Goodbye 20s

Today I turn 30. I find myself in a place I didn’t dream of when I was 20. I live in a world I couldn’t have imagined when I was 10.

I’m in the throes of my first year of medical school. A whirlwind of biochemistry, anatomy, patient evaluation techniques, nerd jokes, and discussions of ethics and why access to health care is a right. But, that’s not all. This morning, I woke to the smell of cinnamon rolls and a bouquet of flowers. Since August, I didn’t just fall down the rabbit hole of medicine, but I might have fallen in love.

October last year, the last October of my 20s, I was forging through medical school applications. Diving into interviews. Wondering if any school would take me. If I was good enough. If I was going to ever be a doctor. I think the feelings I had while applying to medical school aptly summarize my 20s. The 10 years between 19 and 30, I spent self-doubting, reflecting, and growing. The doubt is largely gone now—for that, I’m stoked. My personality won’t allow me to stop reflecting and attempting to be a better, even as I race toward being old, and I think that’s good.

This October comes with its own challenges and misgivings, but there is something surprisingly settling about 30. It helps that a weight lifted when I started school. And though I spend hours daily learning 3-4 letter acronyms that stand for proteins that stand for whole signaling pathways that keep you alive when they work and make you sick when they go wrong, I’m happy underneath it all. I’m happy because I’m exactly where I hoped I would be last year. I’m happy because where I am feels right. It is not often that life follows the course of my plan, so this birthday I’d like to take a moment to celebrate just being here.

Today, I’m grateful for all the people who make me feel loved. I’m grateful for the friends who are there when I need them and who share my joyous moments, who share my love for jokes only a health science dweeb can begin to find funny, and who listen patiently to the latest episode in the chronicles of kombucha making. I’m grateful for the people who have supported me, helped me learn, and pushed me to think differently and be better.

With the joy of being here in mind, bring it on 30. I’m ready for a new decade.

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.

5 Years Later – Quiet Moments

About five years ago I moved to Paraguay. I wasn’t sure what would come of a continental move, but I was ready for a challenge and I wanted a break from the American rat race for a few years. I had high hopes but no clue what to expect. I’d first learned of the Peace Corps when I was in 7th grade and known since then that I needed to do it.

I’m sure I’ve said this somewhere in a pervious post, but living in Paraguay and among Paraguayans changed me. People are always changing, but there are life experiences that expedite change—the Peace Corps (and living abroad for a few years) is one of them.

Living in Paraguay changed my self identity, my daily priorities, and the way I thought and saw the world. My experiences in Paraguay fine-tuned my values. Being a foreigner, the only white girl, the only American, the lunatic who liked to go for runs and hour-plus walks, the veggie addict, the advocate for sex ed and separation from abusive partners, the outspoken supporter of love regardless of gender mix, the not catholic, the woman with unpainted nails, the single one, the over 25 and still childless woman, the one who wouldn’t wear short shorts and small shirts, the female who refused to dance in heels, the one who disliked pork and large amounts of meat…being the odd one in the fish bowl forced me to think about the battles I wanted to pick and those I’d leave for never.

Of all the things I learned, what stays with me is the internal calm and confidence the women in Paraguay shared with me. Life is ridiculous most of the time, but Paraguayan women have a natural grace and pride that is humble and unwavering. I certainly didn’t luck out and get their grace, but what I did learn is that we (humans) are better and happier when we make time for quiet moments. I’ve been thinking about the secret to Paraguayans’ love of life and happiness for these 5 years, and I’m pretty sure it comes down to making time to be still. Everyone has their way of doing this, but mine has come to be drinking mate. I learned to drink mate in Paraguay.

Mate is a tea-like drink made from yerba mate. It’s loose-leaf tea that you put in a cup. In the cup is a metal straw with a filter at the end. You pour hot water over the leaves and drink through the straw almost immediately. With a little practice your lips get used to the hot straw and you don’t burn your tongue on the hot water.

Yerba mate has some caffeine in it, but I mix the yerba mate with so many other herbs (peppermint, hibiscus, lemon grass…) that it hardly has any. I don’t drink it for the energy boost. For me, mate provides moments to reflect. For me, it’s the symbol of my time in Paraguay, personal growth, and the people I care about. Mate is usually a shared drink. Since returning to the US I always drink mate alone (because people here don’t drink it), but I still think of the Peace Corps volunteers and the Paraguayans who shared it with me. I also think of the other people in my life, currently and in the past, who are shaping my world even if they’ve never sipped mate.

Five years later I still drink mate because I learned happiness is in the still moments. I learned that people are where joy comes from and that I am the best human I can be when there is time for mate in my life.

As I write this my mind is quiet, but deep down the excitement and nerves of starting medical school this August are bubbling. I’m about to embark on another journey like none I’ve done before—the expedition of learning and mastering the ways of the human body. The challenge of becoming a medical doctor. But, as hard as medical school is, I know living in Paraguay was harder and I already did that. And though there will be days in medical school when I’ll skip mate, I know that it’ll be quiet moments drinking mate that will propel me through the countless exams, the high stress of learning more than seems possible, the life-or-death decisions, and the sadness of seeing people suffering. Everyone, I think, has their grounding mechanism. It turns out that mine is a dried herb I buy 6 kilograms at a time and often sip before most other people’s morning alarms have started snoozing.

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.

Empathy

One busy day in the emergency department (ED) we had a psych patient in a hallway bed. I don’t remember if he was visiting us to stay safe while struggling with suicidal thoughts or if he had come to the ED for some other mental health reason. We try to put patients with mental health complaints in a room as soon as possible, but sometimes the hallway is all we can do for a few hours. This patient fled even though his condition required him to stay in the hospital. He outran hospital security and escaped hospital grounds. Police brought him back to the ED.

I’d seen him sitting on a stretcher in the hall before he fled, staring into space calmly. When the police brought him back, he was slumped forward in a wheelchair with blood running down his shins. He hadn’t had those scrapes before he fled and they caught him. I knew they must have tackled him, but I couldn’t say because I wasn’t there. Later, I’d rinse those scrapes and the ones on his torso, arms, and hands. Nothing too deep, but the iron smell of blood was strong. The patient was NOT angry about the scrapes; he just didn’t want his mother to see him until he was clean again. I couldn’t help thinking that sometimes the price seems steep for safety and medical treatment.

It was a terrible feeling to see someone start in the ED without a scape and then end up with many before their stay was done. I was shaken. I spoke to a coworker about it. I like to discuss things during shift so everything that happened stays at the hospital when I leave. My coworker listened to me carefully and acknowledged the challenging aspects of the situation. It’s always hard to see someone’s mind betray them and, in their worst moments, need restraint from medical staff or police. It’s hard knowing that the violence is part of the route to recovery. My coworker said, “It’s okay to be bothered. If you weren’t, then you’d know it was time to leave this job. When you don’t feel empathy anymore, it’s time to change careers.”  

Empathy is a harsh beast. I believe most of us are able to ignore empathy at least some of the time because it is too much to always feel our emotions and, also, those of someone else. Which has led me to ask several questions about empathy’s nature. How is empathy turned on and off? Is there a time when empathy is out of place? Is it right to push empathy aside to protect oneself? Why are some people more empathetic than others? What does being very empathetic say about a person? Can empathy be taught and untaught?

The Sunny Side

Last week I flew to Chicago for my last (most likely) medical school interview. I had the window seat on the plane and, surprisingly, wasn’t sleeping as we approached Chicago. I was excited to spend 24 hours in the city and get a feel for a place I hardly knew. I gazed out the window as we started our decent.

Before we decreased our altitude, we zipped along above the clouds, through a bright blue sky with sparkling sun. A thick layer of clouds was below us. The view of bright blue above white divided by shining sun rays conjured images of every version of “seeing the light” imaginable—end of the tunnel, heaven’s gates, nirvana…to name a few. The clearness and stark lines between the blue and white were beautiful.

Slowly, the plane’s path dipped so that we began to approach the clouds. We must have been far above them because it took us a while before we got close to the wall of white. I knew the clouds were a penetrable, gaseous/small particle entities, but they looked solid and impassable. We approached them quickly, and soon the sunny view of blue was obscured and the windows were masked in white. We were in the middle of the clouds and there was nothing to see.

Our journey continued rapidly and, in no time, we were below the clouds, a snowy and gray scene was visible below us. The sun seemed to have vanished, leaving a stark winter city scene. There were no leaves on the trees and the buildings added to the gray of the air between the land and the clouds. It looked cold and brooding. If I hadn’t just observed the sunny blue above I wouldn’t have known it could exist in the same place as we now were.

I smiled as I stared at the houses and streets, a bird’s eye view of the cityscape. I guess it’s just a matter of knowing where to look to find the sun. I held the vision of sunlight within me as I caught the train from the airport to where I’d spend the night before my interview and school tour. I’d been nervous before starting my trip, but I wasn’t anymore. I felt lucky.

Marathon Goals

I remember the conversation I had with my best friend that sealed my desire to become a doctor. We were in our relatively new apartment, in the living room that was an extension of the kitchen. The city sun of Washington, DC filtered in the large windows and onto the bedraggled plants we had lined along the window sills. I’d been contemplating the idea of entering medicine for months. The thought came to me shortly after I started working in health communications. What I liked most about health communications was the medical research, knowledge of life, and opportunities to interact with people. I wanted to find a way to fill my days with those things rather than dabble in them. My friend worked in a primary care office, on the administrative side. She encouraged me as I talked about possibly switching careers. “You’d be a good doctor,” she said. Thus, began my marathon goal to become a doctor, a process I call “the doctorhood quest.”

That conversation was 5 years ago. Recently, what started as a thought became a real possibility. I’ve been accepted to medical school. There’s still the question of financing and survival, but with an acceptance to school, there is hope that the rest of the journey will fall into place. I will be a doctor.

Marathon goals. I’ve always been a planner and as a runner I prefer long distance. But, there is something uniquely challenging about making goals that will take over a decade to accomplish. There is no way to know the future, and absolutely no way to predict a future as distant as 10 years from now. But, somehow, the uncertainty and hidden challenges that the doctorhood quest presents have not deterred me. I reflected on the prospect of doctorhood during my years of Peace Corps service and, once back in the States, I started jumping through the hoops of medical school applications (I had no science background when I began). The long wait to medical school acceptance has only made me more excited to start my studies. The doctorhood quest isn’t even half over—medical school, residency, and board exams will be the longer leg of the journey. Yet, as I sit on an acceptance letter and wait to hear back from more schools, it’s thrilling that I’ve come this far.

People around me, to me or to others, often comment on how intelligent one must be to get into medical school. I usually remain silent, but smirk inwardly. I believe “smart” comes in many forms and not all are suited to medicine. I’m disinclined to suggest one person is smarter than another because life has shown me that humans have different gifts and society needs all of them to function. But, more specifically, my journey has shown me that medical school admittance has less to do with how smart someone is and more to do with how resilient they are. The doctorhood quest requires you to be gritty and determined. It demands that you jump up and try again each time you fall while tackling the perils of the road.

If resiliency and grit is the secret to pursuing marathon goals without losing hope, how does one get those? Experience and inward reflection are my guesses. We learn by doing and we expand our scope of understanding the more different experiences we have. Nothing proved this more to me than my years in Paraguay. I am not the same person I was when I first stepped off the plane in that hot, humid country. The people there showed me how they found happiness; they defined respect and God and love in ways completely different from any definition I’d ever encountered for those things; and, above all, they exposed me to foods, ways of life, and shared moments I could never have imagined.

Experience is the foundation for growth, but to truly grow one must reflect on those experiences. Paraguay, once again, taught me reflection. It is impossible to describe just how lonely and hard it can be to be the only one from your culture in a foreign place unless you’ve experienced it. Your world is turned upside-down and every definition and rule you ever thought was a given is no longer in play. Your default becomes mild confusion and curiosity about the new culture in which you have fallen. Most importantly, you are forced to examine how your culture does things and why. Once you start picking apart your host and native cultures, it’s an easy, logical jump to start evaluating and thinking about different aspects of your personal life—like your interactions, feelings, and activity choices. Once you build in time to reflect on experience you can start to shape your path more purposefully.

The secret to marathon goals is accepting you can’t know the future, but you can influence the present. The secret is celebrating small victories, making educated guesses about the best course of action today, and seeking out the people, places, and experiences that rejuvenate you when your hope falters. We do not achieve marathon goals alone (it takes many helpers) but it is only from within ourselves that we find the strength to withstand what’s hidden behind each bend in the road.

Name the Fear

My stepmother’s friend used to play a game called “Name the Fear and Conquer It” where she identified things that scared her—like bungee jumping— and then did them. My sister has a philosophy about hesitation: If you hesitate because you don’t like something then it’s okay to abort, but if you hesitate because you’re scared you ought to dig for courage and forge onward.

The above thoughts are good summaries of how I, too, approach undertakings that make me nervous. The difference is that I don’t necessarily seek out thrillers like sky diving. I prefer to look around me so I can maximize normal life, avoid falling into mindless routines (I like to break them when they form), and daydream about the next challenge I’m going to tackle. Here’s an example.

Wrestling uncertainty was something I did when I became an EMT. I distinctly remember my tumultuous beginning. I threw myself into a condensed EMT course, having no clinical background, that moved so fast it didn’t even have lectures. It’s one of the only classes, and the only one since sophomore year of undergrad, that made me cry. I didn’t know if I’d survive the class. I didn’t know if I’d pass the licensing exams. I didn’t know if I’d like running on an ambulance. But, I made an educated guess and decided it was worth the gamble.

At first, I felt uncomfortable touching strangers—a necessity when you’re taking a pulse and blood pressure or doing a physical exam. I had to coach myself to be still and not run away when my classmates practiced taking a pulse on me. Understanding how the lungs and heart worked wasn’t intuitive. And, for my mind, memorizing isn’t enough. I must understand. I spent many hours reading and rewriting notes.

I lived through the class. Some tears, but I mostly just buried my nose in my textbook and practiced as much as I could during our practical classes. Despite my efforts, I failed a few stations of the psychomotor exam (physical skills) the first time I took it. I couldn’t concentrate and I messed up things I knew on several stations. (The traditional student in me came through though, and I passed the computer portion of the exam in one shot). I almost quit after failing the psychomotor exam. But, I asked myself, “If you can’t be an EMT how on earth are you ever going to be a doctor?” I practiced more. I gave myself many pep-talks. I passed everything on my second try because I focus on how much I wanted to start working with patients and how certain I was that I was pushing myself in the right direction.

I was so nervous thinking about starting as an EMT that I can’t recall my voyage to my first EMT shift. Despite my panic, though, running on an ambulance started way better than my EMT class had. My crew captain assured me he wouldn’t let me kill anyone. Further, he and the rest of the crew went above and beyond to show me the ropes (well, actually, they showed me the tubes, the gadgets, the bandages, and all the other gear that fills the numerous nooks of an ambulance). Time would show that I enjoyed being on an ambulance. I loved the puzzle of figuring out what was wrong with patients and how to treat their condition. I loved chatting with patients when there was nothing to be done but ride to the hospital. Patients almost always have amazing life stories to tell.

About a year after becoming an EMT, I took another leap. I left my communications job—my undergrad degree was in communications—and dove professionally into health care. I began working as an EMT in the emergency department. Yet, despite the major change, this professional jump wasn’t scary like my EMT class had been. During my first couple of months on the job, I learned a ton of new skills like how to place IVs. While I wasn’t an expert at anything new right away, I knew I’d get there if I focused and practiced. My EMT course proved that.

EMTing pushed the boundaries of my comfort zone. This surprised me because I have a wide comfort zone. After all, I’ve moved and built a life in two completely new countries (once as a student and once as a Peace Corps volunteer) and I’ve moved from the country to the city and the city to the country–which is to say I’m comfortable with change. I think the hands-on work and using assessment to inform treatment of living beings challenged me most when I started learning clinical skills. However, I’m so glad I pushed through the bumpy beginning of my career in health care delivery because medicine is the most fulfilling professional pursuit I’ve undertaken to date.

It’s easy to avoid things we’re bad at because they make us uncomfortable. But, as I told myself many times leading up to round two of the EMT exam, if everything was easy then life would be boring. With that, I leave you with a quote from Amelia Earhart:

“The most difficult thing is the decision to act, the rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life; and the procedure, the process is its own reward.”

On Not Becoming Jaded

One night a coworker in the emergency department, who also aspires to be a doctor, asked me if I was worried about becoming jaded as I worked in health care. I answered confidently that I wasn’t worried about becoming jaded, my hope for humanity waning, or burning out like so many medical professionals do. He was skeptical, but I am certain of only that one aspect of my future.

Defining Jaded

Especially late at night when most patients are tired and grumpy, the drunks roll in after exhausting the bars, and the patients held for mental health evaluations decide to spend the early morning hours holding yelling matches that involve nonsensical accusations against staff, it’s easy to see how one can grow tired of working in a hospital (and specifically the emergency department). In medicine, we take care of everyone, even if they’re jerks to us, because the fundamental principle of health care is that we serve all people.

Not so long ago I was greeting patients in the waiting room at the emergency department. We had around 20 folks waiting for rooms, the rooms weren’t changing over, and the wait times for many were over 2 hours. That’s a recipe for an unpleasant experience as a greeter, and the recipe was rich that night. I had a parent repeatedly insult the staff, including me, and ask why we hadn’t brought her child to a room yet. That was annoying, but manageable. What got to me was when she stormed up and demanded to know why we brought back “a drug addict” (her words, not mine) before her child. Her argument was that her child had a bright future while that person was a lost cause. Of course, I couldn’t tell the hysterical mother just how awful it is to watch a person go through withdrawal shakes and then seizure. That’s something you can only understand once you see it. I couldn’t tell her about the alcoholic who came to us one night shaking so badly he couldn’t drink water from a cup. I couldn’t tell her how he had looked me in the eye and told me he wasn’t human anymore. That mother was choosing to believe him, but I knew that that patient was human even if he didn’t feel like he was. That angry mother in the waiting room clearly had never seen a person beat an addiction—winning the daily fight to not give in to a drug or alcohol for years. I have.

It’s not the job of medical professionals to pass moral judgment. Sometimes we are weak and tired, and we do judge our patients’ life choices. But if we were to slip into a world where we used our personal morals to decide who should receive care, we would betray the heart of medicine. Medicine was never meant for only a select few.

In my view jaded is another way to describe losing empathy. There are many presentations—impatience, anger, and hating work to name a few. These feelings come when we are too tired and too worn out to see patients as humans. They come when we no longer find joy in the small things about the job that are awesome. And jaded becomes the norm when we give too much. It’s easy to work hours no one else would dream of working when you’re in health care. Each hour is rewarding because we help someone feel better, but the hours take a toll on the giver.

Considering all the above, how am I so certain I won’t become jaded?

  1. My empathy comes from selfish sources, so I don’t expect that it will fizzle. The first source is curiosity and the second is a love for stories and puzzles. Each human has a story. Each sick person is a puzzle. The curious mind can’t help but wonder about the story plot and the answer to the puzzle. These two factors are some of the main reasons I veered down the medical path in the first place.
  2. I know that I’m brave enough to step away and recharge as well as to shake things up when caring for patients under specific conditions becomes wearisome.

How do I know I am brave enough? Paraguay. While living in the land of Guarani, I cultivated an ability for self-reflection and the bravery to face fears because they were required to survive the Peace Corps. Paraguayans also showed me the value of letting yourself be still. In America, we are so determined to be productive we schedule every moment. I think running around all the times makes everyone miserable no matter what their profession. I also think those who become jaded forget to reflect and change. They fail to see that their job is draining them until it’s too late and, then, they lack the courage to change their work so it’s fresh again. It comes down to the best professional advice I was ever given. When I asked a presenter in one of my undergraduate classes how she knew when it was time to leave a job (she had an awe-inspiring, lengthy job history) she said, “You’ll know. You know when it’s time to leave.”

She was right. We do know when it’s time to mix things up. The hard part is taking the steps to act upon what we know. But, if we do take those steps, then jadedness can never catch us. The moment she gave me that advice, years ago now, I promised myself I’d be strong enough to change my course whenever I “knew” it was time. That strength sent me to Paraguay and brought me back to Vermont. So, no, I’m not worried about becoming jaded. I’m just excited to see where my adventures in medicine bring me.

Human Side of Medicine

Not so long ago I worked a code (cardiac arrest = patient’s heart stops and they neither have a pulse nor are breathing) in the field. The patient was middle-aged and had a complex medical history. The patient’s father, visiting from out-of-town, found him unresponsive, started compressions, and called 911. We did all we could—did compressions, ventilated, pushed epinephrine and other medications, and analyzed for a shockable rhythm. As we worked the father knelt at his son’s head. The patient’s fiancée sat outside the house. As it became clear that we were not getting our patient back, my crew chief reviewed, outload, all we had done. She asked us if we could think of any other interventions we hadn’t yet done and then she engaged the father, explaining why we were going to stop resuscitation. Once we had stopped she went outside to talk to the fiancée.

As heartbroken as the patient’s family was, they were calm when we stopped CPR. They had seen us sweat over their loved one, try everything we could, and ask for suggestions. We included them in our decision to stop our efforts. We lingered after our care was done to answer questions and offer condolences. This call showed me how it is within the pauses between action that we connect with our patients.

The human side of medicine comes through when we take time to ensure our patients understand what is happening and our plan for treatment. It comes when we include our patients and, when appropriate, their family in decisions about their care. And it’s completed by taking a moment to share their feelings, whether of relief after a successful procedure or sorrow after the loss of a loved one, before we scurry on to our next case.

Amid medical histories and assessments of signs and symptoms that lead to differential diagnoses it can be easy to let the presence of a disease or condition consume our attention. We can focus so intently on the disease that we forget humans bear the illness. But, below the clammy skin and wheezing is a person with a family and life experience just like you and me. And, what the patient will remember from their time during the flurry of a medical crisis is how someone treated them. It’s the offering of a kind word or an act of kindness on the worst day of someone’s life, not just the hope and likelihood that we have a cure, that defines good medicine. I try to remember to take advantage of the pauses by offering a blanket or bit of conversation to my patients. There aren’t always many pauses in my day, but when there are I don’t like letting them go to waste. It’s in the shared moments between points A and B that we build our humanity, but we must be attentive or we’ll miss the opportunity.