Tag Archives: Public Health

Tropical Paradise Has Challenges Too

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“I didn’t have power for 4 months. My daughter got lice because we couldn’t bathe properly; with my long hair, I got them too when I picked them out for her. We washed our clothes by hand. During those months, some areas started to get power and I was able to bring my big items (like bedding) to a laundromat. I lived in a place where I wasn’t allowed to have a generator. But even the rich people with generators didn’t have power because you need gas to run generators and we didn’t have that. I couldn’t keep food all that time because my fridge didn’t work. It was hard… So, I think we all have a little PTSD when it comes to hurricane season,” a Puerto Rican said, recalling her experience during Hurricane Maria. She’d just given me a tour of San Juan’s primary hospital campus, including pointing out the street where they used to have shipping containers lined up to hold corpses during Hurricane Maria because they couldn’t identify them fast enough.

“It was bad. Help didn’t come or it was delayed,” she said. I remembered this; it was all over the news. Hurricane Maria hit Puerto Rico in 2017. You might remember the politics of the US then; there was a lot of news about the hurricane’s effects and how the US government delayed or didn’t send aid. Perhaps 3,000 Puerto Ricans died, but we’re not exactly sure of the true number. Many more lost their homes.

I remember someone asking me if Puerto Rico had been rebuilt since Hurricane Maria when I left for Puerto Rico. At the time, I found the question odd because it’s been 6 years since that hurricane struck. But I have an answer now and have come to realize that it was a good question. The answer is: yes and no. If you visited Puerto Rico today, your first impression would be that it’s a tropical paradise and you might fall in love with the place. There’s a reason why Puerto Ricans are so proud of their home. As a tourist you’ll enjoy both friendly hosts and living accommodations equivalent to those in the continental US. But if you dig deeper than the average tourist experience, you’ll discover that the island has challenges. Despite the beauty of the island and its strong identity people are leaving Puerto Rico. This Washington Post article describes the situation of Puerto Rican’s leaving their home (and people leaving other US territories too).

If you explore beyond San Juan (Puerto Rico’s capital and biggest city), you will see shadows of Puerto Rico’s complicated situation. In the town where I’m staying (and all throughout the island), you find deserted houses on most blocks. A coworker explained that sometimes people just leave their homes and move, often to the continental US. The pay here is lower than in the continental US (often in general) but especially in industries of interest to me such as healthcare. Infrastructure throughout the island, like healthcare, is much like in rural regions of the continental US, which is to say that many people don’t have easy access to the healthcare they need.

My husband and I visited a small island just off Puerto Rico’s coast called Vieques. It’s where the brightest of the 3 bioluminescent bays in Puerto Rico is and that’s why we visited. Being me, I had us walk the 5ish miles from the ferry to the town in which we were staying. Again, being me, I googled to see if there was a hospital on Vieques and the number of beds it has (as I do everywhere I go) just in case I wanted to move there and work. I learned that Vieques doesn’t have a hospital because it wasn’t rebuilt after being destroyed in Hurricane Maria. I also noticed signs demanding that the hospital be rebuilt on a chain-link fence as we walked across the island. On our walk back to the ferry from our Airbnb, a local stopped to offer us a ride because it was hot. We accepted. I can’t remember if I asked about the hospital or if it came up naturally in conversation, but the local explained that the hospital hadn’t been rebuilt and it was a point of political tension. Further, in 2020, a teenage girl died because there wasn’t available transport to San Juan when she needed it and Vieques didn’t have a ventilator to help her breathe. According to the local, even the family of the girl helped manually give her breaths (with a bag-mouth mask which is what EMTs use on ambulances until they get to the hospital), but she died anyway.  

From these conversations, I’ve learned that Puerto Rico has a complexity that can be overlooked as a tourist. Living here a few weeks has not made me an expert (or even a novice) in Puerto Rican anything…except maybe dengue because I’m doing an internship about it and fruit juices because they are delicious. But my time here has allowed me to see that beyond the beautiful beaches, blended frozen beverages, and seafood Puerto Rico has a historical, political, and economic reality. Puerto Rico reminded me of the confusion I had while living in DC: It is odd to me that there are territories that are part of the US where the inhabitants aren’t granted the right to vote and to have congressional representation because it seems rather undemocratic. I don’t know if it would change anything in Puerto Rico if they were represented in US congress or participated in US presidential elections. I also I don’t know if that is something Puerto Ricans want. But, at the very least, I’ve come to see that I have a lot to learn about Puerto Rico’s history, its current governance, and its relationship with the US before I can fully unpack my experience living here.

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Maintaining the Body/Mind

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In zooming around healthcare settings, I’ve noticed that many people approach illness as a weakness or a betrayal of their body and mind. I’ve even noticed myself having a similar feeling occasionally when I must visit my own doctor. This way of thinking is like how I think about my car: I expect my car to get me from A to B every time I ask it to, with minimal effort on my part, and no upkeep.

To further outline the analogy between bodies/minds and cars:

  • The hospital is to the body/mind as the auto shop is to a car after a crash. If something gets damaged, we usually must fix it to run again.
  • The primary care setting is to the body/mind as an oil change, tire change, and alignment are to a car. For optimal performance, we must continuously do some upkeep and occasionally get a tune up.

As we examine the analogy between cars and bodies/minds there is an essential difference. If we have the money, we can buy a new car periodically to avoid all the upkeep that inevitably comes with the wear and tear of use. However, we each only get one body/mind and, therefore, not even money can spare us the required upkeep that comes with the wear and tear of life.

Considering that we each only get one body/mind and life is hard, I’d like to propose the viewpoint that going to a primary care provider isn’t a visit with the enemy. It’s not intended to be a place of judgement or punishment. Instead, think of primary care appointments as tune ups that include chatting with an expert on the human body/mind. In this chat, we can uncover what aspects of our body/mind are optimized, what aspects aren’t optimal, and how we each can make our body/mind run better. By optimizing our body/mind, we may prevent many diseases from occurring (prevention is better than treatment, why get sick if there’s a way to avoid it completely?). 

In a similar fashion, no one wants to stay in the hospital, but needing the hospital isn’t unique; it’s part of the human experience in places where hospitals exist. Hospitals can save lives and fix big health problems. They might not be the most pleasant places, but without them we might not get the care we need to recover when things in our bodies/minds break. If we can think of our hospital care team as a bunch of people on our side who are looking out for our bodies/minds, it might make the whole experience a little better.

 Just as we know our cars require a certain amount of upkeep, I challenge all of us to remember that the body and mind also require a certain amount of upkeep without considering a need for that upkeep a shortcoming.

The Ocean

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I’ve never lived by a sea or ocean before. But for a few weeks this winter I am. And not just any salty expanse but the Caribbean Sea and Atlantic Ocean around Puerto Rico. It’s not hurricane season so, in the few days I’ve been here so far, the waves have crashed with careful, well-mannered regularity. Right now, I’m on the Atlantic Ocean coast. The water is warm and blue. Walking along the beach I find myself covered with a salt film both from the lapping waves and the salt in the air. The temperature has been perfect and the sun a beautiful gold. Proximal to the sand and rocks that meet the water are coconut trees, marking where the beach ends and the rest of the island begins.

As I walk along the rocky bits of the shore crabs scuttle so quickly that they’re hard to see – their shell patterns match the sea plants and the design the sunlight creates as it dances with the waves. Pelicans hover above the water, make a diving plummet with a smack as they break the water’s surface, rest on the ocean’s surface to swallow the fish they caught, and then take flight to follow the wind off the water to only scoop around like a boomerang and head back out to fish again.

People sit on the beach and hangout in the water. They listen to their loud music, dig holes in the sand, throw rocks, and drink alcohol (mostly beer). I walk along the junction between the water and the sand – sometimes more on the side of the sand and other times more on the side of the saltwater. The waves fill the gap between me and the seemingly infinite ocean. Sometimes I’m taken by surprise when a large wave barrels to shore and splashes up against my legs and catches my shirt in its spray.

Where there are tidal pools, I look down at the ruby red sea urchins with deep crimson spikes – their colors remind me of the colors of fresh and dried blood or, perhaps more appealing, the colors of red I’d expect royalty to wear. There are little fish that dart around in the tidal pools; they’re the color and pattern of sand. There are sea plants that look like little green balloons. There are shells hiding live creatures whose names I don’t know. Some of the bigger pools have sea anemones. I peer into each tidal pool, eager to see what it keeps in its mini-sea haven.

I love the sound of the waves and the smell of the salt water against the sand. It’s new to see coconuts. But, in this serene backdrop I can’t help but notice the broken glass and plastic bits, bottles of all varieties, cans, and all the other trash humans on the beach have failed to pick up…or humans elsewhere tossed in such a way that their trash found its way to the beaches where I wander now. I walk barefoot in the sand, but it’s almost a bad idea because so many people have broken their beer bottles.

The creatures and features of the ocean are no less beautiful with the trash present, but I imagine how it would be paradise without the plastic bottles there as a reminder that so many places I love are being filled with trash. Will this beach be swimmable when my grandchildren are alive? There must be a better way. There must be a way to keep this beach with its crabs and sea urchins for the generations to come.

As I turn up the road between where I’m staying and the ocean I see heaps of bottles, cans, Styrofoam, plastic bags, and other discarded single use items on the side of the road. They create a scattering of litter among the snake plants, palm trees, mango trees, papaya trees, pothos vines, and other plants of the tropics. Is there another way or is it already too late to return our natural spaces to paradise?

Back In the Operating Room

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The patient was undergoing emergency surgery for an aortic dissection (when blood gets between the layers of an artery wall) with an aneurysm (dilation/ballooning out). The aorta is the largest artery in the body. It comes off the top of the heart and then travels through the chest and abdomen until it splits into two big arteries that feed the legs. It has many branches along its path. Because this patient’s dissection and aneurysm were close to their heart, without surgery the dissection could spread and damage their heart. Further, if the aneurysm wasn’t fixed and then ruptured, the patient would likely bleed to death.

Conducting this surgery was one surgeon and one physician’s assistant (PA); they were supported by an anesthesiologist, a resident anesthesiologist, 3-5 nurses, and 1-3 surgical techs. Surgeries are always a team effort. This surgery was complicated, the stakes were high, and bad outcomes were more likely than for many other surgeries (but without surgery death was almost certain). For the first 6 or so hours of the surgery the surgeon and PA worked without a break – no water, no bathroom, and no food. After the most time-sensitive part of the surgery was done, the surgeon sipped some water through a straw that a nurse carefully threaded behind his mask. The nurse joked that he was like a gerbil – no one argued with that analogy.

In all, the surgery would take about 11 hours. As the surgeon was finishing up his work, he looked around the room and thanked each person there for their help. He then looked up at me. I’d been watching the surgery for the better part of 8 hours. “What are you? A resident?” the surgeon asked.

“No, a medical student,” I said.

“God bless you,” the surgeon said. He paused. “My son is a third-year resident. I tell him to remember that you’re not supposed to enjoy residency.” The surgeon paused again. “But I still say I would never have wanted to do anything else.”

This surgeon had started working as a surgeon at this hospital when I was 8 years old. Assuming he’d done about 8 years of training to become a cardiothoracic surgeon and that he’d spent his entire career at this one hospital, he’d been operating about as long as I’d been alive.

I reflected on his sense of fulfilment in being a surgeon. I wondered if I’d end up liking my path in medicine as much as he liked his. I wondered if it was possible to enjoy one’s path in medicine as much these days as it was when he started.

~

Medicine has changed a lot in the 30+ years I’ve been alive. We’ve made lots of amazing advancements, but health disparities remain staggering. Work conditions are variable hospital to hospital and clinic to clinic. I love medicine, but I can’t ignore how strained our healthcare system was before the COVID pandemic and how much worse it has become even after the COVID vaccine reached the US public. I also know that my path in medicine will be quite different than that of a surgeon.

I am pursuing a medical career that does not involve surgery or procedures and, therefore, is not a hospital money-maker in our current healthcare system. Money gives power even in healthcare, as such, I’ll neither have the high pay nor inherent influence on hospital administration that surgeons do. All physician roles have amazing components and are important for patient care however to say each physician’s place in the system is the same is not simplification, it’s erroneous. I’ve come to feel the differences between physician types more thoroughly as each new step of my doctorhood quest unfolds.

As I wrap up my time as a medical student, I’ve been reflecting on what I’ve learned and seen in healthcare so far and where I want to end up as a physician. As a student, I’ve seen more parts of the patient care system than I will in any other capacity during the doctorhood quest. I’ve participated in countless conversations throughout the inpatient and outpatient healthcare settings. I’ve been a fly on the wall for even more conversations than I’ve participated in. From insurance navigation nightmares to cool medical cases, from nurse-to-patient ratios to supply chain issues I’ve come to understand that healthcare is a complex group sport where the field and rules change based on geographic location (because of geography itself, demographic composition, and regional laws), insurance status, medical society guidelines, government funding, hospital and/or clinic revenue generation, supply chains, ability to hire healthcare professionals, and many other factors.

I start residency in about 6 months. At that point, I’ll continue to learn what I need to know to be an independent physician. After 3 years, I could graduate residency to work as a hospitalist or primary care physician or I could continue my training to further specialize. I’m excited and hopeful about these rapidly approaching adventures. I wonder what I’ll tell a medical student about my journey 30 years from now. I dream that my message will be as positive as this surgeon’s message was to me.

Finding Purpose and Meaning

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

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

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

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

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

My Experience Getting the COVID Vaccine

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Disclaimer: If you’re looking for scientific information about COVID or the COVID vaccines, check out the CDC as a starting place for information. This post doesn’t address science or research surrounding COVID; it is simply a recount of my personal experience getting COVID and the COVID vaccines.

I got COVID almost a year before any vaccine was approved. To be honest, I was one of the luckiest people to catch the virus. I hardly had a fever. I did, however, spend hours lying on the floor too tired and nauseous to get up. I had to force myself to eat because every time I ate, I got sick to my stomach. My brain was foggy. My body drained. I didn’t feel short of breath but, breathing took more energy than usual. I thought about breathing more often than I did normally. I didn’t get diarrhea or lose my taste or gasp for breath like others did when they had COVID. Not once did I think I needed to go to the hospital because of the virus. And, as you can tell because I’m writing this, my case of COVID wasn’t fatal. And, since it was the height of COVID closures when I was sick, I hardly had to change my lifestyle to quarantine because I already wasn’t leaving the house. I was lucky because the subject I was studying in medical school at the time was easy, so I was able to study and pass my exams despite spending hours lying on the floor with my mind floating is some other universe. I was lucky because all the pieces that came together for me resulting in me not getting that sick did not come together for everyone who got COVID.

The first Moderna COVID shot was exciting. Finally, we had something to prevent COVID, that terrible infectious disease that had changed my world and threatened to make it impossible for me to study medicine. Finally, we might be able to prevent people from dying. I think I got a sore arm after that shot, nothing serious.

The second Moderna COVID shot was also exciting because it marked a completion of my duty to prevent COVID from spreading as best I could in addition to wearing a mask and social distancing. I felt like I was contributing to humanity while also protecting myself – how uncommon it is to be able to put yourself first while also helping others.

But, also, the second Moderna COVID shot wiped me out. I passed out the night after getting it. To be honest, I knew I was going to pass out, so I lay on the floor before I fell. I lay on the floor for what seemed like an eternity before the chills and nausea passed enough for me to crawl back to bed from the bathroom. That was a rough night, but I knew it’d be over in 24 hours because I wasn’t sick; my body was just doing exactly what it was supposed to do. My body was making antibodies (those protective proteins that help fight off infections). My body was responding to the vaccine. I felt awful, but still thought science was cool. I mean, we can make our bodies build defenses before we get sick—that’s kind of magic.

Recently, I got my booster Moderna COVID shot. It also hit me hard. I couldn’t sit up without feeling nauseous for at least the first 12 hours the day after I got it. All my joints and muscles ached. The feeling of the blankets against my skin was painful. It was 16 or 20 hours after the shot and two very long, hot showers; a day of maximum recommended Tylenol; and some Ibuprofen later when I finally started to feel like a tired version of my normal self. But, despite how awful I felt, the morning after the shot I was relieved because I knew I wasn’t sick. I was relieved because my reaction showed that I still had COVID antibodies. I was relieved because as bad as I felt, I knew it would pass in 24 hours. When we get sick, we don’t know how long it’s going to last. The uncertainty of illness is part of its trying nature. I’ve always like deadlines and end dates.

Everyone has different reactions to the COVID vaccines. I have a strong reaction, but by no means the strongest reaction. When I work in clinic some patients explain how fearful they are of their COVID vaccine reaction. Fear of feeling sick is valid. It sucks to be confined to bed for any amount of time. But when it comes to the COVID vaccine, it’s nice to know it’ll be short-lived. Just 24 hours, maybe 48 hours. When I had COVID my symptoms were mild, however the fatigue lasted for at least a month after the other symptoms subsided. For me, at least, feeling sick for 24 hours is acceptable knowing that I will decrease my chance of ever getting the real COVID again. I also can’t accept not being part of the group of people willing to try to stop COVID. It’s a legitimate feeling to dislike having a reaction to the COVID vaccine but, it’s a sacrifice I’m willing to make to keep COVID at bay. If it takes getting a COVID booster every year that’s a small price to pay to prevent millions more people from dying from a disease we have a vaccine to help prevent.

Burnt

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Her hands had become so numb she could no longer administer the eyedrops that kept the pressure in her eyes from getting too high. If her eye pressure got too high, she’d go blind. So, her eye doctor said she needed surgery if she couldn’t use the eye drops. There were two surgical options. One surgery would take an hour and she’d leave the operating room able to see. One would take 3 hours and she’d leave the operating room blind, requiring 4-6 weeks of recovery before her vision would return. She was lucky because she had family who already helped her a ton because her other health conditions had made independent living hard for her. For some reason, the insurance would only cover the 3-hour surgery that would leave her blind for over a month. The holidays were coming up. The family members that took care of her had kids. She refused to make them care for her while she was blind over the holidays. She postponed the surgery. Would she go blind before she could get her surgery? Is this the healthcare system we want?

~

The patient wasn’t COVID vaccinated. “What will you do to treat me if I get COVID?” she asked. I thought about the patient a resident had told me about. That patient had been dependent on family for care. His family didn’t vaccinate him. He got COVID. He came to the emergency room with trouble breathing and then went to the intensive care unit. He lived on the intensive care unit for a year. Eventually, his healthcare team cut a hole in his neck to put a breathing tube in because he needed it. They did everything they could to keep him alive. The resident said when the patient first came to the emergency room, he was a happy, funny soul. The patient lost his happiness slowly during the year he fought to breath. After a year of an entire hospital trying keep him alive, he died. When exactly did avoiding sickness fall out of favor? Do you ask what firefighters will do if you set fire to your house or do you make a concerted effort to not catch your house on fire knowing that firefighters will do their best to stop a fire if it occurs but are limited because fires are destructive and destroy houses and the people who try to stop them?

~

The patient asked, “Why are so many doctors retiring?” I wondered how he didn’t know the answer to that question already. It seems so obvious. Then, I realized he was not a medical student. Being a medical student is to have a front row seat for observing the current state of healthcare. What had I seen? Why did it seem perfectly logical to me that so many people were retiring from healthcare even as I was striving to make it my career?

Not just doctors and nurses, but everyone in healthcare seems to be retiring…

We report our COVID cases. Our COVID test rates. Our COVID survival rates after hospital admission. Our COVID deaths. Who was there to perform those tests, to care for those people when they came to the hospital, and to close the curtain when the ventilator wasn’t needed anymore? Healthcare workers. But, they were also there for all the other things too. The heart attacks. The stomach pain. The broken bones. The cancer. The normal healthcare screenings. They were there when people looked for help with their depression and their anxiety. Healthcare workers’ hours increased. They worked the job of two, three, four, and five people because the hospital was short-staffed before the pandemic hit. Again, healthcare workers were already working long hours and doing the work of several workers before COVID came. Then healthcare workers got sick. And the ones left standing worked for their sick colleagues, worked for themselves, and worked for the staff who were missing before the pandemic came. Wages stayed the same.

Housing and food got expensive for everyone, including healthcare workers. Healthcare workers missed the same performances, social events, and restaurants that everyone else was missing. Life got more expensive because everything including industry was disrupted by COVID. Healthcare wages stayed the same. Healthcare workers got sick. Sick leave was used up. Shifts were harder because healthcare was short staffed and there were more patients than before. And the patients were dying. And insurance didn’t want to pay for the treatments that patients needed, not that that was new, but it remained disheartening. And there was the need to wear masks at work. And to put on goggles and gowns and for healthcare workers to take extra time to protect themselves from infection. There was the risk of bringing COVID home after working in healthcare. Wages stayed the same.

People got sick. And healthcare workers got tired. Wages stayed the same. Hours were long. Vacations couldn’t be taken like they used to be taken. And just like their patients, healthcare workers got sick, tired, depressed, and anxious. Staff shortages increased in the hospitals and clinics.

People denied that COVID was real. People invented vaccines that helped prevent COVID infection. People refused to get vaccinated. People complained about wearing masks. People got tired of social distancing. People got sick. The intensive care unit was full. The psychiatric ward was full. The cardiac ward was full. Alcohol use disorder, diabetes, high blood pressure, and all the other medical conditions that always exist marched on because they don’t stop during a pandemic. Healthcare workers shouldered the workload of several workers each because some of their colleagues had left, some had died, and some were sick. Wages stayed the same.

In such an avalanche, how long would you have waited to change careers? For many, the answer was between 1 and 2 years.

~

There is always hope and healthcare has been grounded in hope since the beginning. But as a student so excited to become a physician I know that change must happen if hope is to materialize into lives saved. And for my sake and all the people who might need the hospital or a clinic in the coming years, let’s not make it take a healthcare collapse before we seriously consider how we might improve and restructure our healthcare system. I’d very much like some seasoned healthcare workers who are not completed burnt at my side when I start practicing as an independent physician because experience is gold in medicine. I’d also really like to have enough staff to care for patients without having to burn myself and burn my colleagues with the weight of too many lives in each of our two hands.

The Psychiatric Rotation

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Disclosure: The patient story here was written with a patient I saw in mind, but the details have been changed to protect anonymity. The story is reflective of many patients I saw during my psych rotation and while working in the ED. You will note that I chose nonbinary pronouns. This is because brain illnesses (just like many illnesses of other organs) set in regardless of gender. Brain diseases, like many other diseases, are related to genetics, life experiences, and other social and environmental factors. A tricky aspect about brain diseases is that we aren’t exactly sure how most of them develop and we are quite far from having a cure.

I looked down at them lying on the stretcher in an ED bed. They were snoring quietly, and their face was neatly framed by their hair. Their eyes were closed, and they looked peaceful. I didn’t have much time to ponder the full circle that this scene represented and the eerie foreshadowing of the end of my psych rotation. They had received the magic 5-2, 5mg Haldol and 2 mg Ativan. Haldol is an antipsychotic that is sedating and Ativan a benzo that’s also sedating. In other words, the patient was chemically restrained. Put again, they were put to sleep for a short time to end their psychosis. And a scary psychosis it must have been as it was filled with delusions of people hurting them and murdering children. We shall call this patient The Singer.

I’d seen The Singer awake and stable during the first few days of my psychiatry rotation, weeks before I saw them sedated. When I first met them, they were being discharged from the psychiatric inpatient unit of the hospital. They’d been in the hospital for weeks. They’d been restrained many times. They’d spent a good chunk of their stay believing the hospital staff were hurting them. When I met them, they didn’t have those delusions. They were looking forward to finishing a song they’d started writing before entering the hospital. They were looking forward to going back to their job and were inspired to possibly start biking again. They were discharged from inpatient to home with quetiapine and an intensive outpatient treatment plan (dialectic behavioral therapy group sessions). Quetiapine is an antipsychotic. Did you know most drugs in its class are effective about 20%-50% of the time? That’s not a passing test grade. But, then again, 20% of patients helped is better than zero. And, of course, medications only have a chance of working if you take them.

As my psychiatry rotation marched along, I changed from inpatient psychiatry to outpatient psychiatry. I’d see The Singer in the outpatient setting too. I observed their dialectic behavioral therapy session (group therapy focused on developing social skills and strategies to manage emotions). I interviewed them at their medication follow-up meeting. At that meeting, they told us they’d stopped their quetiapine. They didn’t want to take it. They didn’t like it. We could not and were not going to force The Singer to take their medication. They complained about not being themselves when taking the medication. I couldn’t blame them because quetiapine is sedating and does sometimes make people feel flat, emotionless. The psychiatrist counseled The Singer on looking for signs that they might be slipping into psychosis again. The Singer identified not sleeping as one of the triggering factors. I worried for them. I worried their delusions would return if they weren’t on quetiapine.

After outpatient psychiatry, I transitioned to the consult service which determines if patients in the ED need psychiatric hospital admission and provides psychiatric evaluation of patients anywhere in the hospital. I was with the consult service when I saw the sedated version of The Singer in the ED. The Singer had been sedated because they were not safe. Their delusions of rape had returned. They were agitated and not taking care of themselves. They were making risky decisions. We hoped to help them by admitting them to the hospital.

I knew The Singer was a musician because the ED was the third setting in which I’d seen them; the first time I met them, they told me they were a singer.  I knew their living situation and their hobbies because I’d talked to them about them. I knew why they had stopped taking their medications and I knew that part of the reason their psychosis had returned was because they’d stopped taking quetiapine. After leaving their ED room, I drafted the psychiatry consult note that would be a record used as justification for involuntarily admission to the hospital for stabilization. We’d come full circle, The Singer and I. I started my time on psychiatry with them being discharged from inpatient treatment and I was ending my rotation with them being admitted again to inpatient treatment. Same cause. Similar presentation as last time. Had we made progress? How many times would The Singer repeat this cycle? I reflected on the fact that chronic illnesses are just that, a chronic struggle to be well. A chronic ebb and flow of good and bad days.

The ED consult note I wrote about The Singer was the first psychiatry note where I left the mental status blank and simply said they were chemically restrained at the time of consult. The mental status is the bulk of a psychiatry note. It’s where you summarize a patient’s emotions, thoughts, words, and behavior. A psychiatry note without a mental status exam is quite limited. Psychiatry is about talking to patients to understand their feelings, thoughts, and emotions. It is almost impossible to evaluate for feelings, thoughts, and emotions if you can’t or don’t speak to a patient. Sure, when patients aren’t sedated, you can observe them or try to use writing or sign if you can’t speak to them formally. But, talking is the core of psychiatry. Psychiatry is the one field of medicine that does not forget to ask the patient’s opinion. I reflected on that bit. It reminded me of the key lesson I hoped to remember on future rotations when time was crunched and my patience strained – you have to talk to patients in order to know their thoughts and story. It may sound simple. Perhaps it is. Perhaps the pile of labs and medications and interventions that occur in the hospital make it difficult to always remember that patients are people who got sick. The sickness doesn’t remove the fact that they might be a singer or a biker, it just adds another layer to them as a person. Seems straightforward. We’ll if it remains straightforward at the end of a 13-plus hour shift on surgery.

The COVID-19 Vaccine: Celebration and Differences

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Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original (split into 2 posts) here and here.

My partner and I both work in healthcare and had the opportunity to get our COVID-19 vaccines months ago. Never in the past would I have expected to await a vaccine with such anticipation and feel such gratitude upon receiving it. Among the many other social and scientific features COVID has brought to the forefront of our attention—one, at least for me, is a renewed appreciation for all the vaccines we have previously developed. To think that we can stop smallpox and polio is a relief. But, also, COVID is a reminder of all the diseases that have escaped vaccines to prevent them. HIV comes to mind.

My friends and family in the US are in various stages of COVID vaccine completion. The variance is largely because of their age, profession, and which state they live in. What is reassuring to me is that for my US community the debate is not whether to get the vaccine but, rather, when.

The conversation about the vaccine is very different for my Paraguayan friends. I have not experienced vaccine fear among the Paraguayans I’ve known—which is to say their access to the COVID vaccine is not limited by personal belief but rather distribution.

I connected with all my friends in Paraguay on Easter, an important holiday in a predominately catholic country. I was excited to hear about their celebrations. In Paraguay, the week leading up to Easter is called Semana Santa (Saints Week) and is especially important. It is a time of sharing chipa (a traditional food that’s like a hard cheese biscuit) and enjoying the company of family and friends. Visiting has been limited this year because of continued concern for COVID, but my friends still report making chipa and enjoying the company of family.

When the topic of COVID came up, one of my friends said, “Estamos acá en la lucha, en Paraguay no hay vacuna, a nosotros es imposible recibir la vacuna…primero tiene que ser por las personas saludes, por los militares… y después recién por nosotros, dicen que van a inmunizarnos, pero no sé…por nosotros acá nuestra lucha es esperar la vacuna y quedar en casa. (We are struggling here, in Paraguay there is no vaccine, it is impossible for us to get the vaccine…first it must be for healthcare workers, for military personal…and then, after, for us. They say they’re going to vaccinate us, but I don’t know. Here our struggle is to wait for the vaccine and stay home.)”

This friend has been studying online since the pandemic began. She hopes to someday work in healthcare, but she is not able to go to the hospital to continue her clinical training for fear of catching COVID. One of her uncles was hospitalized for 15 days for COVID (he is doing well and made in home for Easter). Many of her family members caught COVID this March, but only the one uncle ended up in the hospital.

One of the things that continues to strike me about my Paraguayan friends is an unwavering optimistic outlook even though COVID-19 vaccination in just beginning in their country. My friend’s comment, “Here our struggle is to wait for the vaccine and stay home” struck me. She said it in a matter-of-fact tone that did NOT hint at frustration but, rather, exuded unwavering patience.  In thinking about my friends in Paraguay, I began to wonder if the closeness of families (not just emotionally but geographically) is a protective factor against feelings of isolation I’ve heard from many of my US friends. My friends in Paraguay either live with their parents and extended family or on the same block as them; compare this to my friends in the US whose families are spread out across distant states. This comparison reminded me that even though this pandemic has touched lives across the globe our shared experience is also a highly personal experience shaped not only by our uniqueness as individuals but also by the culture of the society in which each of us live. 

In the World With COVID-19: COVID-19 Continues to Test Our Resilience and Flexibility

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Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original post here.

When I joined the Peace Corps in Paraguay, we had two mantras: resilience and flexibility. Those words would take on an infinite number of meanings during my service. Spending twenty-seven months living and working in a new language and culture challenged me more than anything ever had. It also allowed me to forge some of the deepest friendships I’ve cultivated, and it pushed me to become a better self. 

Resilience is a word tossed around frequently in medical school, just as in the Peace Corps. The two endeavors have in common a series of obstacles to hurdle. However, “flexibility” faded from my vocabulary when I became a medical student. I first brushed the word aside when I began my premed classes, for which I measured exact amounts in my science labs. As I entered medical school, each minute became precious and tests with multiple choice answers almost erased the idea of flexibility from my mind. Then, COVID-19 arrived. School moved entirely online and everything that had been normal for medical school became a memory of the good old days. 

It’s been about nine months since my classes went online. My friends who work in the emergency department, where I worked before medical school, look tired. Their faces are chapped from wearing masks and face shields. They haven’t been able to see their coworkers’ facial expressions since the pandemic began. My classmates and professors look tired too, on Zoom. My parents, siblings, and friends also look weary when we chat on WhatsApp. These past nine months have been nothing but a test in both resilience and flexibility. 

Resilience is defined in many ways, but I think of it as the ability to endure and still find joy in the little things of life. This past Thanksgiving, I was cheered to see the Zoom collages of families and atypical feasts a Thanksgiving without travel cultivated. I’ve been amazed at how well Zoom can connect us for classes and how easy it makes project planning. While I miss my classmates’ physical presence, I don’t feel disconnected from them because I know they are in their homes studying for classes and STEP (first medical board exam for medical students) just as I am. What’s more is that we can Facetime or WhatsApp at any time. When time is scarce, video calls do afford the benefit of decreased travel time. 

I am surprised to see how flexible medicine can be. Physicians are finding ways to deliver healthcare to their communities even with COVID-19 limiting their options. Those physicians in global health have had the unique opportunity to look at home with a new eye and explore how global health is not only going to different countries but, also, working with communities of new arrivals in their own country. The rise of Zoom has also opened a door for students and physicians across the globe to share ideas and have conversations we might not have had before COVID-19 limited our ability to travel. 

As we look forward to global news that a vaccine to COVID-19 may become available relatively soon, I dream to start my clinical years on time and physically in the hospital. 

Even with the good news, however, I know that we cannot easily predict what will happen in March when my clinicals start. The expectations I have for clinicals, therefore, are largely from watching the students who started their clinicals last spring because they showed that despite setbacks, medicinal learning can adapt to the ongoing challenges of a global pandemic. And while my colleagues, friends, and family look exhausted after these months of weathering the COVID-19 storm, I see the power of their resilience and I am grateful to remember that the adventure of life requires flexibility as it unfolds. As I transition from the primarily academic to the more clinically-focused years of my medical training, remembering flexibility is important.