Count Down

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The sun sparkled through the bright green leaves of late spring. The osprey floated overhead, having returned to Richmond at the first signs of spring months earlier. The James River still roared because summer’s dryness hadn’t set in yet. My morning soundtrack was birds singing, then replaced by the bustle of slow Richmond when the city finally awoke. The late morning sky was speckled with swallows. The crows cawed. The birds that flew past had nest material in their beaks. I drank mate as the day lazily passed.

When the sun returns and the days are warm and humid, I think of Paraguay. The land of the Guarani; a place that hasn’t been my home for years yet, somehow, is where I’m grounded. When I have slow moments, my mind slips back to the breeze in the mango trees and the sun dancing on the red dirt. I think of my Paraguayans neighbors and friends who smiled so easily and were quick to laugh. In Paraguay the music always blasts too loudly and at the wrong hour. The motos zoomed up the road, their riders helmetless. In Paraguay, the days were slow even when they were fast. I thought the pace was because of the heat when I lived there. But, perhaps, there is more to the calm that sits it the lowlands around the Paraguayan River than just the temperature.

Virginia summer is like Paraguay. Maybe that’s why I like it here. Or I could like it because Virginia is a warm version of Vermont. Vermont, my original home with its harsh winters, perfect summers, and rugged greenness. It’s also possible that I like Virginia just because I do. Richmond, the city no one’s been to. A hidden gem of sorts – not too big and not too small. It’s home to a diverse assortment of people. Richmond feels very southern but not lost in the south. Odd, given its history. I feel at home here despite having a New England constitution and a Vermonter’s tenacity for liberty. Liberty of spirit, body, and mind…something I’ve noticed our country has been undermining recently.

The late spring unfolding to summer is a transition time. It’s a change of season. And for me, along with every other medical resident, it’s also a transition from one residency year to the next. In a few short months, I’ll start my last year of residency. As such, it’s time to start planning my next steps. I’ve been thinking about the job I hope to have after residency and how I might find it. Medicine is for planners, everything in medicine takes a long time and requires strategy. I’m a planner so I fit right in. But I’m also a dreamer. Not all doctors are dreamers, yet I am. I’ve been dreaming of birds singing all day, never to be replaced by noisy cars and music I didn’t pick. Dreaming of grass between my toes and the quietness of trees. I’ve been dreaming of trails yet to be explored and reflecting on the trails I’ve already walked.

I’m always counting down to things that will come. Some counting is more meaningful than other counting. My residency countdown is meaningful. It was for the “after residency” phase of being a physician that I went into medicine. I’m finally almost there. Just 14 months left of the doctorhood quest. A year-ish is a short time when I remember that I’ve been chipping away at the doctorhood quest for 8 years already. What an invigorating thing to look for a job again rather than think about school. I’m excited to have a job that allows more time than I have currently to sip mate and contemplate if the sun is prettier here or in Paraguay. There isn’t enough time allocated to such contemplation during residency.

Giving the Body Time to Heal or to Live

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When reading a book on ventilators* (mechanical breathing machines) to expand my knowledge of how to use them, I was struck by the author’s comment that ventilators are not curative but simply tools to buy the body time to cure itself. This factoid is known (at least subconsciously) by many physicians though not often so simply stated or at the forefront of our minds. The author’s bluntness made me wonder whether most of medicine is like that – interventions designed to keep death at bay until the body can mend itself, if such mending is possible. Or, if not mending, interventions that slow down damage to the body thereby allowing people to live longer than they would without the intervention.

The thought of medicine acting as a time warp – bending time to give the body space to mend– renewed my awe and appreciation of the body and its functioning. Without intervention the body is extremely resilient. With medicine available to help it along the way, it is incredible.

In primary care clinic, my patients and I frequently discuss the need for putting in time before results are realized. Medications and actions inherent to primary care are usually designed to prevent damage that would need mending. In that way, preventative medicine, as primary care is, is designed to give the body more time to live. Primary care time is composed of daily endeavors to live healthfully. It includes time spent doing physical therapy to optimize muscle function. Time spent sleeping, exercising, and eating well. Time – built from seconds – with each small action and decision along the way adding together, hopefully generating an outcome that may not have otherwise been possible.

In contrast to primary care, hospital time is more finite and about letting the body heal itself. In the hospital I also discuss time with my patients often. Common conversations include time left before patients can leave the hospital, time left to live, and time needed to recover. We discuss the shortcomings of the crystal ball I don’t have. We review the annoying truth that medicine isn’t magic and that sometimes it takes days to reduce leg swelling with pills that make one pee, to heal tissues that are infected, or to get medications to reach their therapeutic level in the body.

Bending time to let the body heal or to delay deadly damage is a simple concept but complex when applied to real life. The question remains: If time is bent will it change the outcome? And the more medicine I do the more muddied my answer to that question becomes. The answer is between sometimes and often. Medicine is based in research that investigates if behaviors, medications, and procedures help improve outcomes – survival, functionality, etc. Yet even the medical recommendations we are confident about are still probabilities and not certainties.

For example, there is no promise that if we control patients’ diabetes, they won’t die of a heart attack. They might. Research suggests that if we treat diabetes the chance of dying from a heart attack is lower for the person with diabetes. Similarly, we know that if we don’t place someone who can’t breathe for themselves on a ventilator, they will die. But we can’t promise that they won’t die after we place them on the ventilator. They might. In both examples, we are just giving the body a chance to pursue an alternative outcome from what is most likely at the time we act. It’s a chance, not a promise.

Even in the case of more definitive medical cures – like surgical removal of a tumor or chemotherapy – cure is not a guarantee. The body first must recover from surgery and avoid complications like infection to benefit from the surgery. The body first must survive chemotherapy before benefiting from the cure, and there is a risk of cancer returning.  Considering the limitations of even curative interventions, the argument that their primary role is to give the body an opportunity to heal itself remains. Fate is like magic, beyond medicine. Yet, the body is capable of astounding things. As such, even if medicine does nothing more than bend time for the body it is still a worthwhile pursuit. Because with medicine we might extend life and reduce suffering during whatever days remain in a person’s life. That opportunity, even if not guaranteed, is why people like me go into medicine.

*The Ventilator Book by William Owens

The Floors Don’t Shine Like They Used To

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I walked into the Veterans Affairs (VA) hospital where I have primary care clinic. I hadn’t been there for a few weeks between vacation and working in the ICU (critical care unit) at a different hospital. Yet, I’d heard about the budget cuts and other residents had shared murmurs of uncertainty related to what was to come for our patients. Entering the VA hospital for the first time since the budget cuts started to take effect, I was immediately struck by how gross the floors looked. And, as I was processing the dullness of the floors and their peeling finish, I heard a woman next to me comment on the floors too.

I used to joke to my spouse about how frequently they refinished the floors at the VA hospital. Over the past 2 years it seemed that every time I worked nights or left late, they were refinishing the floors. These efforts resulted in a floor as shiny as the shoes of the sentinels at the Tomb of the Unknown Soldier in Arlington Cemetery. And, until the floors looked dull, I’d never thought about their symbolism.

Every patient seen at the VA hospital is a veteran. Some of them wouldn’t have access to healthcare if it weren’t for the VA. Most of them wouldn’t have access to some of the most critical medical resources that our veterans need for good health without the VA. Mental health care is one example of such a resource.

I settled into my day at the clinic. A patient I hadn’t seen before was among my first patients. “I’d like to be screened for PTSD,” he said.

“Okay, why?” I asked. PTSD stands for “post-traumatic stress disorder.” It’s a condition that can occur when people experience things that are mentally traumatic. It can include flashbacks to the event(s) that disrupt life, nightmares that prevent sleep, and mood challenges that make it difficult to function in daily life.

“My daughter thinks I have it,” he said.

“Do you have nightmares?” I asked.

“No. But I think about things that happened. I just push the thoughts out of my head though. You know, I saw people die in Vietnam,” he said.

“How often do you have those thoughts?” I asked.

“Multiple times a day,” he said.

“How long has that been going on?” I asked.

“Years. I also get angry really easily,” he said.

“Do you get angry over things that other people don’t?” I asked.

“Yeah, all the time. I just get angry fast,” he said.

“Any thoughts of hurting yourself?” I asked.

“Hasn’t come to that,” he said.

“What about thoughts of hurting others?” I asked.

“All the time, but I don’t act on it,” he said.

The conversation unfolded. From my assessment he easily met criteria for PTSD. “Well, I think your daughter’s right that you have PTSD. Do you want treatment for it?” I said.

“Yes,” he said.

We discussed our options for treatment. I was grateful that we had options. How awful it was to think he’d potentially lived for 50 years with thoughts of the people he saw die in Vietnam haunting him multiple times daily.

Mental health is a huge part of health for all people and an especially common challenge for veterans. It has taken years of population education and eradication of misinformation to create an environment where veterans feel comfortable asking medical providers for help with their mental health. In my experience younger veterans are more comfortable discussing things like depression and PTSD than older veterans. But it’s an important issue for all veterans. To put it in perspective, about 18 veterans across the US die by suicide daily.

The VA offers more mental health services than any other healthcare system I have encountered. People using civilian healthcare often wait months to be seen by a therapist and longer to see a psychiatrist. When working at the VA, I can ensure my patients’ mental health is supported as soon as I learn it is a challenge for them thanks to the VA’s dedication to the mental health of our veterans. The VA’s effort to help manage mental health challenges among veterans matters. For example, suicides among veterans diagnosed with PTSD decreased by 32% been 2001 and 2022.

What makes medicine different from most other industries is that we don’t deal in money, property, or things. We deal in lives saved, lives lost, and human suffering. What does the shine of the VA hospital floor say about the future of our veterans’ healthcare? Time will tell. Yet, looking at the landscape of US federal budget cuts and executive mandates, people’s access to healthcare in this country is declining. I suspect that it’s only a matter of time before the health effects are felt broadly. Of course, these federal healthcare budget cuts and restrictions are concurrent with cuts in federal funding for research. As a result, we probably won’t be able to quantify the impact politics today had in terms of lives lost and population health deterioration. Perhaps the symbolism of a floor, which one walks all over for their personal benefit, is fitting symbolism for the value current political figures place on the health of others.

References:

  1. VA releases 2024 National Veteran Suicide Prevention Annual Report: https://news.va.gov/137221/va-2024-suicide-prevention-annual-report/

The Language of Medicine

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“63 yo M with a hx of DDKT (2019), ESDR 2/2 membranous nephropathy, DMT2, ischemic cardiomyopathy, HFrEF (EF 30% in 2023), Afib (on apixaban), CAD s/p stent and CAGB who presented with SOB with exertion and orthopnea. Admitted for CHF exacerbation 2/2 rhinovirus and missing medications. Course c/b Afib with RVR and AHRF requiring BiPAP.”

The above is an example of a typical “one-liner” in medicine using a fictional patient. A one-liner is a summary of a patient meant to communicate to other physicians the most important features of a patient’s medical situation. The spelled-out version of the above one-liner may be slightly more comprehensible for non-medical people, but likely not by much:

“63-year-old male with a history of deceased donor kidney transplant (2019), end stage renal disease secondary to membranous nephropathy, type 2 diabetes mellitus, ischemic cardiomyopathy, heart failure with reduced ejection fraction (ejection fraction 30% in 2023), atrial fibrillation (on apixaban), coronary artery disease status post stent and coronary artery bypass grafting who presented with shortness of breath with exertion and orthopnea. Admitted for congestive heart failure exacerbation secondary to rhinovirus and missing medications. Course complicated by atrial fibrillation with rapid ventricular response and acute hypoxic respiratory failure requiring bilevel positive airway pressure.”

I present these patient summaries to illustrate that medicine has its own language. Much like one might learn Spanish if planning to work in Mexico, part of becoming a doctor is learning the language of medicine. What makes medicine even more challenging is that each specialty has its own dialect which comes with unique acronyms and fancy terms. In part, the reason it takes so long to become a physician is the time needed to master medical language.  

Yet, despite so much effort spent understanding medical language, the best physicians don’t just communicate with each other. Physicians also communicate with patients. It’s a unique language mastery to be able to translate complex medical terms and concepts into language that nonmedical people can understand well enough to make informed decisions about their healthcare. Part of the physician’s job is to be a translator between medicine and everyday language. At times, this can be more challenging than one might imagine.

Becoming a physician takes at least 7 (usually more) years of training. And since being a physician is a job, physicians spend their entire work week thinking about medicine. Spending so much time lost in the language of medicine makes it easy to forget which phrases are medical jargon and which aren’t. The seasoned physicians I most admire are those who, despite so much time spent thinking in medical language, can easily code switch (going between different languages and cultures) to everyday language when working with patients. I strive to be like these physicians. Often, it takes a lot longer to explain medical information in nonmedical terms because medical language provides a means of synthesizing information. The extra time is worth the effort to ensure patients understand their medical situation. 

So, to break down the above one-liner into everyday language as an example:

“This 63-year-old man has a complex medical history. He has a condition called ‘heart failure.’ Heart failure is when one’s heart does not pump as well as a healthy heart. He has heart failure because the blood flow to his heart was blocked before he had his heart surgery. When the heart doesn’t pump as well as a healthy heart, fluid can build up in the body. One place that fluid builds up is in the lungs; this causes trouble breathing.  This man came to the hospital with trouble breathing, likely because of a heart failure exacerbation. A heart failure exacerbation is worsening of heart function usually because of a stressor. In his case, he likely had worsening heart function because he got a common cold (caused by a virus called “rhinovirus”). He was at particular risk of severe cold symptoms because his immune system is weaker than normal because of the medications he takes for his kidney transplant. His heart failure also likely got worse because he missed medications for his heart. While he was in the hospital his heart rate was very fast because of an abnormal heart rhythm. He was at risk of developing a fast heart rate because of his history of an abnormal heart rhythm called “atrial fibrillation” (“Afib” for short). Also, while he was in the hospital, his breathing got worse. When his breathing worsened, we placed him on a machine called “BiPAP” which helped him breathe and gave him oxygen.”

I used to code switch often when I was in the Peace Corps. I transitioned between Spanish, Guarani, and English depending on who I was talking to and the topic of conversation. I never expected how much practicing code switching then would help me now. But, every day at work I shift between medical and everyday language. When I forget to switch to everyday language, I’m quickly reminded by the confused look on my patients’ faces. I enjoy being able to explore different worlds. Transitioning between medical language and everyday language is one example of exploring different worlds. The better I get at translating the more I feel like a bridge connecting the medical world to the rest of humanity. It’s rewarding to be an expert in medicine and a guide who helps nonmedical people understand the strange world I’ve spent years mastering.  

Quandaries of Liver Transplant

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In the US about 10% of those on the liver transplant list die prior to transplant and over 20% are removed from the liver transplant list after being listed1. The hospital where I’m completing residency is a major liver transplant center. While living donor liver transplant is an option for some people, the patients I take care of are awaiting a liver donation from someone who died and donated their organs to others.

The patient was the color of a yellow highlighter. Perhaps you think I’m exaggerating that a person can be so yellow – I’m not. People turn bright yellow when their liver fails. The color comes from a pigment called “bilirubin” that the body can’t eliminate easily when the liver is sick. The patient’s eyes gazed off into the distance, into the future, or perhaps they gazed into nothing. They told me their name and answered questions, reassuring, but the slowness of their speech hinted at how sick they were. They were under my team’s care as we did the workup to determine if they were a liver transplant candidate. To be a transplant candidate patients must go through a thorough social and medical review to ensure they have the social support needed for post-transplant recovery and that they have no other medical conditions (like cancer) that would disqualify them from being a liver transplant candidate. If deemed a candidate for transplant, then a patient will be placed on the liver transplant waiting list (“transplant list” for short) which means they can receive an offer for a liver when one becomes available.

The workup of the patient the color of a yellow highlighter was ongoing. People whose livers have already failed are in a precarious state. They are at risk of confusion from toxins building up in their blood because their liver doesn’t filter the blood anymore. They are at risk of infection which can quickly kill them because without the liver working properly their immune system is weakened. They are at risk of both bleeding and forming clots. (Yes, these are opposite problems, and a failing liver puts one at risk for both through several complex mechanisms.) When the liver fails it disrupts the fluid dynamics of the body. Blood and other body fluids pool where they shouldn’t which can lead to swelling in the abdomen (and other places like the legs) and possible damage to the kidneys, heart, and/or lungs. In short, when the liver fails it causes just about everything else in the body to fail too.

When someone needs a transplant, it becomes a race to see if death or transplant will come first. The workup is prescribed. We hurry to send off the tests and complete the exams and procedures that the patient needs. Besides the workup, there are other barriers to liver transplant. For example, there is no road to transplant without health insurance. Just as there is no road to transplant if patients do not have friends or family to take care of them after their transplant. One also must have stable housing. Many people are not placed on the transplant list because they are disqualified or die along the way. Those who do make it on the transplant list frequently don’t survive until transplant. Livers are scarce. When a patient is on the transplant list, they are waiting for a person to die who has a liver that matches their body. Not any liver can be transplanted into any person. The liver and person receiving the liver must match so that the body of the person receiving the liver doesn’t reject it.

There are many people who need livers. When a liver becomes available who gets it? The answer is a combination of luck, being the sickest, and being the best match for the organ (like having a matching blood type and being the right size). Is it fair who gets a liver? Unlikely. There are race and gender disparities. Geography matters in terms of access to organs. Many patients never qualify for the transplant list because of the social determinants of health including problems related to poverty and lack of social support.

I thought of the patient the color of a yellow highlighter as I left the hospital for the day. No one could predict what their outcome would be. Even though experience and science told me the odds were against them, I hoped they’d get a new liver and recover well from the surgery. After all, I went into medicine not because I thought all outcomes would be happy but because I wanted to help people fight for the best outcome they could. Getting a liver transplant and having it work was the best outcome for this patient; it was the outcome the patient was fighting for. I came to work every day to help them survive until transplant. It was a big task, but few things are more motivating than the chance to help change another person’s life for the better. No matter what happened, I was grateful to be on the patient’s team. Grateful they trusted me to help support them through this challenging stretch of their life. Grateful we can transplant livers – giving hope for a new life in a situation where death used to be the only outcome.

  1. Annual Data Report of the US Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) from HRSA: https://srtr.transplant.hrsa.gov/ADR/Chapter?name=Liver&year=2022

The Branching Plan

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I’ve arrived at the phase in residency where colleagues ask what my next step is. The 3 major options after internal medicine residency are:

1) work as a hospitalist (a generalist who only works in the hospital)

2) work as primary care physician (a generalist who only works in clinic)

3) do additional training in a medical sub-specialty (like infectious disease, pulmonology, etc.)

Yep, I know you’re amazed. It’s possible to do more training after residency…it’s called “fellowship”. Medicine is the kind of profession where one starts planning their next step year(s) in advance so now (over halfway through my 3-year residency) is exactly when I need to know my next step. Luckily, I have a plan.

My plan is branching which allows for wandering and discovery along the way. I’ll start as a hospitalist both to enjoy a pause from training and strengthen my financial foundation. Then, I’ll either start fellowship or tailor my generalist work to focus on the populations and medicine that interest me most.

As the residency tunnel starts to show its brilliant end, I’ve been thinking more about the bigger goal – why I decided to become a doctor in the first place. I started the Doctorhood Quest because I wanted to have a career that tangibly helped people. I wanted my daily work to involve direct interaction with the people I was helping. And the help I wanted to give was empowerment. Improving health and banishing illness is empowering because when we are sick, we simply can’t achieve our full potential. As a doctor I’m an ally with my patients on their quest to fulfilment. I love seeing my patients get better from acute illness. I’m honored to help patients die with dignity or to be part of the reason their suffering is minimized. I’m stoked to keep people out of the hospital by optimizing their chronic medical conditions and overall health.

I joined medicine because of the opportunity to work with patients. My branching plan is a strategy to ensure that no matter what happens with healthcare, I can adjust and adapt to achieve my bigger goal of fostering empowerment. People have inequitable access to healthcare and the healthcare industry is flawed but, despite healthcare’s many shortcomings, there is much opportunity to do good as a physician. In an ever-changing environment (like medicine) one must be flexible and adaptable. Having a multilayered and branching plan acknowledges that I’ll have to change throughout my career to achieve my bigger goals. What fun it’ll be to see where I end up 20 years from now!  

Hospital White

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The stretcher looked different from the 100s of others I’d seen. It was empty and it had an unexpected metal bar at the head of the bed. I glanced in the room outside which the stretcher had stopped. On the bed was a white bag, zipped up, and just the height and length of a sleeping human. I realized the stretcher was there to take a body to the morgue.

Death has been present on many of my hospital shifts – especially in the ICU (intensive care unit) where this sighting occurred. Yet, until this moment, I hadn’t seen the patients who died taken out of their rooms. I’d pronounced them dead. I’d seen patients’ families crying at bedside. I’d seen the closed doors with butterflies on them marking that someone was dying or dead. I’d seen the strangely empty and freshly made beds where those who had died once lay.

The body in the white bag was lifted onto the stretcher. White sheets surrounded them. Then they were wheeled to the morgue – their family wouldn’t see them again. Of course, the person’s soul was gone well before the body was put in a white bag. Off to a better place. If nothing else, watching many people die has made me certain there is a soul which leaves when death calls. To where the soul goes after death, no one knows.  Long ago, I decided to believe souls always go to a better place when the body dies. No one can prove my theory wrong, so no need to worry about the journey of souls.

The sighting of the white bag made me sad. It wasn’t the kind of sadness that made me feel like crying. It was more of a sinking feeling placed on top of an already crummy night. Heaviness on the chest and shoulders. We had multiple sick patients. My co-resident had pronounced dead a patient almost every night that week. Somehow, he’d gotten that burden. I had not pronounced anyone that week; I was caring for people who were staying alive (for the time being). It was night shift, making the already dreary worse. A string of unpleasant nights with one-way transport of white bags out of the ICU. Some of these nights were so busy we only just managed to do the things most necessary. Our patient list was younger than it should have been. It’s easier to accept death when people have lived a long life. Of course, there were a couple happier cases; those patients would make it out of the ICU and then the hospital.

I don’t think one can ever get used to witnessing death. One can come to peace with it. That’s what I’ve done as my years in medicine accumulate. There is an intrinsic link between life and death. The two cannot be separated and are not whole without each other. In the US, black usually represents death. In many other places, death is represented by white. The more time I spend in the hospital, the more I think white is the most representative of life’s end. Hospital white. A blank sheet. All the shades of light together. The absence of physical color. It seems fitting that death is represented by light and not physical being.

The image of the white bag lingered in my mental peripheral vision for the night. I didn’t know anything about the person whose body was in the bag. Sometimes, one doesn’t need to know the details to understand. Death is like that. Simple once it happens. How we arrive at death is what is complicated. Everyone eventually arrives there at their own time and in their own way. Death is one of the most unifying features of being human. But that doesn’t make it easy. Some things are never easy.

No Alarm Today

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I woke up because my body was ready to leave dreamland behind and start the day. There was no beeping alarm or bright light from my sunrise alarm clock jolting me awake. Today my schedule is fluid. I have a to-do list (I always have one) but today I can ignore every item on the list if I want to. It is a rare day with no objective and no place to be. I could, if I really wanted, lie in bed and watch the day start without leaving the warmth of my covers. Or I could get up and sip mate for several hours. I could sit on the couch and watch the plants grow. I could go for a walk, do a workout, or write. I could do anything or nothing. The lack of expectations and requirements for today is freeing.

No alarm days are rare and lovely. Having spent the past many years in medical school and then residency my life has been filled with productivity and hard work. But, just as too much free time makes me stir crazy, too long spent with an overly packed schedule depresses me. Letting the day begin spontaneously reminds me of my years in Paraguay. In Paraguay, most days flowed in a semi-planned way. My life was free in Paraguay. Even though I had work, obligations, and social activities in the Peace Corps, I’ve never had as much free time during my adult life as I did in the land of the Guarani.

Sometimes, when the sun shimmers into my apartment and my houseplants glow with the joy only photosynthesizing entities have in the sun, I’m transported back to my Paraguay naps and meditations under the shade of the mango trees with the nearby palms swaying in the breeze. On those mental journeys, I’m reminded that quiet is an underappreciated aspect of life. Of course, us humans need purpose and connection to be happy. But every moment needn’t be assigned. The happiest folks I’ve met are those who embrace the slow days when they come, sometimes even setting aside calendar days for nothing. I want to be among the ranks of the happiest people. I think this goal starts with no alarm days. My no alarm days are for basking in the strange meandering that occurs when I decide to let spontaneity determine the agenda.

Today is a no alarm day. The sun is shining. The mate is perfect as the steam curls up from each pour of water over the yerba leaves. The yerba is fresh and so it bubbles. The plants in my house look good. Maybe I’ll water them later because it’s sunny and they’ll need it. Some of my orchids are blooming, some will bloom soon, and some are pondering their future (deciding if they will flourish or die for no reason). My house trees seem tall today. Beyond my plants, through the window, and past the balcony the cranes move. Richmond is constructing several new tall buildings. There are 4 cranes to watch from my balcony. The cars bustle below, sometimes their music is loud. Life continues. I sit. Today is a no alarm day. I’ll probably go for a walk later. But this moment is for drinking mate and observing my plants. What a beautiful moment it is.

Over 48 Hours Without Running Water in the City of Richmond

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“See these?” my mom asked flexing her biceps, “Hauling water.”  

When I was young, my family lived in rural Vermont in a hunting cabin without running water. My parents hauled water from the stream for bathing and we filled jugs at my dad’s work for drinking water. Those years in the woods prepared me for life as a Peace Corps volunteer in rural Paraguay where amenities were often lacking.

When my mom visited me in Paraguay, I flexed my biceps. “See these?” I asked. “Washing clothes by hand.” But it wasn’t just that. In Paraguay the water and electricity went out often. Just as my parents had done when I was a child, I developed ways of conserving water and making do when the utilities were down. One of my kitchen walls was lined with 2-liter bottles (recycled soda bottles) filled with clean water – so I was ready when the water went out. Some of my Paraguayan friends had different water sources from me and therefore often still had water even if I didn’t. My friends in Paraguay were used to the water outages and had a communal approach to getting through those annoying stretches. I could count on them to invite me to shower or to wash clothes at their homes if my water was out for more than a day.

When I returned to the US after completing my Peace Corps service, I figured my only time without running water would be when I was backpacking or camping. Self-imposed in those cases and short-lived. But Richmond surprised me this winter. In classic southern fashion (being from Vermont, I must poke fun at how the southern US handles snow), all went awry when Richmond was hit with a true snowstorm and sub-freezing temperatures. One of the city’s water pumps broke, multiple backup systems failed, and fixing the problem was harder than officials expected. As such, almost the entire city lost water for just over 48 hours and had to boil water for drinking for almost a week.

In the grand scheme of things, no running water for 48 hours and a boil advisory for about a week are insignificant compared to the water hardships many people around the world face. However, I found it interesting that such a utility failure could occur in a modern US city in the absence of a natural disaster. My husband and I (both from New England and used to winter power/water outages) were prepared. We filled pots and buckets with water just before the city turned the water off. We refilled our buckets in the river as needed to ensure we could flush our toilet. I took a baby-wipe bath one day. I washed my hair in the sink another day when the water was starting to come back but we still didn’t have enough water pressure to run the shower. I’ve known how to take a bucket bath since I was a child. Though it is a nuisance; it is simple.

48 hours did not restore the bicep muscles I’ve lost since returning to the US and living with modern, reliable running water and all the amenities that come with it. Yet, during Richmond’s water outage, I found myself flexing my biceps and thinking about the many people across the globe who have unclean water or minimal access to water daily. In the US reliable utilities are taken for granted. Richmond’s loss of water was a good reminder of how precious functional utilities are. I expect Richmond officials to review how the system failed and take steps to ensure such a failure doesn’t occur again. I also consider the water outage an opportunity for myself and other citizens to reflect on the event. In a world faced with global climate change which is leading to more severe weather and more chance for disasters that could cut-off utilities, how prepared are we if the systems we take for granted fail? How does one function without running water? Without electricity? What do we need to learn to be better prepared to navigate these situations when they arise? What can we do to prevent utilities from failing? How can we protect our water resources?

The Stickiness of Capacity

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“It’s my religion, my decision!” they yelled as the elevator doors closed, the climax of their escape (though no one was stopping them) from the hospital. They often spoke in rhymes. Where they would go and what condition they’d be in when they got there were mysteries. They’d been in the hospital for almost 2 weeks as we tried to find a safe place for them to discharge to. Their house was in such disrepair that their electricity had been turned off because leaving it on was a fire hazard. They’d had frostbite before, and winter was near. Their mental state was such that we did not believe they could make safe decisions for themselves. They had no way of getting home without our help. Despite all these features they were not in immediate danger of harm and so we had no legal grounds to keep them when they decided they were ready to leave the hospital. We tried to convince them to stay, but they would not listen. They were ready to leave; they wouldn’t wait for us any longer, not even to arrange a ride home. We were worried that they were leaving without a safe plan, but the US medical system is not a jail system. Except for several clear situations, our patients are free to leave the hospital whenever they please even if their doctors think it’s a bad idea.  

Capacity, a patient’s ability to make informed decisions about their healthcare, is more complex than one might think. It’s grounded in the ethical principle of autonomy, which means that patients have the right to decide what happens to their bodies. To understand the complexity of capacity requires at least some understanding of the history of medicine and how we conduct medicine today.

Medicine was paternalistic historically (and in some places it still is). It also wasn’t, seemly, originally centered on doing what was best for patients. There are classic examples of medicine’s unpleasant history, among them: the Tuskegee Syphilis Study, Henrietta Lacks’ stolen cells, stealing corpses to supply cadavers for anatomy labs, and the history of insane asylums. Given its concerning past, there are strict laws outlining which patients can be kept in the hospital against their will and for how long. There are also laws ensuring patients are informed about the risks and benefits of their healthcare and allowed to decide if they would like to pursue or decline tests and treatments their doctors recommend.

When a patient doesn’t have the ability to make their own decisions (for reasons such as acute illness or chronic conditions like dementia) we say that they “lack capacity.” In such instances we identify a person who can legally make decisions on their behalf. Capacity is decision dependent – so a patient may have capacity to say they don’t want to eat lunch but lack capacity to decide to undergo vs. decline a life-saving surgery. Capacity also can be fluid, so perhaps an acutely ill person doesn’t have capacity initially but as they start to recover, they regain capacity. For patients with conditions like dementia, often capacity is never restored if lost.

In tricky cases like the patient described above, the healthcare system can do less than you might think. We can easily treat acute illnesses that are a complication of a patient’s confusion (such as frost bite) but we have few ways to help avoid frost bite in the first place. Hospital social workers can help find nursing facilities to offer at discharge, but seldom can we force patients to go to a nursing facility if they don’t want to go. It’s also worth noting that we do not have the ability to find housing for people experiencing homelessness – so unless they need a short-term skilled nursing facility at discharge, we often have no choice but to discharge patients experiencing homelessness back to the street once they’re medically stable.

In these circumstances, sometimes those of us in healthcare are left with unsettling discharges either because our patients discharge even though we don’t think they’re ready or because we discharge them to the street (or to an unsafe home). In the case of the patient who yelled “It’s my religion, my decision!” as they made their dramatic exit, the patient declined our safe discharge ideas. Even though their medical decision-makers agreed with us, no one could force the patient to do something they did not want to do. After discharging the patient, we (their care team) found ourselves keeping an eye out for them as we drove to and from work. Our plan was to call Adult Protective Services if we saw the patient – because we all knew they had no way to get home. We couldn’t force them to wait for a ride and they had no money for the bus. We also weren’t convinced they knew how to get home. We all suspected they’d end up wandering the streets. As I drove on the lookout, I was reminded how limited our healthcare system can be. I was also reminded that balancing patient autonomy and medical beneficence is not always easy.