (they’re common apparently) were sewed up. The obstetricians tell me vaginal tissue heals quickly. Life is a curious thing, especially the beginning and the end.

Mom and dad were lost in staring at their baby as we cleaned up mom. The nurses made little ink baby footprints on a certificate for the parents and on hospital paperwork. They took baby’s vital signs – baby was doing well with its itsy-bitsy everything.

We left their room. Time to return to our station. Many little hearts running between 110 and 160 beats per minute bopped along on our monitors counting down the hours until their parents got to meet the baby they’d made. We joke that labor and delivery is the only floor in the hospital were pain is a good thing, only because it means that it might be time to have a baby.

Birth is trepidatious, exciting, and boring all at the same time. I’ve seen the toughest cry at the sight of their child. I’ve seen smiles and laughter and looks of amazement and terror at being a new parent. And I’ve only been on labor and delivery for a few weeks. Imagine what it’s like to make a career of helping people bring their babies into the world.

The Psychiatric Rotation

Disclosure: The patient story here was written with a patient I saw in mind, but the details have been changed to protect anonymity. The story is reflective of many patients I saw during my psych rotation and while working in the ED. You will note that I chose nonbinary pronouns. This is because brain illnesses (just like many illnesses of other organs) set in regardless of gender. Brain diseases, like many other diseases, are related to genetics, life experiences, and other social and environmental factors. A tricky aspect about brain diseases is that we aren’t exactly sure how most of them develop and we are quite far from having a cure.

I looked down at them lying on the stretcher in an ED bed. They were snoring quietly, and their face was neatly framed by their hair. Their eyes were closed, and they looked peaceful. I didn’t have much time to ponder the full circle that this scene represented and the eerie foreshadowing of the end of my psych rotation. They had received the magic 5-2, 5mg Haldol and 2 mg Ativan. Haldol is an antipsychotic that is sedating and Ativan a benzo that’s also sedating. In other words, the patient was chemically restrained. Put again, they were put to sleep for a short time to end their psychosis. And a scary psychosis it must have been as it was filled with delusions of people hurting them and murdering children. We shall call this patient The Singer.

I’d seen The Singer awake and stable during the first few days of my psychiatry rotation, weeks before I saw them sedated. When I first met them, they were being discharged from the psychiatric inpatient unit of the hospital. They’d been in the hospital for weeks. They’d been restrained many times. They’d spent a good chunk of their stay believing the hospital staff were hurting them. When I met them, they didn’t have those delusions. They were looking forward to finishing a song they’d started writing before entering the hospital. They were looking forward to going back to their job and were inspired to possibly start biking again. They were discharged from inpatient to home with quetiapine and an intensive outpatient treatment plan (dialectic behavioral therapy group sessions). Quetiapine is an antipsychotic. Did you know most drugs in its class are effective about 20%-50% of the time? That’s not a passing test grade. But, then again, 20% of patients helped is better than zero. And, of course, medications only have a chance of working if you take them.

As my psychiatry rotation marched along, I changed from inpatient psychiatry to outpatient psychiatry. I’d see The Singer in the outpatient setting too. I observed their dialectic behavioral therapy session (group therapy focused on developing social skills and strategies to manage emotions). I interviewed them at their medication follow-up meeting. At that meeting, they told us they’d stopped their quetiapine. They didn’t want to take it. They didn’t like it. We could not and were not going to force The Singer to take their medication. They complained about not being themselves when taking the medication. I couldn’t blame them because quetiapine is sedating and does sometimes make people feel flat, emotionless. The psychiatrist counseled The Singer on looking for signs that they might be slipping into psychosis again. The Singer identified not sleeping as one of the triggering factors. I worried for them. I worried their delusions would return if they weren’t on quetiapine.

After outpatient psychiatry, I transitioned to the consult service which determines if patients in the ED need psychiatric hospital admission and provides psychiatric evaluation of patients anywhere in the hospital. I was with the consult service when I saw the sedated version of The Singer in the ED. The Singer had been sedated because they were not safe. Their delusions of rape had returned. They were agitated and not taking care of themselves. They were making risky decisions. We hoped to help them by admitting them to the hospital.

I knew The Singer was a musician because the ED was the third setting in which I’d seen them; the first time I met them, they told me they were a singer.  I knew their living situation and their hobbies because I’d talked to them about them. I knew why they had stopped taking their medications and I knew that part of the reason their psychosis had returned was because they’d stopped taking quetiapine. After leaving their ED room, I drafted the psychiatry consult note that would be a record used as justification for involuntarily admission to the hospital for stabilization. We’d come full circle, The Singer and I. I started my time on psychiatry with them being discharged from inpatient treatment and I was ending my rotation with them being admitted again to inpatient treatment. Same cause. Similar presentation as last time. Had we made progress? How many times would The Singer repeat this cycle? I reflected on the fact that chronic illnesses are just that, a chronic struggle to be well. A chronic ebb and flow of good and bad days.

The ED consult note I wrote about The Singer was the first psychiatry note where I left the mental status blank and simply said they were chemically restrained at the time of consult. The mental status is the bulk of a psychiatry note. It’s where you summarize a patient’s emotions, thoughts, words, and behavior. A psychiatry note without a mental status exam is quite limited. Psychiatry is about talking to patients to understand their feelings, thoughts, and emotions. It is almost impossible to evaluate for feelings, thoughts, and emotions if you can’t or don’t speak to a patient. Sure, when patients aren’t sedated, you can observe them or try to use writing or sign if you can’t speak to them formally. But, talking is the core of psychiatry. Psychiatry is the one field of medicine that does not forget to ask the patient’s opinion. I reflected on that bit. It reminded me of the key lesson I hoped to remember on future rotations when time was crunched and my patience strained – you have to talk to patients in order to know their thoughts and story. It may sound simple. Perhaps it is. Perhaps the pile of labs and medications and interventions that occur in the hospital make it difficult to always remember that patients are people who got sick. The sickness doesn’t remove the fact that they might be a singer or a biker, it just adds another layer to them as a person. Seems straightforward. We’ll if it remains straightforward at the end of a 13-plus hour shift on surgery.

The COVID-19 Vaccine: Celebration and Differences

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 (split into 2 posts) here and here.

My partner and I both work in healthcare and had the opportunity to get our COVID-19 vaccines months ago. Never in the past would I have expected to await a vaccine with such anticipation and feel such gratitude upon receiving it. Among the many other social and scientific features COVID has brought to the forefront of our attention—one, at least for me, is a renewed appreciation for all the vaccines we have previously developed. To think that we can stop smallpox and polio is a relief. But, also, COVID is a reminder of all the diseases that have escaped vaccines to prevent them. HIV comes to mind.

My friends and family in the US are in various stages of COVID vaccine completion. The variance is largely because of their age, profession, and which state they live in. What is reassuring to me is that for my US community the debate is not whether to get the vaccine but, rather, when.

The conversation about the vaccine is very different for my Paraguayan friends. I have not experienced vaccine fear among the Paraguayans I’ve known—which is to say their access to the COVID vaccine is not limited by personal belief but rather distribution.

I connected with all my friends in Paraguay on Easter, an important holiday in a predominately catholic country. I was excited to hear about their celebrations. In Paraguay, the week leading up to Easter is called Semana Santa (Saints Week) and is especially important. It is a time of sharing chipa (a traditional food that’s like a hard cheese biscuit) and enjoying the company of family and friends. Visiting has been limited this year because of continued concern for COVID, but my friends still report making chipa and enjoying the company of family.

When the topic of COVID came up, one of my friends said, “Estamos acá en la lucha, en Paraguay no hay vacuna, a nosotros es imposible recibir la vacuna…primero tiene que ser por las personas saludes, por los militares… y después recién por nosotros, dicen que van a inmunizarnos, pero no sé…por nosotros acá nuestra lucha es esperar la vacuna y quedar en casa. (We are struggling here, in Paraguay there is no vaccine, it is impossible for us to get the vaccine…first it must be for healthcare workers, for military personal…and then, after, for us. They say they’re going to vaccinate us, but I don’t know. Here our struggle is to wait for the vaccine and stay home.)”

This friend has been studying online since the pandemic began. She hopes to someday work in healthcare, but she is not able to go to the hospital to continue her clinical training for fear of catching COVID. One of her uncles was hospitalized for 15 days for COVID (he is doing well and made in home for Easter). Many of her family members caught COVID this March, but only the one uncle ended up in the hospital.

One of the things that continues to strike me about my Paraguayan friends is an unwavering optimistic outlook even though COVID-19 vaccination in just beginning in their country. My friend’s comment, “Here our struggle is to wait for the vaccine and stay home” struck me. She said it in a matter-of-fact tone that did NOT hint at frustration but, rather, exuded unwavering patience.  In thinking about my friends in Paraguay, I began to wonder if the closeness of families (not just emotionally but geographically) is a protective factor against feelings of isolation I’ve heard from many of my US friends. My friends in Paraguay either live with their parents and extended family or on the same block as them; compare this to my friends in the US whose families are spread out across distant states. This comparison reminded me that even though this pandemic has touched lives across the globe our shared experience is also a highly personal experience shaped not only by our uniqueness as individuals but also by the culture of the society in which each of us live. 

Medicine of the Mind

“It’s a privilege to learn their stories…really get to know people,” he said when I asked for his nugget of advice for us students as we continue our medical school journey. “In what time you think you have, try to know them [patients]…exercise your privilege.” Before we get into the weeds, let me clarify what he meant as this quote is just a piece of a longer conversation. By “privilege” he meant the honor of getting to meet patients and having the opportunity to hear their stories. By “exercise” he meant take the time to be a good doctor which includes getting to know people’s stories.

This piece of advice came from a retired psychiatrist who, as rumor has it, retired several times and each time his patients convinced him to come back to practice. The way he carried himself reminded me of my late grandfather – tall but not imposing, with straight white hair that covered just enough of his forehead, and a quiet voice. But more than how he carried himself, his curiosity caught my attention. He was an old human, an old physician at that, who the week before he gave the above advice had comfortably engaged in conversation about pronouns and transgender care. He was a physician who listened to learn when I offered a rudimentary definition of “nonbinary.” I’ve met many a young person, with far fewer years to settle into old ways, who showed less interest in uncovering the nuances of the human experience.

“Really get to know people.” His words made me hopeful because they showed that even at the end of a long career there are physicians who still have a passion for the human story as much as I do at the beginning of the Doctorhood Quest. Being only 5 weeks into working in the hospital as a medical student, I have a long way to go before I can offer advice to students. But, for now, challenge accepted good sir. Let’s see how I do in the coming weeks and years at uncovering stories while also learning labs, diseases, medications, and all the other factoids that will help me reduce symptoms and cure disease in the patients I see.

Pull Up Your Compression Socks

Some of my friends and family have asked how I study so much. Others just give me a funny look, shake their head, and say becoming a doctor is too much school. And, to be honest, I mostly agree.

And that’s were compression socks come in.

When I was studying for my first board exam (aka STEP 1 which is a 7-hour exam that lightly touches most topics in medicine from skin rashes to embryological development) I started wearing compression socks. Every day before sitting at my desk with mate and breakfast and before firing up my computer, I’d spend a few moments pulling on the rainbow or patterned compression socks I’d chosen for the day. I’d never worn compression socks before I started studying for STEP 1 – not while hiking multiple 10-mile plus hikes a week, not while working 10-hour shifts on my feet, and not while training for marathons on city streets.

But studying from well before dawn to well past dark did me in. The truth is that studying all day is terribly grueling in the most passive way imaginable. The body rebels against stillness, and my bodying not only rebelled but went to war. My calves became so tight I could hardly walk. They’d throb at night. They’d throb in the morning. My shoulders and back were full of knots. My hamstrings constricted to a fraction of their normal length. I have a standing desk. It only made my hips tight. And. Yet. The studying had to be done. To help get through the hours, I’d stretched when I could. My workout routine become very consistent because without it I couldn’t concentrate.

The compression socks fixed my calves. I discovered them by accident. My partner wears them at work to avoid varicose veins, and one day I tried on some of his socks. It was a game changer; I could study all day and my legs would be okay. Just okay, but okay was way better than terrible.

It seems a bit dramatic to say it feels like your body is going to turn to stone simply because you sit still too much. “How do you study so much?” family would ask me in the final weeks leading up to my exam. I never exactly knew how to answer. And now I realize why – because studying  in medical school is less about the “how” and more about the “why.”

Why do I study so much?

It comes down to the end. The goal. The reason I bothered to enter medicine at all. It is only knowing where I wish to go that makes studying so much that I must wear compression socks worth it. I didn’t come to medicine because I wanted to study all day. I entered medicine because curing diseases and helping people through sickness is the professional contribution I wish to make to our world. I had plenty of time before starting school to explore many different professions. But, the one that captivated me was medicine. Medicine combines puzzles, science, and true stories. I study so much because every piece of information about symptoms and labs and geography and humans is a tool that might help me understand what is ailing a patient. I don’t study because I like it, I study because I want all the knowledge tools I can fit into my toolbox brain so that when I meet someone’s grandmother, someone’s father, someone’s friend, someone’s brother in a moment when their health is faulting…I know how to help them heal. 

Goodbye For Now Vermont

It had been over 2 years since I’d set foot in the US and almost a decade since I’d lived in Vermont when I returned 5 years ago. In my time away, I’d forgotten that men might choose to grow beards, plaid shirts are stylish in some people’s eyes, and baggy pants on men (and women) are normal in some regions of the globe. I’d just come from a place where those things – beards, plaid, and baggy pants – were only seen on people experiencing homeness and overheating Peace Corps volunteers clearly out of place in the Paraguayan sun.

Yet, despite the plaid, the cold, and the lack of sun Vermont was better than I remembered it. It was nice being in a place where I was confident everyone I talked to knew how many legs a chicken has (I’ve met people in the urban US who don’t). When I arrived, I wasn’t too worried about liking Vermont. I thought that I’d just come back to start my journey to medical school and that was all. Vermont had more in mind.

I started my pre-med classes which can easily be summarized like this: I’d write a lab report then revise it until it was so boring it made me yawn. Only if I was absolutely bored reading a lab report could I be sure I’d get an A on it.

As part of the journey to medical school, I became an EMT. I remember being petrified showing up for me first EMT shift. My nerves eased when my crew chief (who’d started working on ambulances over a decade before I was born) told me in a matter-of-fact voice that the crew would not let me kill anyone. Our crew would have dinner together every shift (unless we got a call and had to jump in the ambulance). We’d talk about patient cases, science, sci-fi, trucks, and cake. We’d get 2 am calls. I learned to write patient reports in the middle of the night. I practiced finding things to talk about with anyone – an important skill when you have a stable patient and a 30 plus-minute ambulance ride to the hospital. I saw hoarder houses. I learned what it looks like when people fall and can’t get up. I saw what happens when a blood sugar gets too low. I reinforced the knowledge that drunk humans are poor historians.

After running all night (that’s what we called being on the ambulance responding to calls), I’d change into my business-very-casual work clothes and go to work. Then class. Then lab. The hours studying merged as they always do. But, as I prepared for the MCAT (an entrance exam for med school) I knew exactly who to ask to explain some of the physics concepts that weren’t sticking – the brilliant kid with the Vermont accent on my ambulance crew. He’d driven trucks almost as long as he’d been walking and hadn’t done much school. He was smart and if he’d wished to follow different stars he could have. 

“I don’t know the physics equations or anything,” he said when I asked if he could explain how hydraulic lifts work and the physics of pistons.

“That’s not an issue, you understand the concepts,” I said.

I could do pages of equations and get the answer, but it was the meaning behind the symbols and numbers I wanted. And as he drew out a dump truck to explain hydraulics, drawing to explain just as my father and step-father always do, I realized that I liked the people in Vermont more than I’d expected I would.

School, my first job after returning to Vermont, and my time on the ambulance ended around the same time. I transitioned to a new job as an EMT in the emergency department (ED). I learned how to place IVs and draw blood. I saw how the brain, heart, and bones can break. I sat with families as their loved ones died. I saw babies be born and people smile despite the unluckiest circumstances. I learned from fellow EMTs, nurses, and other key players in the ED. The ED attracts fiery spirits and I enjoyed being among them. The patients came and went – suicidal thoughts, dog bite, chest pain, weird rash, car crash, fall, stroke, homeless, ski accident, rape, stomach pain – and I learned about humanity. Healthcare gave me a new angle from which to view Vermont. I saw the stoic Vermonters I’d known growing up. I saw people who had just immigrated to this frigid, snowy state. I met people who have the lives that make up the opioid epidemic. I met folks like me and very different from me.

The people of Vermont gave me a window into medicine. I got into medical school and I decided to study at our state school.

While much of my time in Vermont has been centered on learning medicine, that is not all Vermont has been. I rediscovered the mountains and the forests. I spent countless hours walking along Lake Champlain. I heard the hermit thrush sing as I wandered in the forest. I was reminded how both loud and quiet the trees are. Between the mountaintops and the lake, I also found my life partner. We were hiking and feasting buddies at first, but life has a way of pushing the limits of friendship. I also found friends with whom I cackle and giggle, enjoy the sunset and a stroll, and who I know are standing by ready for anything when the going gets tough. And the going is tough sometimes because becoming a doctor is a long road.

Since returning to Vermont, I rediscovered why Vermonters are stubborn, fierce, loving, and independent – just spend a winter here and you’ll understand. And, while Vermont has been so much more than I imagined, I must say goodbye for now. Every time I leave a place, I can not promise I’ll return for good or stay away forever. I can only promise that the people and hidden hallows that shaped me while I was here will always be with me no matter where I am. As I look ahead to the last years of medical school, I plan to complete them in Connecticut (my Vermont medical school has a clinical partnership there).

With excitement that I’m moving once again to a neighborhood where we speak Spanish and with a heavy heart for the dearest friends I’ve left in my home state let me say, “Until we meet again dear Vermont, may the snow be deep in winter and the summer be sparkly and green.”

In the World With COVID-19: COVID-19 Continues to Test Our Resilience and Flexibility

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 post here.

When I joined the Peace Corps in Paraguay, we had two mantras: resilience and flexibility. Those words would take on an infinite number of meanings during my service. Spending twenty-seven months living and working in a new language and culture challenged me more than anything ever had. It also allowed me to forge some of the deepest friendships I’ve cultivated, and it pushed me to become a better self. 

Resilience is a word tossed around frequently in medical school, just as in the Peace Corps. The two endeavors have in common a series of obstacles to hurdle. However, “flexibility” faded from my vocabulary when I became a medical student. I first brushed the word aside when I began my premed classes, for which I measured exact amounts in my science labs. As I entered medical school, each minute became precious and tests with multiple choice answers almost erased the idea of flexibility from my mind. Then, COVID-19 arrived. School moved entirely online and everything that had been normal for medical school became a memory of the good old days. 

It’s been about nine months since my classes went online. My friends who work in the emergency department, where I worked before medical school, look tired. Their faces are chapped from wearing masks and face shields. They haven’t been able to see their coworkers’ facial expressions since the pandemic began. My classmates and professors look tired too, on Zoom. My parents, siblings, and friends also look weary when we chat on WhatsApp. These past nine months have been nothing but a test in both resilience and flexibility. 

Resilience is defined in many ways, but I think of it as the ability to endure and still find joy in the little things of life. This past Thanksgiving, I was cheered to see the Zoom collages of families and atypical feasts a Thanksgiving without travel cultivated. I’ve been amazed at how well Zoom can connect us for classes and how easy it makes project planning. While I miss my classmates’ physical presence, I don’t feel disconnected from them because I know they are in their homes studying for classes and STEP (first medical board exam for medical students) just as I am. What’s more is that we can Facetime or WhatsApp at any time. When time is scarce, video calls do afford the benefit of decreased travel time. 

I am surprised to see how flexible medicine can be. Physicians are finding ways to deliver healthcare to their communities even with COVID-19 limiting their options. Those physicians in global health have had the unique opportunity to look at home with a new eye and explore how global health is not only going to different countries but, also, working with communities of new arrivals in their own country. The rise of Zoom has also opened a door for students and physicians across the globe to share ideas and have conversations we might not have had before COVID-19 limited our ability to travel. 

As we look forward to global news that a vaccine to COVID-19 may become available relatively soon, I dream to start my clinical years on time and physically in the hospital. 

Even with the good news, however, I know that we cannot easily predict what will happen in March when my clinicals start. The expectations I have for clinicals, therefore, are largely from watching the students who started their clinicals last spring because they showed that despite setbacks, medicinal learning can adapt to the ongoing challenges of a global pandemic. And while my colleagues, friends, and family look exhausted after these months of weathering the COVID-19 storm, I see the power of their resilience and I am grateful to remember that the adventure of life requires flexibility as it unfolds. As I transition from the primarily academic to the more clinically-focused years of my medical training, remembering flexibility is important.

Until Death Do Us Part

A reflection on COVID, not of families grieving or people in danger, simply the emotional toll of an increased number of people dying.

There is no way to capture what it is like to feel someone go from warm to cold. There are no words to describe what it is like when the electricity rushes from a person’s body and everything within them falls still and silent. Even photos, which can capture pain, cannot capture the sensation you have when someone dies in your hands. The realization that they will not blink or speak again sits heavily. The knowledge that their burdens and joys have been left with us, the living, is conflicting.

CPR trainings, nursing school, and medical school try to prepare those of us destined to forge a career in healthcare for the days our patients die. But trainings over plastic mannequins and long-winded discussions over patient scenarios or tear-jerking stories can not prepare you for the moment a soul evaporates.

While not all who work in healthcare see people die, many do. It is part of the job. Most of us know that before we decide to enter the field. Those of us in healthcare put up emotional walls. We become used to knowing people will die. We can see suffering, guess the ending, and then leave the witnessed outcome at the job. But, no matter how strong healthcare workers become, there are times when the emptiness of a cold hand stays with us long after our workday ends.

Some of the best advice I was given when I first started working in the emergency department (ED) was to know where the empty spaces are in the hospital. At the time, I worked nights. This meant that my empty place was the waiting room for radiology because it was open and only used during the day. It was one of the few places I could go in the hospital that was unlocked and had corners hidden from the security cameras and the hallway. Over the years I worked in the ED, I would sit alone in the dark radiology waiting room on several occasions. I’d sit there only for a few minutes before returning to the floor to help the next patient.

As my career in healthcare unfolds, I’ve learned to stop and remain still when one of my colleagues tells me they lost a patient that day. Sometimes they will want to talk through what happened but, more often, they just want to sit with me and reflect silently. There are no words to describe what it’s like to be involved in someone’s death, even if your role was trying to prevent it. And, sometimes, there are no thoughts to describe it either. But, those of us in medicine know that death is part of life. And while the stories of some people linger long after they pass, we’re still glad to have been there to help them through the last stage of their life.

The False Limitations We Put on Despair and Happiness

The pit of despair and the pool of happiness are bottomless. Which means you and I can both suffer and revel in glee to any degree without limiting the pain and joy of others.  

My partner works in the emergency department (ED) and I used to work there too (that’s where we met). From time to time, our non-healthcare friends will ask, “So if I have to go to the ED, what should I say so my wait is shorter?” When this classic question is asked, my partner and I glance at each other and smirk. Anyone who has worked in the ED can tell you that you don’t want to be the first person to go back to a room from the waiting room…because the people who don’t have a wait are the people most likely to never walk out of the hospital.

No one wants to go to the hospital. It is miserable to be there as a patient. But, let’s say you go to the ED because you broke your arm skiing. Your arm is painful. The friend who accompanied you to the hospital is desperately trying to help you stay calm while also struggling to maintain their own composure because the odd angle of your arm makes them sick to their stomach. While you and your friend wait in the ED, there are others who have been in the hospital for days and there are some who have been there moments; in each of these groups of patients there are people who will die during their hospital stay. I tell you this not to diminish the suffering of your broken arm. I tell you simply to say that we don’t suffer alone. Your broken arm is not made less painful by the heart attack and death of Mr. Doe that occurred while you waited in the ED, but his death might remind you that we do not all suffer to the same degree during a particular patch of time.

The same goes for happiness. Some of the joys of this COVID era are the baby announcements, the engagements, the house improvements finally complete, the adopted fuzzy friends, and the fitness goals achieved. My social media feeds are full of cute kittens, puppies, and shiny rings. One of the things I love about all these great landmarks in my friends’ lives is that the engagement of one friend does not detract from the puppy adoption of another. It turns out that my friend with a fiancé can be dreamy about their forever while my other friend can melt with love for their new puppy.

I think the infinity of the pit of despair and the pool of happiness are important to keep in mind. You can take as much as humanly possible from both or either and there will still be a limitless amount for the next person. Not many things in life are that way.

Since the COVID pandemic started and the death of George Floyd there has been arguing among individuals and over the news about the validity and gravity of the pain and inequity experienced by different groups in America. The argument goes some like, “I’ve also had a hard life. I’ve suffered from injustice. So, I don’t see why their hardship and the inequity they face is special.”

The suffering you’ve faced does not neutralize the suffering of others. The suffering you’ve experienced does not lessen the burden of suffering for the rest of humanity. Suffering and happiness have no bounds. The argument for equity is not that your suffering does not matter. Your suffering does matter. The argument for equity is that the systems we’ve developed so far to organize our government, personal lives, education, and work make it harder for certain people to access the pool of happiness while at the same time making the pit of despair easier to fall into. The underpinning of equity is simply that there should be no gatekeeper to happiness and no funnel to despair and, therefore, where they exist they should be eliminated.

COVID-19: Oddity of a Shared Experience While Living Continents Apart from My Paraguayan Friends

Reposting 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 post here.

In early March, I had a Zoom call with the other community health Peace Corps volunteers I served with in Paraguay from 2014-2016. One of my colleagues still lives in Paraguay and he shared his impression of the Paraguayan response to COVID-19 compared to that of the US this spring: “Here [Paraguay] everything is locked down. Police will stop you if you’re on the street to ask why you’re out. People are getting restless because, as you know, here many people don’t eat if they don’t work. But Paraguay is taking this seriously. It’s mind-blowing to hear what’s happening in the United States. It’s hard to believe the news of people protesting masks and attending large gatherings during these times.”

At the time of that comment, the US was still widely debating the validity of masks and COVID-19 cases and deaths were still increasing. Vermont, where I live, was among the US states that chose a more aggressive public health approach with the hope of containing viral spread. For much of the spring and summer most business in Vermont were closed, including gyms and many restaurants. There was no curfew, however school was cancelled or switched to completely online and wearing masks in public places was mandated. The almost complete shutdown only lasted a few months. In late summer, many businesses in Vermont started to open again. Now, schools are back in session (many school districts have a hybrid of online and in-person classes). As a second-year medical student, I have in-person classes twice a week and online classes three days a week. I am required to get a weekly COVID-19 test and report any new symptoms and contacts daily.

The short shutdown and recent opening of Vermont is in stark contrast with the experiences of my Paraguayan friends during these past 6 months. I’ve remained in contact with friends in the Paraguayan community where I worked when I lived there during my Peace Corps service.

This fall, just as in the spring, my friends in Paraguay are mostly restricted to their homes. When my friends and I spoke in early summer, they said that only a few members of their extended family were still allowed to go to work. One friend shared her perspective on Paraguay’s infrastructure, “Our hospitals can’t take care of people if they get sick,” she said. “We are worried.”

In early September, I got a voice message from one of the Paraguayan women who is like a mother to me. She was on the verge of tears. She is the primary caretake of her 90-year-old mother. In my friend’s message she told me that she is scared that her mother will die of COVID-19. My friend does not have a car. The nearest hospital is 2 hours by bus. I don’t know if the buses are running right now.

I’ve returned to Paraguay twice since leaving, once for a friend’s wedding and once to meet a friend’s son before he turned one. I was planning to visit again this year because two of the children I taught when I worked there will turn 15. In Paraguay, 15 is considered an important birthday and some families have a large, wedding-like birthday party to celebrate. The two children turning 15 are like younger siblings to me and I wanted to see them during their special year.

In late September, realizing that I probably won’t travel anywhere outside of the US soon, I made a traditional Paraguayan drink called cocido. It is a warm beverage made from steeped yerba mate (similar to tea) and burnt sugar. It’s a perfect study beverage for fall and it reminds me of my Paraguayan friends and our times together. I shared a video of making cocido with my Paraguay friends. One of them mentioned that I should make chipa, a traditional Paraguayan biscuit that is often eaten with cocido. “I miss chipa!” I said over text. “I haven’t made it because it’s better in Paraguay. I’ve been waiting to visit again so I can have it there.”

My Paraguayan friend responded, “You should make chipa. Don’t wait to come to Paraguay. You’re not going to be able to come for a long time. Things are not well. Lots of people are getting sick here now. We don’t know what is going to happen with this virus.”

My friend’s comment was in stark contrast to any previous conversation we’d had about me visiting Paraguay. My Paraguayan friends remind me often that I am always welcome in their homes. Before COVID-19, every time we talked they asked when I was returning to Paraguay. Now my friends seem too far away to visit. Yet, despite the feeling that travel to Paraguay is morally forbidden during these times, there is something novel about sharing the same public health crisis in my home country as friends abroad. It is not often that the primary public health concern in the United States is the same as that in Paraguay. It is the first time since I’ve left Paraguay that I feel my life is still intertwined with the lives of my friends in Paraguay. It’s not reassuring, but it is interesting to consider how interconnected our global community is despite the borders, oceans, and mountains that separate us.