Tag Archives: Resilience

Hospital White

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

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

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

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

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

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

No Alarm Today

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

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

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

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

Reading the Crystal Ball I Don’t Have

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“Will I make it until then?” the patient asked. They were referring to the cancer treatment which was their only chance at long-term survival. Their cancer was everywhere yet, likely, treatable and maybe curable…but only if they got treatment. Their social situation created roadblocks. To be approved for chemotherapy in our medical system they had many hoops yet to jump through and hills to climb.

“I don’t know. I hope so,” I said. My answer was genuine.

The patient signed. They closed their eyes for a long blink. They looked down. They slumped in their chair. Their stuffiness (from lymph nodes so large it was hard for them to breathe) made their breathing loud. The room felt small.

“You’re strong. You’re a fighter. You told me recently you wanted to do everything you could to beat this. We are trying to get you there,” I said. These were truths but they didn’t mean much.

This post could easily be about the inequities of our healthcare system. This patient was a victim of those inequities. But whether everything is going right or going wrong, the truth remains that neither I nor any physician know the future. We have probabilities and expert opinions to guide us. We have previous similar patient cases and the risks/benefits of medications and other treatments to consider.  But as much information as we have, we do not have a crystal ball that tells us exactly what is to come. We make educated guesses which are often right but also have a higher-than-desired chance of being wrong.

What is to come, the outcome, is exactly what my patients want to know. And, if I were in my patients’ shoes, that is what I’d like to know too. When thinking about my patients’ futures, I try to balance hope with reality which (for me) manifests as honesty. If I’m worried, I say so. If I’m confident in their chance, I say so. And, if I’m unsure then I will explain the contrary things I’m considering and why I’m undecided.

I didn’t know if the above patient would make it to chemotherapy. The oncologists (cancer doctors) were not offering this patient treatment when the patient and I had the above conversation. The oncologists felt that the patient had too many other things going on to start chemotherapy. Chemotherapy is hard to endure. One must be physically strong to survive it. One also requires lots of social support.

“We are trying to get you treatment. Remember the next steps we talked about?” I reviewed the follow up appointments and things lined up for the patient before they saw the oncologists.

The patient nodded. They looked out the window. “I’ve been here [the hospital] so long,” they said. They’d been in the hospital for about 6 weeks.

“I know,” I said. “You still have a long road ahead.”

I wish there was a crystal ball like in fantasy books that would reveal my patient’s futures. But part of life is not knowing exactly where it’s going. Part of being a physician is becoming comfortable with uncertainty. Perhaps that’s one reason why physicians study for so many years. Day by day my predictions about my patients’ futures are more informed and more often correct. But, on the opposite end of the spectrum, even the most seasoned physician is sometimes wrong about a patient’s future.

When the patient and I had the above conversation, their survival was unlikely but possible. The sliver of hope that remained is why I reminded the patient that they had told me they wanted to fight their cancer. That is also why, when the prediction is tragic and my patients say they believe in miracles, I say “I hope you’re right.” No physician wants their sad-outcome predictions to come true. Yet, we are obligated to provide our best guess even if it is bad news. As physicians we also plan for all the likely outcomes.

While I reminded the patient of their desire to fight, I also reminded them that if things changed there was an alternative option called “comfort care*.” I reminded them that they could change their mind about their goals at any time. I reminded them that we (their care team) were here to help them on their journey regardless of where it led them.

The only certainty about my patients’ futures is that their care team will be there no matter what. And while patients’ care teams change with work shifts and specialty, the purpose remains the same: to help as the unknown unfolds. Being a physician hasn’t given me a crystal ball to see the future. But being a physician has given me hope. While there are illnesses no human body can overcome, the body is incredibly resilient. Further, the human soul is a force of bravery and grace even when faced with insurmountable challenge. And when I witness these human strengths, my faith in life is renewed.  

*Comfort care is end of life care where the focus is treating symptoms rather than prolonging life. For example, if a patient has anxiety, then we will treat it; or if they have pain, we will treat it. Comfort care is offered to patients who have conditions that will kill them and either there is no treatment or the patient declines treatment. In comfort care we don’t treat chronic conditions such as high blood pressure or diabetes because the focus is to make the patient’s remaining time as comfortable as possible rather than trying to make them live as long as possible. Comfort care is the type of care that people receive in hospice. Hospice is end-of-life care for people whose life expectancy is 6 months or less. Comfort care is not about hastening death, but it is possible that people will die sooner on comfort care than with traditional care because the goal is no longer to cure illness.

The Last Stop on the Bus Line

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I looked out the window. I’d been here before, almost 2 years previously, it was the end of the bus line. Arriving here meant I’d taken the wrong bus. There were several buses with the same number that had overlapping routes but ended in different places. The last time I’d caught this wrong bus was shortly after I moved to my Peace Corps volunteer site in Paraguay. At that time, I was still learning my community and Paraguayan culture. The first time I ended up at this bus line end, I wasn’t sure how I’d get home. The uncertainty made my heart beat faster. I asked the bus driver for directions; he had been able to help. It took several hours but I ended up home, unharmed though slightly frustrated I’d mixed up the buses.

I’d learned so much since I first visited this bus depot accidentally. Since then, Emboscada, Paraguay had become my home. Emboscada was, perhaps, the first place I’d ever lived where I was certain it was home. As the days that added up to the previous two years had unfolded, I’d found a community and made friends. I’d been a schoolteacher and connected with youth over music, English, and dreams. In my Paraguayan community, older friends had died, younger friends had married, and I’d been to parties and celebrations of every variety and magnitude you can imagine.

I looked out the window and I laughed. I was an expert, yet I still took the wrong bus and didn’t realize it until I arrived here at this bus depot. In a few short months I’d leave Paraguay. I’d say “goodbye” to the home I’d found and created. I’d return to my native country and start the Doctorhood Quest. I laughed because arriving at this bus depot wasn’t scary like it had been the first time I ended up here. I knew it would take a few hours to catch the right bus and travel to the bus stop in front of my house. I’d arrive home eventually. My little Paraguayan house would be waiting for me.

This event was about 8 years ago, yet I’ve found myself thinking about it a lot recently. I’ve been reminded of it because I recently turned a page in the Doctorhood Quest that is like what I was turning in my Peace Corps service at that time. I feel settled in my role as a resident physician. I feel comfortable with what kind of doctor I am. I am happy with what I’ve accomplished and look forward to my future goals. I had similar sentiments about my Peace Corps service while I waited for the right bus to pick me up at that last bus stop.

It might seem premature to have such contented feelings about residency. But I know that the remaining 20ish months of residency will be over soon. I have so much to learn in those remaining months. Yet I know I will learn what needs to be learned. For the first time in my journey of becoming a physician, I’m confident that I’m where I need to be. I know how to get home even when I take a wrong turn.

Being an expert isn’t about always catching the right bus, it’s about knowing how to find your way home when you catch the wrong one. It’s about being calm even when things are unexpected. It’s about embracing the journey. It’s about laughing at yourself because experiences that make you grow and challenge you also put you in ridiculous situations.

How ridiculous is it to take the wrong bus after having taken the right one 100s of times? “Quite ridiculous” is the answer. But mistakes are what make us human. We learn from mistakes, even if the lesson is simply a reminder to laugh at ourselves. Life is serious, but not so serious that we can’t appreciate its absurd moments.

Listening to the Birds

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As our appointment was ending, I congratulated the patient on getting fitted for new hearing aids earlier that day.

“Yes, we are looking forward to the new hearing aids,” the patient’s spouse said. The hearing aids would be shipped to them soon. “They love hearing the birds. They know all the birds’ names.” The spouse paused. “I miss them telling me which birds we hear. Now I’ll say, ‘Hear that bird?’ and they’ll say, ‘What bird?’ because they can’t hear it singing.”

As my patients like to tell me, “Getting old is not for the faint of heart.” Being not as old as them, I don’t know what it feels like to be their age. But, having worked with hundreds of people as they age, I’ve had the opportunity to observe what getting old is like. Perhaps the most interesting thing is that no two people experience aging the same way. Despite the variation, there are some truths I think are universal about aging: 1) one cannot do everything at 80 that one could do at 20, 2) life experience cannot be erased, and 3) attitude matters.

The happiest old people I’ve met are those who embrace aging as life’s reality. They are flexible and willing to adapt their goals and expectations to meet their ever-changing body and mind. For some people this means that they give up the independence they once cherished. They turn in their car keys forever, accepting that their slow reflexes and poor vision have made them dangerous drivers. For others, they let their children or other trusted people help them navigate new technology that they don’t understand because navigating that technology is essential for life admin (like bills) and connectivity (communicating with others). Others relinquish their identity as the one who cares for everyone else and accept help from people they previously cared for. Going from the person everyone depended on to the one that depends on everyone else is one of the hardest transitions I’ve witnessed my patients make. Whatever transitions people go through as they age, they are huge and require self-reflection and grit.

And while aging is a lot about the mind, it is also about accepting that our bodies change with time. The most resilient old people I’ve met are the ones who are flexible not just with how they approach life, but also with what they expect of their body. Many elderly people remain healthy and independent until they die. But even in healthy old people, their bodies are not what they were at 20. They simply move slower and, perhaps, are less physically strong. The happiest old people I’ve met know that their slowed body is not a sign of weakness, but a sign of wisdom. The happiest old people I know, continue to challenge themselves in new ways that they could not have imagined in their youth. They do not have the same expectations of themselves that they did at 30 because they already mastered being 30.

As people age, it is common for them to interact with the health system more than they did in their youth. Regardless of how many diseases and ailments an elderly person develops, I’ve noticed that the ones who endure the hospital and their doctors’ appointments best are those who accept that caring for an aging body takes lots of time. They dislike spending days in the hospital, but they also know that sometimes that is an adventure they must undertake. They weather their healthcare interactions with inspiring patience and endurance.

My clinic day ended hours after the patient who couldn’t hear birds anymore left. As I walked to my car, I thought about how much I loved listening to birds sing. I thought about how hard it must have been for that patient to realize, perhaps all at once or perhaps over time, that they couldn’t hear the birds anymore. I hoped that their hearing aids would help them. What a strange goal to have, the goal to hear birds again. The goal of regaining something previously taken for granted. I wondered what my goals would be when I was that patient’s age. I hoped I had as much perseverance as they had.

The Strength of a Mother

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Her son was dying. Yes, we were keeping him alive in that moment, but he was dying anyway. We could not fix what was killing him; it was simply too progressed. There was no way out except death. We knew this and, perhaps, he knew it too as the soul peeking through his eyes became more distant and the fear that had been there was replaced by blankness. He was too sick to make his own decisions. The decision about what to do fell upon his wife. Having to make decisions about the end of her husband’s life tormented the patient’s wife. He was a fighter and he had always told his wife he wanted to live. The patient’s wife could not imagine life without her husband. She felt alone. She feared past demons reemerging when he left her. Yet, the fact remained that this wife’s husband, this mother’s son, was dying. As the plan stood, he was dying slowly.

It was under these circumstances that the mother and wife sat down to talk with us, the patient’s care team, to discuss how the plan could change to reduce suffering. We described the options. There was the option to continue forward as we were; using every medication and intervention we could to keep the patient alive. We explained that this would be futile and would still result in death, but the decision was theirs. The second option was to stop the medications and interventions keeping the patient alive and replace them with medications and interventions to keep him comfortable. We could not predict the future. We guessed he would die within days if we turned off the medications currently keeping him alive. He would die more quickly without medications to raise his blood pressure and transfusions to replace his red blood cells and platelets, but he would not suffer because we would treat every symptom he had from pain to breathlessness and anxiety to insomnia.

After we described the above options, the wife began crying. She accused the healthcare system of missing something. Of not doing everything. If emotions were tangible, then this wife was the physical manifestation of agony. That’s when the mother spoke.

“This is not their fault. I believe them… I believe that they have done everything they can.” The mother paused. “I have cared for my son his whole life. I have loved him and fed him. He is my son. I will not see my son suffer. I do not want my son to suffer like this.” The mother paused again. “My son is already gone. I see it in his eyes. He is not there. It is time to let him go.”

The conversation unfolded between the mother and wife. The care team was there as witness but it was not our conversation. It was not our right to decide what happened next.

“I am all alone. I am afraid,” the wife said.

“You are not alone. You have me,” the mother said. “And if you have me then you have my people because they do what I say. I will stand by you.”

The patient was one of this mother’s children. The mother was old enough to have grandchildren and great-grandchildren. In the days leading to this conversation, it became clear how large her family was from how many visitors the patient had. The mother sat tall and confident. She spoke with sadness and wisdom. She spoke as someone who had seen others die before.

“I will not see my son suffer. Let’s do this together. We will do this together. Let him go,” the mother said. “I know my son. He is gone. You can decide, but I will not visit again because he is already gone.” The mother paused and held the wife’s hand. “We will do this together. We will mourn together.”

The patient died less than a day after he was transitioned to medications to treat only his symptoms. Most of his family had seen him prior to his death. I will never know how the story of the wife and the mother unfolded after the patient’s passing. Yet, I believed the mother when she said she would be there for the wife. From the conversation I witnessed it was evident that the patient’s mother knew more about life and death than most people; she had a knowledge gained over her lifetime. She also knew her son as only a mother could. The guidance and support the mother offered the patient’s wife as the patient died were some of the bravest acts I’ve witnessed.

The Difference of One Day

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The Doctorhood quest is a journey with finite phases.  To reach the next phase you must pass through the hurdles of the previous phase. Like all quests, each phase must end. Now having passed 2 phases, I’ve noticed that the transition between the phases is jarring.

I recently finished my first year of residency, called “intern year.” In the Doctorhood quest, many consider intern year the hardest phase because it’s the time when you begin to practice as a physician and know the least. You are a student one day and then the next day walk into the hospital with your new title of “doctor.” You find yourself with a mountain of responsibilities that you aren’t sure how to manage. It’s a bit of a joke because one day does not make a physician. So, even though you have the “doctor” title starting the first day of intern year, the difference between an intern and a student only begins to emerge as the months drag on. By the end of intern year, you find yourself teaching medical students and realize that you are, in fact, more knowledgeable than you were 12 months prior.

A similar transition exists between intern year and the second year of residency. In my residency program, we even get a new badge declaring us “resident physician” rather than “intern physician.” One day you’re an intern, working under 2-3 layers of senior physicians and the next day you’re a resident with only a very senior physician overseeing your work. As an intern you always have a resident to ask for help. When you’re a resident you’re the one that the interns turn to with questions. Of course, there are people who teach and help you as a resident, but they are more distant and more senior than before. As a resident, you are expected to find answers to many of your questions and you are expected to make many decisions on your own.

On the second day of my second year of residency, a physician who has been teaching residents for years entered the room to lead one of the educational sessions we (residents) have weekly. Before he started his lesson, he acted out strutting down the hall as James Bond does, “Now that you’re all residents you even walk differently. You have that swagger,” he said. We all laughed. A day does not make a physician. A physician is made over years. Today I feel like how I felt during the last days of intern year because the time between today (early on during my second year of residency) and the end of intern year is short. I’ve been questing long enough to trust the process. I know I’ll feel confident as a resident by the end of this year. And, who knows, maybe I do walk the hall a little differently now than I did a year ago. I did, after all, forge intern year and live to tell the tale.

She Must Be Just a Number to You

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“You see so many patients, she must be just a number to you,” the patient’s son said as he watched me perform the official exam declaring his mother dead.

“We care about all our patients and take the best care of them we can. Of course, I haven’t known your mother for as long as you have. You’ve known her your whole life,” I said. I finished my exam. I stated the time of death, gave my condolences, and left the room.

I had pronounced a patient dead almost daily that week. During this patient’s exam my emotions were not the emotions of a son who had just lost his mother without much warning. My emotions as the patient’s physician could not be the same as her son’s. I was sad, of course, but I also knew we had done everything we could for her. As a physician I must balance being emotional and being clear-headed so that I can make objective decisions about how to help patients with their medical challenges.

In medicine we push to the edge of current scientific knowledge, yet we are not capable of magic or miracles. We cannot predict the future and we cannot stop the inevitable. Death is part of life. Since medicine in the science of life it inherently involves death.

As a physician my mission is to prevent and cure disease and reduce suffering. A lot of suffering can happen when a person is gravely ill. Part of my job is to recognize when the fight for life is futile. Once the fight becomes futile, anything we do to prolong life also prolongs suffering. It is at the time of futility that I can offer a path that leads to greater comfort and death with dignity. This path requires a shift from a goal of prolonging life to one of promoting comfort. To stop fighting death is not a decision to take lightly. Further, the decision must be made by the patient or their appointed decision-maker (when the patient is too sick to decide). I can only offer guidance as part of the patient’s care team.

This patient, the mother of this son, had fought for her life. She had maxed out every treatment we could offer. She had failed other treatments. When she was worsening, we called the family to come into the hospital. When everyone who needed to be there was at her side, we turned off the medications and interventions that were keeping her alive. We did this because to keep those medications and interventions going would not save her. She would die regardless. She was suffering. Most importantly, she had made it clear when she was well that she would not have wanted to keep going in these circumstances.

When we turned off the medications and interventions keeping her alive, we gave the patient medications to treat her discomfort. She had pain, shortness of breath, and anxiety. She died shortly after we changed our approach from treatment to comfort. She died peacefully and surrounded by the people most important to her. None of this struggle made her a number. She was a person who had fought bravely and died with dignity. And, sometimes, that is all we can offer in medicine – a place that illuminates a person’s intrinsic bravery and permission to stop struggling.   

I have seen and will see many people die. My role in these circumstances is not a counting role. As a physician I ensure my patients get the best treatment available when there is a fight to have and the most comfort possible when there is no fight left. My role is to adhere to their wishes regarding their life and death as best as I can within the constraints of medicine. These are serious responsibilities that are both rewarding and harrowing. Rewarding because I know my patients receive the best care we can offer and a death as close as possible to what they would want if they had a choice. Harrowing because it is hard to lose someone I cared for and because I feel each patient’s loss, not as a friend or family member, but as a partner in the patient’s battle against death.

Being a physician has made me realize exactly how people aren’t numbers. It is my job to learn my patients’ stories and to partner with my patients to tackle their health goals. What happens to my patients is partially a reflection of how well I did my job and partially a reflection of the complexity of being human. The depth of the patient-physician relationship is part of the reason I chose medicine. My patients’ stories are sometimes tragedies and my relationship with my patients is sometimes difficult, but the opportunity to heal, cure, and reduce suffering is enough to make those challenges worth it. I am grateful for the opportunity to take part in my patients’ lives. Grateful even if we meet under extremely unfortunate circumstances. Grateful even if we meet at the end of their life.

A Letter to My Intern Self

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Dear About-To-Be-Intern Self,

Intern year (as the first year of residency is called) is going to be tough. At times, in fact, it’s going to be downright awful. There will be stretches where you don’t see the sun and can’t remember the last time you felt anything but exhausted. The trend you noticed in medical school, in which current physicians and administrators don’t value your time (and waste it) and then wonder why your mental health is poor, will persist. You will be told by some to do more because “you’re a doctor now” and you’ll be belittled by others because you’re new and you don’t know what they think you should know.

You will be impressed by how your health deteriorates intern year. You are welcome to take some of the blame for your decline if you’d like, but the truth is that everything about intern year is the opposite of the wellness advice we give our patients. From your sleep schedule to your stress level, or from the food the residency program gives you to your work hours, there is very little healthy about intern year. It would be misleading to ignore these negative things that will unfold, one way or another, as they have for every intern. They manifest a bit differently for each person, but their occurrence is a guarantee.

Like all things in life, the negative of intern year is paired with the positive of these 12 months. First off, you’re paid – a huge victory after 4 years as a medical student. Your salary will be meager compared to your future salary (and it will be poop if you calculate the hourly rate) but remember that the intern salary is higher than the average annual income of Americans. Second, you are a doctor now. A real doctor. This title, alone, allows you to meet the most extraordinary people and hear their amazing stories. People will tell you things they never told anyone else. Your kind patients and your brave patients will be beacons helping you through intern year.  Focus on remembering the kind and brave patients more than the hard and mean patients; it’s the opposite of what your mind will want to do. I assure you that remembering the kind and the brave will help you more than you realize.

There will be difficult senior residents and supervising physicians; there will also be amazing ones. Take a moment to appreciate the inspiring senior residents and supervising physicians and reflect on why you respect them. You’ll be in their shoes before you know it and you can learn from them. Let the degrading and unkind supervising physicians and residents bounce off you; let them be a lesson of what you do not wish to become. The same goes for the nurses and other staff in the hospital. Nurses will be your biggest nightmare and your biggest savior throughout intern year. A knowledgeable and respectful nurse is gold. Thank the hard working and thoughtful nurses. Learn how to navigate the mean and not patient-focused nurses. You’re a doctor now and, once intern year is over, you’re going to be a team leader. Intern year is about getting ready to be a leader.

No one is good at being an intern when they start. Every intern gets better at medicine, navigating the healthcare system, and working with the interdisciplinary teams of healthcare. You won’t notice how much you’re learning at first. The days will pass slowly and the weeks quickly – before you know it, you’ll wake up and realize that you are a new version of you. You’ll blink and a new July 1st will be just around the corner. Then, intern year will be behind you…forever. I’m not delusional enough to say, “enjoy it while it lasts.” I am delusional enough to say fight for your health (because you’ll need to) during this year and soak up as much knowledge as you can. In the end, intern year exists to help you get closer to becoming the best doctor you can be. Intern year will force you to grow. It will challenge and push you to a new level. Always remember that intern year is finite and only one small phase of the Doctorhood Quest. It will pass.

You go this. I know you got it. At the end, you’ll know you got it too.

Yours truly,

Jett

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.