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.

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.

Burnout

Alarm. Study. Class. Study. Eat. Study. Bed. Alarm. Study. Class. Workout. Study. Study. Bed. Alarm…Repeat. Repeat. Repeat. Sometime in the future substitute work for class and study.

My sister and I have a term for the life leading up to burnout. We call it living like a robot. It’s a life where work and/or school consumes you and sometimes you fit in sleep and things that make you happy. Most of the time in the robot life you simply work and wish you were sleeping.

The robot life is unavoidable sometimes if you have hard goals. I have always justified it by knowing when it will end. I’ve had several bouts of that life with years of rest between. Most of my undergrad I was a robot. My two years of post-bacc, pre-med studies plus all the work piled on top were some of the worst years I’ve known. Medical school is the first time I’ve not worked as I studied since middle school. It’s nice to have one job, just medical school. But, honestly, it’s still hard.

Medicine is cursed with a heavy dose of the robot life. This is partly because physicians have peoples’ lives in their hands, so expectations are high. It is partly because the type of people who become physicians are A types and have high personal goals. It is partly because health is ubiquitous and illness unavoidable. As humans, our ability to reach our full potential is partially determined by our health. If we are in pain or ill, we can’t do all the things we would if we felt well.

Medical school and then working as a doctor are challenging because the hours can be long. They’re also draining because the work is complicated and requires focus and lots of puzzling through piles of clues to find the best answer. The pressure is high because the puzzle directly impacts a human’s life. And depending on the gravity of the puzzle, the answer might impact a whole family.

Time and intellectual challenge aren’t all that makes medicine difficult. It’s a team sport, so office politics and business relationships come into play. But even teamwork isn’t the hardest part of medicine. Medicine is an emotional job. People who come to us as patients die. They lose function. They lose the ability to lead the lives they’ve always led. There are many happy outcomes, but not all patients’ stories end with joy. The sad outcomes add up as time goes on.

My time in healthcare as an EMT showed me that no individual patient impacted me unbearably. However, there are days when I feel the weight of all the patients I’ve helped. For example, I felt heavy after the last CODE I worked before I left the ED for medical school. A CODE is when you do CPR, shock, ventilate, and take other measures to try to revive a person whose heart has stopped.

That night I closed the curtain on a 30-something-year old with a wedding ring who hadn’t been identified yet. He was dead before he arrived, but we did CPR anyway. I was one of the last to leave his room. I never leave a dead patient before ensuring they’re presentable for family. CODEs are messy. If the family isn’t there to see us work, I see no need for them to experience the mess. I knew sometime in the night his partner would learn he was dead.

Tucking in that patient right before I ended my shift was hard. The death rested on top of the morning I walked into the ED to find teens on the phone crying. They, the teens, were calling their family to tell them their mother and uncle had died. Odd to have children deliver news most adults barely can. The sadness those teens felt added to the day I cleaned two CODEd patients back-to-back so they wouldn’t be bloody and dirty when their family arrived to say goodbye. After tucking in the second of these, I walked out of the room to find a visitor approaching. I interceded and joined her, but only upon entering the room did I realize she, the daughter, didn’t know her mother was already dead.

The sad endings add up. But, so do the good journeys and happy endings. The patients who turn our days around by sharing the most amazing stories or giving advice that is perfectly wise. Days in healthcare are brightened by visitors who show raw love toward someone stuck in a hospital bed. I’ve seen true love hiding in ED rooms on multiple occasions. It was working with old couples in the ED that showed me how I’d like to age.

It’s no surprise between the stress of the job and the rigor of the schedule that doctors and medical students burn out. However, knowing our challenges gives us the knowledge we need to persevere. Even within the field of medicine there are many decisions we can make to suit our goals. It begins with specialty and is followed by location and type of hospital. We have the information we need to know how a specialty, location, specific hospital, and extra projects we take on will impact our life or encroach on free time. We can decide, within the scope of meeting our obligations, when we wish to do extra and when we wish to do the minimum. Most importantly, we know that no state is permanent unless we let it be. 

I think at the root of avoiding burnout is being honest with ourselves and checking in with ourselves. There are stretches of school and work that must be survived. The robot life must be lived sometimes. But, amidst the madness we must decide when it will end. We can choose to rein things in when needed. We can choose to prioritize family or life outside work. Of course, to do this, we must know ourselves and what makes us happy. Once we know where we find happiness we can fight for it as fiercely as we fight for our patients. In the end, if we are not well, we can’t help anyone else at the level we can when we are in good health.

People Get Sick – Some Rise and Some Fall When Faced With That Reality

As the COVID19 pandemic continues, it’s brought out the different sides of people directly and indirectly in my life. I continue to be impressed by the many folks who fearfully, yet generously, show up to work at the grocery stores, the hospitals, and the other businesses of service that we can’t live without and can’t be run remotely. I am equally surprised by those who had the opportunity to help and instead fled. Fear is powerful. It makes those who consider themselves generous selfish.

I’ve seen great efforts of humanity from handmade protective equipment to online hangouts bringing people who haven’t talked in years together. I’ve seen folks put on fitness, meditation, and medical school classes virtually—I’m amazed how much can be done over online video chat it a pinch.

I’ve also seen people lash out at people who are sick but not dying, in anger and fear. It is easy to blame those who are sick for their illness and label them as a threat but, like everything in life, it isn’t that simple. It’s worth remembering that pandemics are not the work of individuals; they are the work of collectives. What is more, viruses and other microbes are perfectly simple and wonderfully complex. Nothing made by humans can be quite as clever as they are, so no need to find human scapegoats to blame for a disease they could not have made.

The idea of not knowing if someone has an illness you can catch is scary. But, that’s the nature of many infectious diseases, not just COVID19. And while many of us born in America do not necessarily think of potentially deadly infectious diseases often, that is a luxury people in different parts of the world do not have. It helps give perspective to remember that millions of people die of infectious diarrhea and malaria, for example, each year. And their plight isn’t one the larger world community has committed to ending. It will go on…perhaps as long as humans exist.   

We are strained by social distancing today. Yet, we carry on because we have a sliver of hope that by limiting our interactions we can end COVID19. We believe that we can limit the number who die or get sick. As we hold on to these ideas, we should also remember that social distancing need not make us less compassionate for others. Protecting ourselves does not require that we compromise kindness. I would hope that we all see this time as an opportunity to discover creative ways to help those who are sick while also protecting those who aren’t yet. The infection count is not a numbers game of distant people we don’t know, it is happening right here, today, and to real people with families and a story. Just remember that those numbers you’re refreshing are humans. Don’t forget that, because if you do you just might become apathetic. We have a pandemic to end. It will take the actions of each of us to be successful. Stay engaged.

Last Day in the Emergency Department (for Now)

July 25 was my last shift at the emergency department (ED) as an EMT. It’s hard to believe in a few short weeks I’ll start medical school, and my time as an emergency medical technician will be filed away as part of history. Becoming an EMT challenged me and made me face personal fears. The uncertainty I had when I first embarked seems comical now that I have those years of patient care under my belt.

I couldn’t be more excited (and nervous) to start training to be a medical doctor. But, leaving the ED was bitter-sweet. I’ll miss my crew—the ED is filled with dedicated people focused on improving their patients’ lives. If every team I work on is like mine was in the ED, then my career as a doctor will pass quickly and happily. What also makes me sad to leave the job and start school is that I won’t have many opportunities to work directly with patients for a few years. The first two years of medical school emphasize learning all the facts you need to know to be a doctor and, in years 3 and 4, you start applying that knowledge in real health care settings. I got into healthcare because I want to help people. I find learning thrilling, but my motivation comes from the practical applications of the knowledge I gain. I can’t wait until I am back in the trenches seeing patients and trying to solve real health mysteries.

I became an EMT because it was the fastest certification that would allow me to work directly with patients in a way that required me to assess their signs and symptoms and then make clinical judgements. Becoming a doctor will give me a lot more knowledge and a much bigger toolkit to help my patients than I have now. But no matter where I end up in healthcare, I won’t forget from where I came. As an EMT, I learned to identify a sick human in a split second. I learned how to ask for people’s health stories and focus on the information I needed to help them. I saw firsthand how excellent patient outcomes are the result of teamwork (between all players not just the docs) and that poor communication leads to worse results. I hope these lessons stay fresh as I cram new ones into my brain.

True Love

Not so long ago in the ED, I was helping a patient in one of the acute care beds. Through the curtain that divided the room I was in from the next patient room, I heard someone reading out loud. Where the reading was coming from, a post-retirement man was the patient and his wife was with him.

I saw through a gap in the curtain that the wife was happily reading a book to her husband. Her voice rose and fell with the emphasis of someone who had read aloud many times. Her voice mixed with the sound of her husband’s snoring. When she stopped reading, he stopped snoring and became restless. Sometimes she paused and looked at him. She’d smile and then continue reading before he fully awoke.

The sleeping husband and reading wife seemed so content and peaceful despite being in the middle of the ED on a day when people around them were having their worst days. The husband could have been very sick too but, unlike many of our patients waiting to be seen, he wasn’t sitting alone staring into space as he waited.

That woman reading to her husband was the clearest example I’d seen of true love in months. We see a lot of couples and families come through the ED every day. Accompanying a sick loved one often brings out the caring side of people, however there was something about the calm, closeness of those two (sleeping and reading) that highlighted the strength of their connection. I was reminded, for the millionth time, that it’s the little things that add up to indomitable forces.

Home Lab: Kombucha

This winter I started brewing kombucha. Kombucha is a fermented, non-alcoholic drink that (like yogurt) has probiotics that are helpful for your gut. It’s made from tea, sugar, and a SCOBY (symbiotic culture of bacteria and yeast). There are many ways to flavor kombucha, but I use herbal teas—mostly fruity ones.

Kombucha is a little tangy, a little sweet, and a little bitter. When all goes well it’s wonderfully fizzy. The fun part about making kombucha is every batch is a little science experiment. The goal is to produce a drink with a nice flavor combination and delightful carbonation—but it all depends on how happy the SCOBY is. The teas you use, the temperature, the amount of sugar, and the time you wait all influence the kombucha outcome. If you wait too long, the batch turns out very much like vinegar. If you’re too impatient, the kombucha is too sweet (because the microbes haven’t had time to eat it) and flat.

I’m just getting used to brewing in the summer, where the temperature is much warmer and the process goes way faster. Today when I checked my bottles, I had to put each one I opened in the sink because they had so much fizz they overflowed like a shaken soda bottle!

The kombucha process changes the flavor of the tea you use—sometimes for the best, sometimes for the bitter. For example, I DON’T like peach tea, but when I turn it into kombucha it’s quite yummy and not as painfully sweet as I find straight peach tea.

There’s something highly satisfying about cultivating microbes to produce something healthy. Many of us only think of bacteria when we get sick or when we want to kill germs—which makes us forget how many microbes are working for us each and every day. I like the meditation of thinking about microbes as my teammates.

Brewing kombucha has made me think more about the good microbes in my life, and it’s also made me feel better. A glass of kombucha a day, seems to keep the stomach aches away. I noticed this when I traveled in Spain for 2 weeks on vacation recently—many days my stomach hurt even though I was eating healthfully. I think it was a combination of my gut missing kombucha and my digestive system wanting to know where the yerba mate was (mate also changes how you digest food and I drink a lot of mate too). Not entirely by accidentally, the beverages I enjoy daily (mate and kombucha) both help with digestion. When I was younger I used to have a stomach ache almost every time I ate. I almost never do now. It could be growing up. It could be the microbes. Regardless, I enjoy the challenge of making my SCOBY happy so it works for me—I figure one more symbiotic relationship in my life can only be good.

Finding the Path

We all have bad days. The problem with having a bad day and working in healthcare is that it’s unacceptable for your mood to affect the quality of your care and people are sick every day. The trouble with healthcare on a bad day is that healthcare requires hundreds of human interactions within a shift. Hundreds of moments where patience is required, where you must do small tasks that are annoying and big tasks that are important, and all the tasks between that together help people heal. You notice everything a little more on a bad day. So how do you get through it?

Not so long ago, my shift landed on a bad day. But, there was a patient who turned the shift around for me. He told me how he raised his sons. He was a single father. He had a path he wanted them to go on and he thought his job was to lift them back up to that path when they fell rather than push them down. That’s what he did and he was proud of them. He told me he was lucky.

I think I’d like to approach bad days like this father approached his sons. A bad day is a fall from the right path. It just takes some nudging to get back on track again.

The benefits of working in healthcare on a bad day are the kind, wise patients you’ll likely encounter. They’ll set things right, even though you’re the one that’s supposed to be curing, if you listen to them.

Why I Go Back for Each Shift

Not long ago, I walked into an emergency department room (a cube defined by some walls but mostly curtains) to place an IV. An elderly man was on the hospital stretcher. He was there with his son. I began my normal banter—introducing myself, explaining why I was there, and narrating what I was doing as I went. The man might have asked me about my name, about 30%-50% of patients do because it’s unique. He might have asked about my necklace, it’s a wolf and about 25% or so of my patients ask about it.

“I’m going to raise the bed so I don’t have to stoop,” I said. “I need my back for many years to come.”

The patient and his son laughed. “You know what you need, music. Do you listen to music?” the patient asked.

“Not here, it’s not the right place. But, I like to dance, so I do listen to music,” I said.

“My wife liked to dance. She died a year and a half ago,” the patient said.

“I’m sorry to for your loss, sir,” I said.

“We were together 60 years,” the patient said.

“That’s amazing! I don’t think I’ll be with anyone for 60 years at this point. Did you take her dancing?” I said. I maintained a jovial tone because he seemed merry when he mentioned his wife and dancing.

“I did,” the patient said. I looked down to find him crying. I paused and put a hand on his forearm. Giving him a squeeze. I’d recently visited my grandmother. A big part of our visit was discussing how my grandfather, who’d died 2 years prior, was still with us.

“How lucky she was to have you take her dancing! How amazing it must have been to have had so many years together,” I said.

“Sorry, I always cry when I think of her,” the patient said. He half-shrugged and looked away.

“It’s okay. She’s with us still and you’ll see her again, sir,” I said.

“I hope so,” the patient said.

“I know you will,” I said.

The patient and his son nodded. The tears ebbed. I placed the IV. All humans have stories. Sometimes they find space to share them when they visit us in the emergency department.   

Mental Health and the Emergency Department

Checking into the ED for a psychological complaint

When a person comes to the emergency department (ED) with suicidal thoughts or another mental health state that could be a threat to themselves or others (ex. extreme paranoia, homicidal thoughts, mania, etc.) the processes is simple. They change into paper scrubs and their clothes and belongs are locked in a secure closest, returned upon their discharge from the hospital. A hospital staff member sits outside of (or just inside) the person’s ED room conducting constant observation—which includes observing the patient at all times and recording their location and general behavior every 15 minutes. The constant observation is to ensure that the patient does not try to hurt themselves, try to leave, or try to hurt anyone else during their ED stay. Many people who check in for psychological evaluation are not allowed to leave the hospital until their mental condition has been cleared by a psychologist, meaning they are forced to stay in the ED until a doctor says that they will be safe returning to society. Patients suffering from psychological conditions that require more treatment than the ED can provide remain in the ED until a bed in a specialize treatment facility (or in the hospital psychology unit) opens.

One way to define “a national mental health crisis” in the US

When I think of a mental health crisis in the US, I think of all the people stuck in the ED waiting for a psych evaluation and then waiting for a bed in a facility that specializes in psychological treatment. I think of the patients who remain on lockdown in the ED for 100s of hours because if they leave they might knowingly or accidentally hurt themselves or someone else. These patients have no other safe place to wait for an in-patient bed. I think of the people who come to the ED and, even under the watchful eye of our staff, try to kill themselves. I think of the people who end up in restraints, literally tied to a bed, because their condition escalates to the point that they try to escape, attack hospital staff, or harm themselves. To me, the mental health crisis in the US is that we don’t have enough 24-7 services and specialized treatment facilities to keep patients with mental health conditions out of the ED. To me, mental health is just like any other aspect of health. We need to bolster our programs to help prevent acute mental health problems, but we also need adequate mental health treatment programs for those struggling with psychological conditions. The crisis, I think, is a lack of preventative care and readily available treatment, not the existence of diseases.

The ED does welcome mental health patients as we do all patients, but the ED is not equipped to find long-term solutions for any health condition. It is true that the ED can help with acute symptoms, which is all some patients need for a short period of time, but we don’t have a calming environment nor do we have the staff to provide intensive treatment for mental health conditions. We serve as a gatekeeper to specialized treatment and as a place to go when there is nowhere else to go. Just like the ED is not an appropriate place to perform and recover from surgery, it is not the right place for those who need in-depth evaluation or long-term treatment. The ED was designed to keep patients for ideally a few hours or, at most, for part of a day before sending them home or to an in-patient facility. But, what happens with some of our gravely ill psychological patients is that they must stay in the ED for days, even weeks, because there are no openings in specialized facilities.

Conclusion

Using the ED as a long-term home for people suffering from psychological conditions is neither therapeutic for them nor is it a cost-efficient design of the health care system. We need more mental health treatment facilities in the US. We need more programs designed to help those coping with mental health conditions manage their symptoms at home. We need more people going into the psychology fields and social work. In summary, we need to dedicate more resources to mental health in the United States. I think to do that we need to start by acknowledging how many people struggle with mental health and how weak or absent our treatment options currently are for those people. Next, we need to make mental health a budget and policy priority at all levels of government and in private health care systems. Right now, EDs are serving as the catch-all. They are not the solution. While the ED might be the right place for folks in any kind of acute health crisis to go initially, the ED only works if there are specialists and specialized facilities to refer our patients to once we’ve identified the sustained medical care they need. It’s times we prioritize mental health as we have heart health, lung health, and cancer-free health so that no patient is held in the ED because they have no other safe place to go.