Tag Archives: Resilience

The Doctor Pronounced Them Dead, The Doctor Was Me

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

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

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

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

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

The Winter Doldrums

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

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

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

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

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

Maybe Tomorrow

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“Maybe tomorrow you can be discharged,” the doctor leading my team said to the patient. I’d lost track of how many days in a row he had said that.

The patient had cancer and was undergoing treatment. Did you know that chemo is poison? We use it hoping to destroy cancer before we destroy the person who has the cancer. Chemo saves lives. Chemo causes all kinds of side effects. Chemo often works. Chemo doesn’t always work.

This patient was neutropenic which means that they had no white blood cells to fight infection. No white blood cells to fight infection means even the wimpiest infection could kill them. To avoid death by infection, they needed to stay in the hospital for IV antibiotics and monitoring every time they had a fever.

We couldn’t find the cause of their fever. No source of infection. 24 hours without a fever, “Maybe tomorrow you can discharge, you just need to be 48 hours without a fever to go home,” my supervising doctor said to the patient.

The patient’s red blood cell count dropped so they needed a blood transfusion. Were they bleeding? “Maybe tomorrow you can discharge, if you don’t need another transfusion.”

 They also had a rash. Was that from chemo, cancer, or something else? It was a really uncomfortable-looking rash. Blisters and red all over their torso. “Maybe tomorrow.”

The “maybe tomorrows” dragged on. All the patient wanted to do was go home. They wanted to have some control over their life. They wanted to feel the breeze on their cheeks. They wanted to live. They wanted to see their friends and family. But cancer is a tricky beast. It takes one’s freedom and lands one in the hospital more days than anyone would ever choose.

But, at last, tomorrow did come. We were all happy when the supervising doctor said the patient could leave the hospital. The patient was excited to go home. No one mentioned that it was only a matter of time before they’d be back to start another string of maybe tomorrows. Sometimes there’s no point in saying things that everyone already knows. No need to speak the unpleasant into existence. It will come when it comes.

The patients and families on the cancer wards are among the strongest people you’ll ever meet. Their strength is like the endurance of ultramarathoners, not sprinters. Their strength is one of days running into weeks running into months. Counting the years. Their strength is one of setbacks and small victories. Of bodies changed and freedom lost to be reinvented. Their strength is keeping hope for tomorrow while knowing that it may never come.

The Social Determinants of Health

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I was walking home from a series of hard shifts. My mind slid back to the first code I ever worked. “Code” is medical slang for when you do CPR and try to get someone’s heart to start again after it stops. My first code was a trauma-code. The story was that the patient lost a literal game of Russian roulette. The injury they had from the close-range bullet was not compatible with life. But the patient was young and when their heart stopped, the doctor overseeing the case didn’t pronounce them dead right away. Their heart didn’t respond to CPR; they died.  

That code was years ago. I hadn’t thought about it too much since it happened. Medicine is full of sad stories. I was surprised that the memory of the code entered my thoughts as I walked home. I wondered why I was thinking of it. I realized quickly: I was angry.

I don’t often get angry when working in medicine. The more common emotions I have on the job are excited, interested, happy, annoyed, exhausted, and sad – sometimes within the same interaction. I’ve only been angry a few times in my ever-lengthening medical career. I wasn’t angry at my first code, so why had I thought of it when I was angry?

On that day when I remembered my first code, I had cared for a patient who was dying of advanced heart failure even though they had the unblemished skin of youth. At first it would seem my current patient and the patient who died during my first code had nothing in common except an early death. But as I thought about it, I realized that they had more in common than it seemed at first.

Both patients would die harsh deaths. The code was fast, and the heart failure would be slow. And while both patients had easily observable health conditions, I found myself wondering if they were dying of those conditions or if they were dying because they were victims of something much greater. Could their deaths have been avoided if society hadn’t pushed them down so many times in their short lives? Were they dying of disease or of the social determinants of health?

The social determinants of health are non-medical factors that influence health; they’re the social and structural realities that shape how people interact and live. The social determinants of health include access to education, food, and secure housing. They include neighborhood exposures (the positive like puppies and playgrounds and the negative like violence and drug misuse). They include skin color, first language, sex, and gender. The list goes on.

I was angry because there was nothing more I could do for the patient with heart failure, just as there had been nothing more I could do for the young patient whose heart stopped all those years ago. Society had failed them. Collectively the two patients had experienced racism, the jail system, drug use disorder, mental health struggles, unfair treatment by employers, barriers to education, and likely countless other obstacles that I did not uncover during my short interactions with them. The patient dying of heart failure was difficult. They didn’t trust the healthcare system and they were profoundly unpleasant to work with. As I learned more about their story, I came to understand that while it is never okay to be mean it is also sometimes easy to see why a person could become mean. This patient had been knocked down so many times throughout their short life that it seemed all they knew how to do was fight. And, unfortunately, they were fighting for their life. And while they had not yet acknowledged it, they were losing. Would it be months before they died? Maybe a year or two because they were young? Maybe they’d be a miracle case and live much longer. I, however, don’t count on miracles.

I was angry because I thought the healthcare system was the last part of society to fail my patient with heart failure. I (and my team) tried to build a case to make them eligible for advanced heart failure treatments, all of which have strict criteria. The criteria are strict because all advanced therapies for heart failure are complex and require incredible collaboration between the patient and their care team, otherwise they fail to work. Among the options for some patients (not all) is heart transplant which has even stricter criteria because organs are scarce. In the end, the patient I was caring for was deemed not a candidate for any advanced therapies. They were not a candidate because they showed a consistent record of disregarding medical advice and missing their follow up medical appointments and prescribed medications.

After days of long conversations with the young patient with heart failure I understood that it wasn’t just personality that drove them to fight against medical advice. It was a fear of death, a desire for independence, and a long history of mistrust built on a life of the system failing them. There were many negative social determinants of health which had worked against them their whole life. I was angry because what is done can’t be undone. Just as death cannot be stopped when it comes calling. It’s unfair when and how death calls; it’s a metaphorical game of Russian roulette.

Being angry about the social determinants of health doesn’t solve them, but sometimes being angry is a place to start. And so, on that walk home and for a little while after, I let myself be angry. Part of writing this post was sorting out why I was angry. The next step is figuring out what can be done to address the social determinants of health. They are numerous and complex so there isn’t one solution and they’re slow to change. The young patient with heart failure reminded me that while I’m focusing on learning the science of medicine right now, I can’t forget the public health and community work I did before I jumped into residency. I can’t forget because when I’m an independently working physician, my patients won’t come to me with just disease. They will come to me with life stories that influence every aspect of their medical care.

Yes, I Can

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I listened to a song about a job interview that went poorly on repeat while I struggled to complete a new workout that I’d written for myself that day. Perhaps the song about the interview resonated with me because I was in my own transition or, perhaps, I just liked the beat. The workout would have been easy for certain versions of my past self. However, recently I’d led a life that didn’t involve intense workouts like this one and, so, the workout was challenging me. “Back to the beginning,” I thought.

I couldn’t ignore the metaphor of my physical fitness and learning medicine because the parallel captured the sentiment I’d been hoping to write about as a reflection of what, exactly, medical school had been like in a broad sense. I’ve had a few months between finishing my medical school classes and starting residency. It’s been a time of celebration and doing things I didn’t have time for during school and won’t have time for during residency. I’ve also taken time to reflect on my medical school experience. “What exactly was the utility of medical school?” I’ve asked myself often during these months of the happy stillness between.

You can guess what medical school was like on a superficial level – it was school. I spent hours studying and hours listening to people instruct me on all kinds of things. I spent more hours practicing skills as varied as suturing cuts shut in the operating room to writing patient medical notes. I attended lectures, engaged in simulated patient interactions, and I worked with real patients and physicians in real hospitals and clinics. I took written exams of various lengths that were proctored by various organizations. Through these actions I learned how the body works and breaks and how we try to make bodies function better with medications and interventions like surgery.

Yet, while learning about the body and how to improve health was the backbone of my medical school learning, it wasn’t the heart of it. The heart of medical school was the exercise of continually starting at the bottom, a place of not knowing much, and climbing to some place of better understanding. Medical school is a lot like the process of doing a hard workout after not working out for a long time and being unable to finish it, then engaging in a few weeks of intent and thoughtful exercise, and finally being able to do the original workout and more.

Medical school taught me that I can learn anything with time and effort. The hardest concepts can be cracked. The first year, I struggled to understand how the body worked. The second year, I expanded my knowledge from how the body worked to how it can go wrong and what we can do about it. Then, years three and four, I learned more about how different specialties in medicine address different diseases and injuries. Each year built on the year prior and then expanded beyond what I knew to things I didn’t yet know. Each time the curriculum expanded I felt like I was starting over. Much like starting in the beginner exercise class and working my way to the advanced class…repeatedly.

I bet you’ve had the experience of riding the rollercoaster of being excellent then falling to subpar and then, through sheer will, climbing to a place of excellence again. And if you have experience doing that in any area of life, then you can imagine what medical school is like. Because it’s just like that. Every month or so you start at the bottom of one area of medicine and climb to the top just to fall again and start the process all over in a different area of medicine.

Medical school is an exercise in being mediocre with a drive to be extraordinary. Each lesson helps move your personal dial from mediocre to better, but there’s a catch. Medicine is founded in science and research and, as such, it’s forever expanding and changing as we (humans) learn more. And so, there is no possible way to ever know everything. To be a physician is to be forever learning while also mastering the knowledge that you explored before. There is no end to medicine, no time when you can’t get better.

Medical school taught me that I can learn anything while I can’t know everything. It taught me not to be intimidated by an obviously hard road, but to take it one step at a time just like I take my plank exercises after a long time not engaging my core. Medical school taught me that experts are built with time and effort. It also taught me that experts remain humble and equally aware of the things they know and the things they don’t know. Medical school taught me that I can do whatever it is I choose to do if I’m willing to put in the effort. The heart of medical school for me was learning that when faced with a challenge to think “yes, I can” instead of “maybe it’ll work out.”

At Long Last, I Know Where I’m Doing Residency

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Last time I wrote, I was waiting for Match Day (the day graduating medical students find out where they’re headed to residency). I’m now on the other side and know that I’m heading to Richmond, VA for internal medicine residency! I’m stoked!

Having never applied to residency before, I wasn’t sure what it would be like when I started the application process last April. Now that the year-long application cycle is done, the thing that surprised me most about applying to residency programs was how hard it was to decide which program/location I wanted to go to most. Let me explain a little bit about how the residency application process works to put my challenge into context. Then I’ll explain my process.

Applying to Internal Medicine Residency

When applying for residency, medical students rank all the residency programs where they interviewed from their favorite to least favorite, and residency programs rank all the applicants they interviewed from their preferred to least preferred. Both the applicant’s list and the program’s list are called “rank lists” because they rank their options in order of preference. Then, a computer program attempts to match the students with the highest program choice on their rank list and the programs with preferred applicants on their rank list – if you’re familiar with sororities then you’ll realize it’s the same system used to place new recruits in sororities.

There are many internal medicine residency programs each with multiple positions to fill, so entering internal medicine is less competitive than entering a specialty with fewer available residency positions (for example surgery or radiology). What this means is that, if they have between 10-15 interviews (the magic number that almost guarantees a match somewhere), US-based MD internal medicine applicants (like me) have a lot of control over where they go for residency. According to my research, most US-based MD students will end up in one of their top 5 internal medicine residency choices. So, I knew the order in which I placed the top 5 programs on my rank list had a large influence on where I’d end up for residency.

Challenge of Forming My Program Rank List

Having the above background, here’s my processes for creating my rank list (realizing every medical student has their own process). You might think that the programs (themselves) would have enough unique features to guide how I ranked them. However, the more I researched and thought, the more it seemed that all my programs were more similar than disparate when it came to almost everything except location. Using program culture as gathered from my interview and academic rigor together, I was able to determine which programs I would rank in my bottom third (well below the top 5). I still had to put all the programs in order from my first to last choice with special emphasis on the top 5. In other words, I felt confident that I’d become a good physician regardless of which of the programs in my top two thirds I attended. I also came to realize that the location could potentially change the course of who I would become as a physician and my future life. This did not simplify things but rather made them more challenging.

Being a geographically flexible person, I interviewed with programs mostly on the West Coast and in the mid-Atlantic region (plus a few outliers) with no preference for one region over another. The geographic clustering came out of a long list of criteria I used to define the ideal place where I’d like to live and was how I determined which residency programs to apply to in the first place. As I continued to research after interviewing, I found that these same criteria (which I hoped to use to rank program locations) were often mutually exclusive. For example, I wanted a location with a diverse patient and physician population that was also close to mountains. My list of comparisons went in a similar fashion with all programs missing several criteria (just different ones). I realized the hard truth that I simply couldn’t have it all when it came to location.

“Great,” I thought. “I can’t have it all when it comes to location and I’m confident that any program in my top two thirds will teach me to be a good physician…Now how do I put them in order?”

Having exhausted external factors to rank programs, I turned to self-reflection on my personal values and how those values might be upheld in the different program locations. Reflecting on personal values is a funny exercise and it’s not one I’ve had time to do since starting medical school (however it was a large part of my life as a Peace Corps volunteer so it’s quite familiar to me). It’s an odd and uncomfortable place looking inward and trying to make sense of the thoughts and feelings zooming around your mind. It’s uncomfortable in a different way than standing in the operating room for 8 hours or getting up at 4am to go to hospital so you can see patients are uncomfortable. I felt lucky and privileged to be in a place where I had enough choice over where I’d go to residency to grapple with something like personal values as a key part of my choice, but it was still uncomfortable.

The curious thing about values is that they form the core of who you are and while they shift with time my experience suggests they don’t change dramatically. Despite going around in circles trying to decide how to rank residency programs, I found myself most valuing the same things that sent me to Washington, DC for undergrad so many years ago: weather, quality of life, diversity, and politics. (I also value challenge, but residency is always challenging so that wasn’t helpful). So weather, quality of life, diversity, and politics are what ultimately determined my residency rank list order. All that hullabaloo to decide on a program based on 4 things that have nothing (and yet, perhaps, everything) to do with medicine.

Like many things in life, I won’t be able to go back and see how attending a different residency program would change the course of my career and life. But, in addition to being thrilled with where I matched, I’m at peace knowing I had a chance to look inward before I cast my dice this time. I find that in America we spend a lot of time looking outward, yet often the answer comes from within and not from without. I try to break this trend and make space to sit uncomfortably for a while to find the answer within when it comes to big decisions. I was successful this time around.  

Nothing to Do but Be Happy

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The water is so clear it’s like looking through nothing to see the creatures and plants that are stuck in small salty pools contained in the rocks until the tide comes in again. I’m on the edge of the tide, so an especially high wave crashes on the rocks and skuttles across the other pools and seaweed to reach the pool absorbing my gaze. The longer I gaze into the pool, the more I see and the more the patterns swirl. The wind ripples the surface of the pool, such that I must be patient if I want to take a picture – timing my snapshot for when a high wave isn’t threating to dowse me, and the wind isn’t distorting my image.  

I love walking along the ocean’s edge and gazing into the tidal pools – each is a mini world populated by the randomness of being caught in a rock hole as the ocean slides toward center, letting its edges dry for a few hours. The creatures in the tidal pools are waiting for the ocean to return but, until then, they live their lives and try to avoid the birds and others searching the pools for their next meal.

I can’t help but identify with the little stripy fish in the tidal pools. My life, too, is in the tidal pool phase. The daily requirements of living and being a responsible adult remain, but I’m suspended in time – I’m caught between being a med student lost in her studies and residency. These days I’m finishing up my last medical school credits, by design some of the easiest courses I’ve taken. I continue to strive to remember the medicine I know and solidify and learn new things. But mostly I’m enjoying the salty air while I wait to find out where I’ll do residency.

As my husband pointed out recently, “There’s nothing to do but be happy.” It’s hard as a planner to not think of the future. But, when you’re in limbo there is no future only now, the moment. Once I know where I’m destined to train as a resident there will be hundreds of things to sort out – but none of these things can be tackled until I know where I’m headed. I have about a month of not knowing and shortly after that I wrap up my last rotations of med school.

The stripy fish darts around the tidal pool, at first worried I’m going to eat it. It becomes bolder and still as I wait; its attention span is shorter than mine. I peer into the pool. We stare at each other. The sound of the waves is my soundtrack. The sun is sparkling in the sky. By some happenchance of luck and delivery on the part of my planning nature, 7 of my last 12 weeks of medical school rotations are in Puerto Rico, which is even more awesome when you realize these weeks fall exactly in the worst of New England’s winter. I’m studying while I’m in Puerto Rico, but I have plenty of time to explore the island.

Nothing to do but be happy and be present. And it’s not a hard task with the sun shining down on me, the waves and wind fluffing my hair with salt spray, and a party of palms and plants wearing their best green, red, and yellow dancing at the edge of the beach which abuts a turquoise sea. Nothing to do but be happy, what a wonderful situation. Eventually the tide will come in and I’ll be tossed into the wake of wrapping up school and starting residency, but that’s the tide chart of a different day.   

Battle at the Kitchen Sink

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Disclaimer

This is a throwback story from my Peace Corps days. I’ve been thinking a lot about Paraguay lately and decided it was time to share some of the stories I didn’t share when I lived there. I always find myself thinking about Paraguay when the weather gets cold in New England (my current home), because I miss the sun and the mango trees Paraguay reliably had year-round.

Setting

The last quarter of my 27 months in Paraguay as a Peace Corps volunteer. Which is to say, I was very comfortable. At that point, Paraguay was my home.

Battle at the Kitchen Sink

It was grapefruit season. I remember this because we had gone foraging for grapefruits. In Paraguay there’s a citrus season (there’s also a season for every fruit you love… passion fruit, avocadoes, mangos, pineapples…). The Peace Corps volunteers who came before me had shown me how to hunt for grapefruits, so it was one of the first things I showed the new Peace Corps volunteer visiting me that weekend. It was her first time traveling beyond the training community in Paraguay where all Paraguay Peace Corps volunteers in my era spent their first three months learning language, culture, and other skills they might need once they arrived in their sites (where’d they work for 2 years). She was visiting me to learn about what it was like to transition from training to working in Paraguay.

After our lesson on foraging grapefruit, I showed the visiting volunteer (just as the Paraguayans had shown me) how to peel the grapefruit properly. This involved using a knife to carefully cut the peel off in a spiral, leaving a thick layer of that bitter white stuff that hides under the colorful part of the peel. I showed her how to cut a little cone-shaped hole in the top of the grapefruit. Then, how to squeeze the whole thing and suck the juice out until the grapefruit was dry. This is how Paraguayans most frequently eat grapefruit and oranges. It is my preferred method above all methods I’ve tried.

We then had lunch. I took the dishes out to my kitchen sink, which was located outside my apartment in the back under a mango tree. I had running water (which was nice) but my kitchen sink was outside – an unfortunate location on rainy days, but perfectly fine on this day. I set the dishes in the sink and then looked around for my soap and sponge. As with all full sinks, the sponge was hard to find. I went to dig under the dishes to see if it was there. Sitting among the dishes exactly where my hand had just been when I put the dishes in the sink, was a tarantula about the size of my palm.

I don’t know your position on spiders. But, living in Paraguay I developed a set of rules for all home invaders. Spiders were included in that list and my rules for them were as follows: they received the death penalty if they were too big and in my home territory (which included my sink), if they were too close to my bed, and if they were too close to the toilet. If they did not violate any of these rules, I was willing to live peacefully together. The tarantula in my sink resoundingly violated the size rule permissible within my territory.

My heart thumbed. I didn’t know much about tarantulas, but it was the largest spider I’d seen outside of a zoo exhibit. I yelped (sound effects are always part of my life) and then promptly went to find my bottle for fighting invaders (obviously I developed rules for invaders because there were many including ants and roaches). My invader-fighting bottle was a rather short (maybe 10 inches in length) plastic bottle that was square and originally contained my favorite yogurt in Paraguay.

I banged at the tarantula as hard as I could. Of course, having never fought one before, I was jittery.

I missed.

The tarantula climbed out of the sink, plopped on the ground, and started marching toward me.

I didn’t miss the second, third, and fourth time I tried to hit it.

Luckily, the new volunteer was at the front of the house and did not witness this battle, though I told her about it promptly thereafter. All in good time. She would likely battle her own home invaders during her years in Paraguay.

Reflection

These years since I’ve returned to the US have been challenging as I plodded through pre-med classes and several jobs and now, medical school. I’ve encountered many challenging situations with people who act tough and aren’t particularly nice. Most, if not all, of these tough-acting people have never battled a tarantula. Knowing that they lack tarantula experience has put my interactions with them into perspective. Afterall, toughness is relative, like all attributes.

There are many times in medical school where I’ve thought of my Peace Corps days as reminder that the current challenge is not harder than ones I’ve encountered before. Resilience comes from knowing where you’ve been even if others don’t. It comes from applying skills you learned in the past to new scenarios in the present. Most challenges can’t be overcome with a plastic bottle weapon. But, having a plan and being ready to implement it even when surprised can be applied to almost anything.