Author Archives: Jett

Finding Purpose and Meaning

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The patient was nicely dressed and collected. They sat with elegance as I chatted with them during their checkup. By most accounts they were doing well. They didn’t have many aching joints or the other common issues of people their age. But, as we finished going through all the normal appointment questions and checklist items for a primary care visit, the conversation turned to the main issue at hand: meaningful existence. 

The patient had recently moved from the south to the north to be close to their adult children. In moving, they had left behind the hair salon where they’d worked for many years and where they continued to work until moving. Nobody in their new, northern community would hire them as a hairdresser because of their age. This disappointed them. They were very energetic. They were involved in many clubs and had many social engagements weekly, yet, they found themselves depressed, tired, and empty. Nothing they were doing gave them the sense of purpose that working had.

We brainstormed together. If not work, could the patient volunteer? Where might they like to volunteer? Our town had many opportunities for volunteering. The patient jotted down a few nonprofit ideas and smiled. They said they’d consider it; it seemed better that sitting around doing pointless things.

Depression is common in the elderly. Among other things, it’s postulated that feelings of isolation and loss of purpose can contribute to depression. On an anecdotal level, I’ve heard many elderly patients describe feeling alone, especially when they’ve moved to be close to adult children and left behind an existing community their age or that they had been part of for a long time. Even children who visit frequently aren’t the same as having a whole community – especially a community that has also lived through the same decades and seen the same changes in the world. What’s more, many elderly people are retired or decrease their activity in work and volunteering. It’s easy to say that retirement and less work is good and that these wise people have worked their whole lives and deserve a rest. This is true; however, what I’ve also noticed anecdotally among the hundreds of patients I’ve met as a medical student, is that the happiest people are the people who have meaningful projects regardless of age.

This elderly patient is an example of someone who was driven to work well after they reached retirement age. Their case showed me that perhaps encouraging and supporting our elders to be active participants in their community would be helpful for their wellbeing. This seems especially important in a place like the US where many families are scattered all over the country and generations tend to live separately. There are many elderly folks who find meaning in caring for grandchildren as I’ve seen in other places like when I lived in Paraguay. However, we must remember that there are many elderly people who didn’t have children or who don’t wish to spend their days caring for their kids’ kids and that their need for meaningful activities is also valid. As we forge forward as a society, it seems prudent to keep this in mind and continue to support and develop programs that help an aging population remain active in their communities’ productivity and progress if they would like to be. Be it work, volunteering, or other projects in and out of the home.

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Listening in Medicine

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This patient was always cheerful. Despite approaching a month in the hospital. Despite extensive injuries for which they required multiple procedures, surgeries, and a long course of antibiotics. Every time I checked in, they had a visitor, were listening to mass, or were simply doing life things.

One day when I stopped in, the patient was different. Still as pleasant as ever, but their cheer was guarded. I noticed that their voice was heavier. That their eyes were drooping at the edges. Their smile seemed more effortful. “Is everything okay? Are you okay?” I asked. In the minutes I was with the patient, I asked these questions periodically. Interleaving with the normal questions about signs and symptoms and physical exams I needed to do. I’ve learned that if you create space for things that haven’t been said to be said, sometimes patients share what’s bothering them and you can do something about it.

I paused as I was preparing to leave and asked one more time if the patient was okay. They started crying. I waited. “It’s just I haven’t seen my children. I miss my children,” the patient said. I’d come to learn that they had two young children who they hadn’t seen since their admission. They video called them but, obviously, that wasn’t the same as seeing their children and giving them hugs.

Since COVID, hospital visitation policies have become more restrictive. There are reasons for these restrictions, however the unintended consequence is patient social isolation which is bad for patient mental health to put it simply. At the time when I was seeing this patient, the hospital I was in was not allowing children to enter the hospital as visitors. Rules, though, usually have exceptions. I spoke with the nursing staff, as they steward hospital floors, and they were able to arrange for the patient to see their children.

This patient interaction reminded me how listening is critical in medicine. The hospital is a difficult place to have a good conversation as patient. The hospital is confusing and foreign to most people; there are unintentional power differences that exist as medical knowledge and understanding are uncommon among those who didn’t study medicine; there are many faces with different roles in the hospital so it’s impossible to keep track of who is the right person to ask for what; and the hospital is busy and short-staffed, so healthcare workers are doing their best but they are always running behind. Given these barriers to communication, the burden falls not on the patient but on their care team to ensure that time to hear patients’ needs is made. To do this doesn’t necessitate longer patient interactions, necessarily, but it does necessitate listening for more than reports of a fever or bowel changes.

It can be hard to listen for things that don’t directly relate to changing a patient’s care plan. Yet, patients are more than carriers of disease and, therefore, to best support them in their journey to better health we in healthcare must listen to all ailments. Sometimes we can lessen a burden and sometimes we can’t. Arranging for a parent to see their children after weeks in the hospital is something we can solve easily. I was glad I was able to help this patient see their children, but I wondered how long the patient had suffered from missing their children. Perhaps, if one of us from their care team had listened more carefully earlier, the patient wouldn’t have had to wait almost a month before seeing their children. To me, it seemed unreasonable to add the burden of missing loved ones to this patient’s burden of healing from an accident that had almost killed them and injuries that would likely change their life. Being sick is hard enough; let us in healthcare not forget the human things, like social supports, that can help make healing less daunting. 

A Palindrome Birthday

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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

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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

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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

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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

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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

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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

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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

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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.