I Don’t Let Anyone Die Alone

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I saw the nurse sitting calmly at bedside. I knew she was the night nurse; it was shift change. Usually, the end of a nursing shift is busy with finishing tasks and telling the next nurse about the patients they’re taking over. I got up to check on the nurse and the patient. We’d just transitioned the patient from full code to comfort care. “Comfort care” means no life-prolonging measures – just medications and other interventions to help people be comfortable as they die. Minutes earlier I had put in the comfort care orders.

“Hey, do you need anything else?” I asked the nurse. “I only put in a few orders and just wanted to make sure I wasn’t missing anything you need.” The nurse was holding the patient’s hand.

“No. They’re dying now,” the nurse said. She was looking at the vitals monitor; I shifted my gaze from her to the monitor too. The blood pressure was 15/0 (recall that normal is 120/80). The heart electrical line (usually a dramatic up and down) was flat. The patient was taking agonal breaths (the last gasps a person takes as they die; they aren’t true breaths). The patient’s eyes were blank. I had known that the patient would die that day but it was happening faster than I expected.

“We let the patient’s pastor know, but she won’t make it for another half hour or so,” I said. The patient didn’t have any family. They had listed their pastor as their emergency contact and the person who would make decisions for them when they couldn’t make decisions for themself.

“I know,” the nurse said. “That’s why I’m here. I’ll be here. I don’t let anyone die alone.”

The nurse sat quietly on a chair next to the patient holding their hand. I stood with her and the patient for a little while watching the monitor. Eventually I left the room and got my stethoscope. When everything on the vitals monitor was zero, the nurse closed the patient’s eyes gently. I did my exam and determined the time of death. Next time I looked at the room there was a picture of a butterfly on the closed door (alerting people that the patient inside had passed).

When I looked at the room later in the day the bed was empty and made with new linens. It was as though the patient from the morning had never been there. Yet, I remembered the nurse and patient holding hands as the patient’s heart stopped forever. I did not know what the patient did when they were alive but, at least, I knew they hadn’t died alone. I was reminded that small acts change lives. I was reminded that heroes only wear capes in movies. I wondered how many people die alone – I was grateful that this patient wasn’t one of them.

Code Status

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“Would you want us to do compressions if your heart were to stop?” I asked.  

“Of course!” the patient said.

“Would you want a breathing tube if you needed help breathing?” I asked.

“Yes, do everything you can,” the patient said.

“Ok, we call that ‘full code.’ If your heart were to stop, we will do what we can to bring you back,” I said.

“To my surprise, I recently learned that there are people who don’t want that,” the patient said.

“Correct,” I said. It was a busy day and given that the patient’s personal goals regarding code status were quite clear I avoided further discussion. 

~

Code status is the first decision people make regarding their goals of care. “Code” is medical slang for a heart attack (which is when the heart stops causing death). “Goals of care” is an umbrella title for the objectives patients have when they interact with the health system. Goals of care exist because patient autonomy is a key ethical principle in medicine. “Patient autonomy” is the idea that patients have the right to information about their care options (the risks and benefits of all the options) and have the right to decline any medical intervention they wish even if declining can result in a sooner death. 

We always ask code status when patients are admitted to the hospital so that we know what the patient would want if the unexpected happens. There are 3 code status options:

  • “Full code” means that a person would like compressions and a breathing tube if their heart stops.
  • “DNR/otherwise full interventions” means a person does not want compressions if their heart stops but would want other interventions (like a breathing tube) if they needed them for some other reason.
  • “DNR/DNI” means that a person does not want compressions or a breathing tube at any time.

Unlike what the patient above believed, picking a code status is not an easy decision for many individuals. There are zillions of reasons why one’s heart might stop; the likelihood increases the older a person gets and the more medical problems they have. There are also multiple situations that might cause young, healthy people to code. A common trajectory (but by no means the only one) for code status is that young people choose to be full code and as people get older (like in their 70s or older) and/or sicker they decide to change to DNR/DNI. If a person doesn’t pick a code status, the default is always full code.

If you ever find yourself in the situation where you are very old and frail and/or very sick your medical team might encourage you to consider changing your code status from full code to DNR/DNI. Some individuals and families are against the idea of DNR/DNI and that is their right. However, let me explain why your healthcare team might recommend DNR/DNI and why the decision is more delicate than it might first appear.

When someone codes it means that their heart stopped; they are dead. The chance of coming back to life after someone’s heart stops is zero if nothing is done. If efforts are made to restart their heart (like compressions, possible shocks, possible breathing tube) then they might come back to life or they might remain dead. The chance of coming back to life if something is done depends on many, many factors. And, even if we can get someone’s heart to restart after it stops, we can’t guarantee that the person will wake up or have brain function again. Medicine is imperfect; we can “save life” and “prolong life” but the nature of that life ranges from fully functional to a vegetative state (dependent on a ventilator and unable to communicate).

The likelihood of someone fully recovering from a code after we get them back depends on how strong and healthy they were before their heart stopped and the reason they coded. It also depends on how long it took us to restart their heart. For example, returning to normal function after coding is more likely in an otherwise healthy person who coded because they had an abnormal heart rhythm and whose heart restarted rapidly after initiating compressions. A full recovery is less likely in a person who has multiple medical conditions and required an hour of compressions before their heart restarted.

Compressions and post-code recovery are invasive medical interventions. For example, compressions often cause rib fractures. Many people require at least several days with a breathing tube and on a ventilator after their heart restarts. This is why, as you may have noticed in the above code status options, there is no option to have compressions without accepting a breathing tube (while you can have the reverse). The reasoning is that there is no point in doing compressions if a person does not want the interventions required to keep them alive after we restart their heart.

An important reason that people choose DNR/DNI over full code is because they believe their chance of surviving and returning to a functional state after a code is low. Often people who choose to stay full code no matter how sick they are do so because they believe any life is worth living. To complicate matters further, a person (or their appointed medical decision maker) can change their code status at any time. The fluidity of code status is why we ask code status every time a person comes to the hospital. Like most things in medicine, there is no “one-size-fits-all” for code status. Choosing a code status is a very personal decision with no right or wrong answer. The decision often depends on an individual’s values about life, beliefs about what happens after death, and baseline state of health.

The State of Being Human

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Being human is an uncomfortable affair at times. No one, perhaps, knows the state of being human better than the internist (internal medicine, my residency) who passes between managing patients in the primary care setting and the hospital setting.  As I gallop toward the end of my first year of residency, I can say with growing certainty exactly what the normal state of being human is.

Being human involves hemorrhoids, knee pain, and back pain. It involves debates (whether internal or external) about what to eat throughout every day and whether to exercise. And if exercise is on the menu, the question becomes: What kind of exercise should one do? Being human involves the occasional-to-frequent stuffy nose and nonspecific ache. It involves external stress such as work, family, and accidents as well as internal stresses like low mood (all the way to depression), anxiety, and difficulty sleeping. Being human involves getting older day by day, grumbling about this certainty, and knowing that the only alternative is death.

One role of internists (and emergency medicine doctors) is helping people sort out if their current uncomfortable state is on the normal spectrum of the human experiences or is out-of-the-ordinary enough to be life-threatening or to cause lasting impairment/injury. Take the classic question, “is my chest pain because my heart is injured?”

The answer is “maybe.” Moving the maybe to “unlikely” or “likely” a heart attack is where medical training and medical tests come in.

If you’re 20 years old and two days ago lifted the heaviest weights you’ve ever lifted and come to me with chest pain, I’ll start by pushing on your chest. If you then tell me that pushing on your chest makes the pain worse that’s enough information for me to say that your pain is likely soreness in the muscles that you worked out and does not involve your heart. To be safe, I could order some tests to confirm my hypothesis. I might not need the tests but if I see you in the emergency room, I’ll probably order them.

If you’re 60 years old and you don’t really have chest pain but, rather, mid-chest pressure as if someone is sitting on your chest…you’ve caught my attention. And if you then tell me that this chest pressure used to only occur when you mowed the lawn but now also occurs when you walk from the couch to the bathroom my concern for a blockage in the vessels that feed your heart is high. I will most definitely order some tests to explore my hypothesis.

I’ve heard hundreds of chest pain stories. With a story I can sort chest pain into categories including “likely normal life chest pain” and “likely heart chest pain.” I have exams and tests to further help me determine if the chest pain is directly related to heart injury. If I’m still concerned even after my first tests are negative, there are additional tests I can order.

One of the most satisfying aspects of being a doctor is helping people move past the uncomfortable affair of humanness so that they can maximize the joyful aspects of being human. Because being human also involves doing well. It also involves getting promoted at work and having kids. It also involves traveling and parties. It also involves loved friends and family. Being human also involves adventures and creative undertakings. It also involves feeling good and achieving goals. It also involves sitting on the pouch relaxing and glorious naps. It also involves conversations while sitting on the couch or at a café. It also involves sipping favorite beverages in favorite places on perfect evenings.

The state of being human is one of contrasts. Medicine occupies the space between the uncomfortable and joy of being a human with the aim to tip the scale back toward joy when things go awry. Medicine doesn’t have all the answers, but it outlines a system for exploring physical and mental discomforts and offers possible solutions. Part of what makes a good doctor is knowing exactly what the normal states of being human are so that we can quickly identify situations that deviate from the range of normal and intervene.

Moral Injury: Taking care of Sam

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Moral Injury

When I Googled “moral injury” the first definition that populated was, “Moral injury refers to the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations.” The definition came from the site Open Arms which provides mental health services to Australian veterans.

You may have heard the term “moral injury” in the context of the military. However, moral injury is also common in other professions, not the least of which is medicine. The 3 reasons that are most prominent in my mind for moral injury in medicine are:

  • Our (the US) healthcare system is limited. Without universal healthcare our healthcare system is a commercial business where those with more money have access to care that those who are poor don’t. It means that the rich get better care overall than the poor regardless of the attempts of individuals working in medicine to deliver just care. The injustice comes because insurance and personal finances have the last word on any person’s access to medications, equipment, home health services, procedures, and surgeries. Without money in the US, you do not get full access to any of these health services.
  • Health is essential to wellbeing. Those who seek medical attention often have serious injury, life changing illnesses, and may be imminently dying. In medicine, we often take care of people at the worst time of their lives. We often deliver terrible news. We don’t always have good outcomes.
  • Healthcare is about people and every individual has their own beliefs and values. The doctors, nurses, and others taking care of a patient have different beliefs/values than the patient and each other. I’ve never had an experience in healthcare where every member of the healthcare team and the patient all had the same beliefs and values. And, in truth, I don’t think it’s possible.

I’ve experienced moral injury multiple times in my medical career. Sam’s case illustrates how my questions related to wellbeing and differing beliefs/values while caring for a patient opened the door to my moral injury. The injustice of commercial healthcare I’ll leave for another day. I’ve modified the details of Sam’s case (including the patient’s name) for patient privacy.

Taking Care of Sam

Sam came to the hospital because they believed their nursing home was abusing them. They were bedbound. They could feed themselves (if someone brought them food); yet they didn’t eat much. Were they refusing to eat because they didn’t want to or because it was uncomfortable to eat for some medical reason? They ate just enough to stay alive but not enough to thrive. In the time I cared for Sam, they became weaker and more confused partly from malnutrition. They also refused their medications. Did they have the right to refuse to eat and to refuse their medications even if it would hasten death and worsen their condition?

It was possible that Sam could live for 40 years more. Given their condition, would they want to live for 40 more years? Sam had days in which they understood what was going on. Yet, they often forgot things. Sam sometimes answered questions correctly and sometimes their thoughts trailed off to a land that was only barely understandable. How confused was Sam? Eventually it was decided that Sam couldn’t make their own decisions because they were too confused. The only person in the world who knew Sam outside of their healthcare team was an ex-partner. The ex-partner was designated as their legal decision maker because there was no one else.  Was an ex-partner the right person to decide what Sam’s medical treatment should be? Did this ex-partner have any idea what Sam would want in complex situations they had never talked about?

Sam was full code and full interventions per their ex-partner’s decision. This meant that every intervention Sam needed for their multiple medical conditions was to be pursued even if it caused discomfort. To do this Sam needed an IV. Sam pulled out every IV we placed (so they pulled one out about daily).They also pulled out multiple more permanent lines (basically deeper IVs that access bigger veins and are often held in place by stitches). We kept replacing the IVs. Was Sam pulling out the IVs because they were confused or because they didn’t want them?

As Sam’s nutritional status worsened and they missed more medications, my team suggested placing a tube in Sam’s stomach so that they could get proper nutrition and medications even if they refused to eat and didn’t have an IV.  Most days when I talked about this feeding tube with Sam, Sam said they didn’t want it. Did Sam know what they wanted? The ex-partner decided that Sam should get the feeding tube in case it helped improve their condition. They got the feeding tube. Did we know what was best for Sam?

Not long after Sam got the feeding tube, they went to the intensive care unit because their blood pressure was too low. They were placed in medical restraints (basically tied to the bed) so they wouldn’t pull out the IV through which they received a medication to help increase their blood pressure. Without that blood pressure medication, they might have died. That medication had to be given through an IV. Were the medical interventions we did for Sam helping or hurting?

Sam hated the restraints. They screamed, pleaded, and cried for us to take off the restraints. Were the restraints doing more harm than good? They screamed and yelled that they didn’t want any of the interventions that we were doing. Was Sam aware enough to know what they did and didn’t want? Sam could tell you their name and where they were; they’d lost track of why they were in the hospital, the month, and the year.

Sam survived and eventually returned to the regular hospital floor before being discharged to a nursing home. Sam’s hospitalization lasted months before a nursing facility accepted them. Did Sam want to prolong their life even though that meant going to a new nursing home? Would they have preferred to be made as comfortable as possible without medications and without being forced to eat? Would anyone ever truly know what Sam wanted? Would Sam’s right to make their own decisions ever be regranted?

Despite doing everything medicine could do for Sam, I’m still not sure if any of it is what Sam wanted. I’m still not sure if we did the right thing. And because of these uncertainties, I’m not sure if Sam’s case broke several of the most important principles of medical ethics: patient autonomy, do no harm, and beneficence.

The Sorting Hat of Medicine

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Recently, I was back in the emergency department (ED). Not as an EMT this time but as a doctor. It’s different as a doctor. In the years leading up to medical school, I worked as an EMT in the ED and volunteered on an ambulance. Being an EMT was my first patient care experience. It was eye-opening in many ways. Among the things I learned as an EMT is that I did not wish to become an emergency medicine doctor. My residency program (internal medicine) has us do a month in the ED as part of our first year of training to get a different experience and a different perspective.

The ED is like no other place in healthcare or in the world. There are few places where the staff have as much camaraderie. There are few places in the hospital where the staff laugh so much and the adrenaline runs so high. The ED also, perhaps, provides as many reasons to cry as to laugh – which is why those who work in the ED find ways to pick laughter over sorrow.

The ED is the sorting hat of medicine. My rotation as a doctor in the ED showed me that ED doctors are the gatekeeps to the hospital and the safety net for everyone who can’t access healthcare anywhere else. The doctor’s role in the ED is different than that of the EMT. As an EMT my day was filled with tasks – placing IVs, performing EKGs, getting snacks for patients, and so on. As an ED doctor there are fewer tasks than as an EMT but the tasks that remain are heavy. ED doctors make big decisions about which tests a patient needs and where they should go next – home, surgery, a regular medical floor, or an intensive care unit. ED doctors stabilize patients before they are shuttled off to other parts of the hospital. ED doctors reassure patients that they are okay before sending them home. ED doctors are the last contact for many people as they leave this world for what comes after death.

Some days in the ED are hectic and some are slow. ED doctors connect with every other specialty in the hospital. They consult specialists and convince other doctors to accept ED patients so that the patients can be admitted into the hospital. As much as ED doctors are the gatekeepers, they are also the connectors.

The ED runs at a blistering pace but when things are running well no patient stays there for long. Hours, yes, but not for days. Yet, some patients become known to the ED. They’re called “frequent fliers.” Frequent fliers are known by their ED doctors much like primary care doctors know their patients. Often frequent fliers don’t have a primary care doctor. And, so, when ED doctors take care of a frequent flier they may be the only doctor that patient has. The only doctor standing between that patient and no medical care at all.

The ED is the sorting hat of the hospital. As the leaders of the sorting hat, ED doctors have many roles. They are gatekeepers. They are also connectors and, for some, the only option. The ED is the bridge between the outside world and the hospital. I’m grateful for the folks (doctors and all the others) who choose to work in the ED because being the sorting hat is no small feat.

Springtime in Richmond

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The ospreys are back on the Richmond James River marking the arrival of spring in this city that sits at the hub of Virginia’s highways. Match Day, a different mark of spring, took place earlier this month. It always falls in March, an odd kind of Ides of March. This year, with that phase of the Doctorhood Quest behind me, I was unaffected by it. My Match Day will forever dwell on St. Patrick’s Day of 2023. That’s the day I found out I was moving to Richmond.

It was about this time last year when I saw Richmond for the first time. We visited the city only a week or so after Match Day to look at apartments. We wanted to move to our new home as soon as we could. I liked Richmond instantly. I’ve visited enough places and lived in enough more to know, as a gut feeling, if a place I visit is a place I could live happily. I had that sense about Richmond.

Spring is always a transition season but since I started the Doctorhood Quest it has come to mark additional important transitions that didn’t exist in my pre-doctor world. As I write this, I’m three-quarters of the way through my first year of residency (or one seventh through the whole thing). Residency years start on July 1, meaning that as spring slides into summer it marks the closing of one year and the opening of another year in residency. Residency years are hard years. As happy as I was last March when I transitioned from medical school for residency, I am enthusiastic to leave my first year of residency behind for the second year.

The seasons of my first year of residency almost followed the seasons as I knew them when I lived in Vermont. Summer was a glowing time when everything seemed possible because the leaves were new and vibrant; the sun stuck around longest. Fall was my favorite season because by that time the year was familiar; the weather was perfect. Winter was dark and gloomy; it was hard to understand why the world didn’t pause the whole season to drink mate and eat chocolate. Spring came with new hope and new beginnings.

With the ospreys back on the river and a recent vacation behind me, I’m excited to embrace spring. I love the ospreys and was so disheartened to learn last fall that they left for the winter. In Richmond there are numerous walking bridges across the James River from which you can see osprey nests and watch them hover-dive-catch fish. This spring marks a year living in Richmond and a year since graduating medical school.

Comparing this spring to last spring, I know the parks of Virginia way better now and so plotting my days off has become more exciting. And, more down to business, I’ve learned so much about medicine and how to be a doctor. The Doctorhood Quest continues just as the seasons march along unwaveringly. Year two of residency will be a time to develop independence and hone my knowledge. Internal medicine residency is three long years. So, I have two springs left before I get to confidently say I’m ready to work independently as a physician. Two more springs of celebrating the ospreys’ return as a resident. Then we’ll see where the Doctorhood Quest sends me. Perhaps I’ll also celebrate the James River ospreys as an independent physician too; only time will tell where I am three springs from now.  

How Strange to Be Unable to Name a Daffodil

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“We saw daffodils!” I said. My voice sang with an enthusiasm that only such a definitive sign of spring could coax from me on such a rainy, gray afternoon in February. My co-resident looked at me blankly. The importance of a daffodil passing through their genius brain just as the medical terminology doctors like to use pass through patients’ ears – jargon without meaning, hardly in and definitely right out. “You know, it’s one of the first flowers of spring. I saw it in the park.  They’re yellow…” I gave up and the conversation moved on to other topics.

Doctors are more diverse than we once were, but our makeup doesn’t come close to mirroring the population we serve. My visible profile is common in the medical world – white (always very common) and female (slightly more females are entering medicine than males these days). Yet my unseen profile, my story before medicine and path to medical school, is unusual for a doctor.

Sometimes I’m reminded of my different background when it’s easier for me to relate to patients than my colleagues who come from medical families and have never known what it is like to not know what “coronary artery disease” and “hypercoagulability” mean. Other times I’m reminded of my different background when it’s easier for me to understand the social determinants of health such as why someone might not have transportation to appointments and why medications might not be worth the monthly bill to a specific individual. Where I grew up if you didn’t have a car you went nowhere; further, I solely used public transportation for most of my 20s. I’ve also run a tight budget most of my life which has given me a lot of practice deciding where my money will and won’t go.

It’s not just my economic background that makes me different from many of my co-residents (though I’ve come to realize more with each passing year that economic background is a mountain that dominates world view). The nuances of my difference from many of my colleagues present themselves at unexpected times such as on slow days when making small talk with co-residents and supervising physicians.

I grew up in a world where medicine was minimally understood, mysterious, and (perhaps) feared. The distance of medicine was partially possible because my family was healthy and required minimal medical care; it was also who we were. Our lack of medical knowledge did not mean, however, a lack of knowledge. For my colleagues who have known the medicine way of life since childhood as they watched their parents (many doctors and some nurses) come and go from work, the hospital system is familiar and almost second nature. I didn’t grow up knowing the hospital. Yet, I know other things that are part of who I was, am, and will be.

For example, I know the birds, trees, and plants of my childhood and I’m learning the ones of my new home in Virginia. I know how to grow plants indoors or in a garden because I grew up in a culture where we all knew how to tend plants. In a similar way, I don’t believe cows are cute because I’ve been almost late to school chasing them after they got out of the fence. I know how to stack 6 cords of wood in a day, use power tools and wood tools, and change my car tires because these are skills that were necessary in the world where I grew up. I notice architectural details, complementary colors, and other design elements because these were some of the themes of my childhood.

Being an older resident with a different background and careers prior to medicine is isolating at times. A small portion of my co-residents can relate or are interested in where I’ve been before medical school. I’ve become accustomed to this. My life extends beyond the hospital. I have family and friends who understand the nonmedical aspects of my life just as my co-residents understand the Doctorhood Quest in a way non-physicians can’t.

I have so much to learn about medicine from my co-residents and supervising physicians regardless of whether they understand any aspect of my life outside of residency. But, on days such as when I find a resident who can’t name a daffodil, I’m torn between amusement and sadness. In my world it’s ridiculous to be unable to name one of the most common spring flowers in the US. The realization that there may be many doctors who can’t name a daffodil reminds me just how different we all are. It also reassures me that there is much I can teach my co-residents too. And, perhaps more importantly, it reminds me how much physicians can learn from our patients and non-doctor colleagues if we find time to listen.

The Doctor Pronounced Them Dead, The Doctor Was Me

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It was raining when I left the hospital. Perhaps the rain marked new beginnings for a soul recently gone or perhaps it was simply droplets falling because the clouds were too full to hold them. Death wasn’t new to me. My years in emergency medicine prior to starting medical school ensured that. I’d felt and smelled death before. I’d contemplated its inevitability and its conflicting identities of tragedy and blessing. Some of the deaths I’ve seen were sad beyond measure and some peaceful.

This patient’s death, the one I’d witnessed just before stepping into the rain, was my first as a doctor. For the first time it was my job to do the exam that declared the patient legally dead. It was my first time stating the time of death and filling out the paperwork declaring death. It was my first time calling a patient’s family to deliver the news that their loved one had died. I’d wondered how long after starting residency it would be before I would complete these somber duties for the first time. Now I know, 8 months.

It was one of the easier deaths I’ve witnessed. It came at the end of a long life. It was expected given the patient’s condition. In fact, just that morning, I’d started the patient on medications to keep them comfortable as they entered the home stretch of their life. I’d spoken to the family as they visited that day. As I walked in the rain, I couldn’t help but wonder if the patient had waited to hear their family members’ voices one last time before giving in to rest. After all, the patient died only hours after their family left the hospital. Their family wouldn’t see them again.

When a patient dies, we complete a discharge order, note summarizing what happened during the patient’s hospitalization, and progress note describing the circumstances of their death. This paperwork makes the process of death much like any other administrative task a doctor has. Yet, though technically similar, these notes feel different. Unlike other daily progress notes and summaries of hospital stays that fill patient’s charts, these death notes are not just a chapter but a conclusion and, because of this, they seem more important.

The inside of my car was fogged when I got in. Somehow the rain had cooled the outside while the warmth of the inside of my car lingered. I turned on the windshield wipers and blasted the air. I couldn’t really see but I decided I could see well enough to start slowly rolling forward. The rain drops bounced off my car. As I drove in the rain, I became sure that it marked new beginnings for a recently passed soul. Nothing else could possibly make the sky weep so beautifully. I wonder if the person whose soul had passed believed in some kind of afterlife. I imagined them observing my little car driving through the rain from wherever they were. I hoped they were happy. At least I knew their troubles in my world were done. May they rest in peace.  

The Winter Doldrums

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Winter in Virginia is quite nice from a weather perspective. Most winter days this year have been in the 50-70s and sunny. Yet, despite the loveliness of winter in Virginia, spending so much time in the hospital (as us residents do) means I only catch glimpses of it. Like a plant kept too far from the window, I feel like I’m missing the sun’s warmth. I’m in the middle of a several-month stretch of hospital rotations where either I have one day off a week or am working nights – which is the perfect environment for the winter doldrums to flourish. So, it comes as no surprise that I’ve found the doldrums creeping in around the edges of my life like a vignette Instagram filter darkens just the outer edges of photos.

My doldrums is a weariness that hovers below the surface and presents itself in small ways. Forgotten facts like place names and life tidbits that were once second-nature. Moments at work feeling longer than eternity and moments at home passing faster than light moves. Waking up tired after sleeping enough. Sitting on the couch sipping mate and watching my plants grow more often than I usually do. Contemplating where I’ve been and missing Paraguay as I trudge home from long shifts. Like most moods, I’ve taken some time to observe my doldrums. It seems stable and temporary, especially knowing better times will be here soon.

Learning medicine is a long journey where knowledge builds with each passing situation, decision, and interaction on the job. Now that I’m over 6 months into residency, residency (itself) is familiar. My focus has shifted from learning my new role and how to complete tasks to growing as a doctor and deepening my knowledge.

The doctorhood quest is a process with a high level of granularity. I make daily tradeoffs between learning more and undertaking life (chores, fitness, rest, etc.) – sometimes the pendulum falls on the side of learning and sometimes it falls on the side of life. Everything can’t be done at once, or ever really, but progress is made step by step.

The upside of the doldrums is that it’s a contemplative state which is suited for winter when the days are too short to maximize outdoor time. I’ve been thinking about what kind of doctor I hope to be by the end of residency. I’ll be done with residency sooner than it seems on these long winter nights. Just as winter will soon be replaced by spring. With the start of spring, winter and its moods will fade. The doldrums will melt away leaving a summer state of mind. Moods and periods of life are nothing more than a type of season. What a lucky thing that summers are long in Virginia and the winter doldrums finite.

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.