Medical Miracles

As much as some people believe that doctors are god, we are not. We are fallible like any other human. We are not all knowing, not all seeing, nor all powerful beings. We rely on our extensive knowledge base (with the ability to look up what we don't know), our physical exam findings, lab and imaging results, and how well the patient responds to different treatments. We often objectively manage patients in situations of uncertainty by covering our bases. This translates into throwing multiple medications at our patients and hoping that one of them was the right one to treat the underlying disease. It's not an ideal way to practice medicine but sometimes it's the best we can do. However, I now know what it feels like to be in the position of my patients' families having personally been faced with this difficult situation.

I will never forget the moment in class on Dec 22 when I received a message from my family that within 24 hours a family member went from being in their usual state of health to being confused to being admitted to the ICU, unresponsive and intubated. Despite extensive blood work, cultures, imaging, and even a lumbar puncture doctors STILL had no idea what was going on and a discussion about DNR (do not resuscitate) had been initiated . What could have possibly happened? How is that no one could figure out the etiology of such a severe and rapid deterioration in an otherwise healthy person? Sometimes our tests fail us. Sometimes everything comes back normal and it can be difficult to reconcile these normal test results with the seemingly dying patient in front of you.

I was shortly thereafter excused for the holidays and it is my philosophy that one must keep on living. Subsequently, I tried to disconnect for some much needed rest and family time. On Christmas Eve, as a gesture of good will, I decided to accompany the in-laws to Christmas Mass. Having grown up in a secular Jewish household, I had never been to mass and was curious. As we sat in the pews, nestled between strangers, I receive a message that my loved one was no longer intubated, but still unresponsive. Dammit, what if this is permanent. Despite being present for the service, I found myself distracted by the children fidgeting and crying nearby, and even more distracted by the thoughts in my head. "We will now take a moment of silence for prayer to heal those who are ill" said the priest. The room fell silent, the only sound the occasional creaking of pews as everyone bowed their heads in prayer. Praying was never something I did regularly but when in Rome; what did I have to lose? I closed my eyes, and like a nervous teenager about to ask someone to prom, said: "Um so I'm not sure if anyone is listening but uh well there is someone I would like you to help...obviously you know who. But...yeah, I would really appreciate it and it would mean a lot to my family. Thanks for listening." It was far from eloquent but I felt comforted nonetheless that there was a chance that I had been heard.

The rest of my evening was uneventful. I awoke Christmas morning to open presents and enjoy the festivities. After breakfast I checked my phone and I had received another message that my loved one was sitting up eating breakfast, completely back to normal. No one knows what exactly was the cause, nor what was the cure. With that comes the unsettling worry of could this happen again, but for now all is well. Whether it was due to divine intervention or stellar medical management or some combination of both, I think we have had a true Christmas miracle.

My First Delivery

"PUSH!" I hear from outside the room.

I run over to the board only to see it's my patient and she's at 10cm.

I open the door to the room to find my patient already pushing, all the tools needed meticulously splayed out on the green blanketed table.

"We have a gown for you, here. It's your turn."

I gown up quickly, put on my white sterile gloves,  and gently make my way over to the patient.

She has her feet in the stirrups, legs fallen to the side and a bright light shining on the exposed area. No baby yet.

She begins to scrunch her face and I see the numbers on the nearby monitor rising. A contraction.

"PUUUUUUUUUSHH!" Yells the nurse. We all count "1, 2, 3, 4"... all the way to ten, repeat it another two times and as the contraction eases of the patient has a chance to relax. Her husband clutches her hand excitedly as the moment of getting to meet their first child draws ever closer.

Another contraction. As she pushes again I can see some tiny tufts of hair for a brief moment and then they are gone. With every contraction that goes by, I see a little more hair and a little more of the baby's head, until finally  the head no longer disappears back into the vaginal canal and stays permanently visible in between contractions. I hold one hand against my patient to help support her delicate tissues and the fingers on the other hand along the baby's head. For every contraction, with the guidance of my staff, I applied gentle pressure to help control the speed at which the baby was coming out. With one big push the whole head is out. I quickly feel around the neck for a loop of umbilical cord. Thankfully there is none. As she pushes again the baby rotates sideways as they always do and with one final push the baby comes rushing out into my hands. With the support of my staff we ease this new baby onto my  patient who is now a first time mom.

"Congratulations! It's a girl"

She begins to cry and her husband eagerly cuts the umbilical cord after we have clamped it. The baby finally begins to cry forcefully and goes from a shade of worrisome blue to rosy pink; a new little human starting it's first day in our great big world.

Finding life in death

"We are ready to turn off the machines, we know he won't come back, we don't want to prolong this anymore"

Every inch of me wanted to run. Run far away from that room. And yet, as if possessed by another being I calmly asked "Do you want me to stay or would you like this in privacy"

"Stay" they all said simultaneously.

The nurse came in and turned off all the monitors, all the IV drips, everything but the respirator. The family stood at the bedside each member holding a one hand of their dying relative and holding each other's hands forming a complete circle. They stood this way for several minutes, but it might as well have been an hour. Time froze. I looked out the window at the nursing station - the monitor was flat lined. The respiratory therapist came in to turn off the ventilator that kept his chest rising and falling.

I had spent all morning helping to order labs, check vitals, adjust the respiration rate, every little thing I could do to give this person a fighting chance. I couldn't understand how yesterday they'd been completely well, and now today leaving this world.

As soon as the button was pushed, the staff left and the room fell silent. No one moved, we all stared. The chest was still. He was gone. All eyes slowly turned towards me.

"Is he gone?"

"Yes," I replied softly. "He's gone"

The family erupted in tears. The nurse came in with tissues for everyone and she started crying. I held hands, shuffled tissues around, listened to stories and thoughts and feelings. I turned to offer one woman a tissue and she replied: "Oh no I'm trying to stop crying," she smiled through sobs.

I took back the boxes and flipped them upside down so the tissue was no longer accessible.

"Ok, there!" I said smiling.

Everyone laughed. A true genuine lighthearted laugh. Exactly the kind of light humor we all needed in that moment. I then felt a tap on my shoulder.

"Tissue?" a family member handed me a box. I didn't even know I was crying.

I'd never seen someone die before. I always expected death to be dramatic, creepy, eerie. And yet everything felt so natural and calm. As the family slowly trickled out I was alone with the body. I took his hand. I was stunned by the fact that it was still warm, in contrast to my cold shaky hands. I squeezed it tight and whispered "Do know you were very loved? I never met you but I had the privilege of saying goodbye. I hope you are happy wherever you are now."

After everyone left I snuck into a transport elevator and cried for 10 minutes, wiped my eyes, and went back to my clerical work with my face red and eyes puffy. Everyone knew I had been crying, I could feel the stares and tried to ignore them. After bidding the evening staff goodbye I headed home. As I meandered towards my front steps lost in thought I stumbled over a notch in the sidewalk. I look down and see a mighty stalk with flowers growing out of it. With all the crazy weather we'd been having and the Autumn frost, these purple flowers bloomed from a crack in the sidewalk. A new life in the midst of death. 

Room 31

*Please note that the age, diagnoses, genders, and all possible identifiers have been altered for patient protection. Any resemblance to real life is purely coincidental*

Sweat is dripping down my forehead as I dash through the ER, chart in hand. I have no idea who this person is, I was just told to grab the chart for room 31 on my list. A last name and a number. That's it. The last patient we have to see during rounds this morning. The one thing between me and breakfast.  I can hear the many pages flapping as I run, barely masking the sound of my belly growling for food. I've got the vitals, I've got the labs, I hope I left enough space for the physical exam section. This should be quick - in and out, admit to the floor. I gently slide open the door and sneak into the room.

My staff is sitting by the bed. Why isn't he examining the patient? I glance down at my list and it says "51 year-old male; perforated appendix". Well I've seen plenty of those.

"We will do everything we can to make him comfortable. I just watched someone I love go through this and if I were them I would have done the same thing. Surgery just isn't worth it", my staff says gently.

What does he mean it isn't worth it? This guy is young. Surgery is what you do for young people with appendicitis, especially perforated appendicitis.

"I just don't think in your condition surgery is right for you. You want to enjoy a certain quality of life and keep your dignity. I think surgery would take that away from you."

What the hell is he talking about?? I discretely open the chart and start flipping through pages. "Metastatic brain cancer". Oh my god. No no no no. I've just walked in on THAT talk. I've never seen one of these talks before. No no no this was supposed to be a simple appendicitis case. Get consent for surgery, fix the problem, send them on their way. Breathe. Just breathe. I try to calm down and look back at what's going on.

"So how much time do I have now? Before I was told months. I  had plans," the patient says with tears welling up in his eyes.

"We can't predict these things...but I wouldn't say more than a few weeks. We'd like you to sign something that says we won't take any heroic measures if you stop breathing or your heart stops. We think it's best."

The surrounding family members start crying as he shakily signs the paper. I robotically dart out and come back with Kleenex. My staff continues to sit and tells the patient that it was very nice to meet him and we will make all the arrangements with palliative care. They shake hands and the staff gets up to leave. The resident, who I never even noticed enter the room, was standing behind me. He abruptly walks out. I quickly answer a few of the family's questions about when the patient will be brought upstairs etc etc and then go to meet up with the rest of my team.

I  approach my resident: "Um excuse me... so just to be clear I don't think I got the entire impression and plan-"

He sighs and shakes his head, grabbing the chart out of my hands. He quickly fills in the remaining information. "This patient is going to palliative care. Nothing left for us to do. You need to be quicker and catch what we say", he says snapping his fingers. He hands me back the chart and walks away. What the hell just happened.

The Life of an Internist

Having had a few weeks on the floor, I can only truly see now how much I have left to learn. Coming up with a complete list of possible diagnoses, examining patients, and writing up all the appropriate documentation takes me hours, whereas my staff seem to do it effortlessly. It will come with time they told me but it almost seems impossible at this stage to imagine myself working as effectively as they do. I'm trying to take it one day at a time but it's hard not to regularly feel a little bit incompetent.

So far internal is exactly as I've expected it to be and nothing like I've expected it to be. I've been blessed with amazing staff who really value team work, wellness, and maintaining a good rapport. The patients, like in any setting, a mixed bag. The type of work - namely daily physical exams, charting, calling specialists for consults is exactly what I expected. What I didn't expect is the complexity of the cases managed on our floor and so much exposure to dying patients.

On a regular basis we do sit around a table, and as a team brainstorm diagnoses and possible issues, and occasionally jot down teaching points on the white board (House style). It is wild how differently patients can present for a given disease compared to how we learned about them in our textbooks and lectures. The cases we sometimes have are particularly complicated because they've already been worked up by family doctors and specialists to no avail. Now they end up in our care, much further down the line in their disease process and it is up to us to continue investigating and help manage the many health and social issues patients may experience.

That was something I found equally surprising; the number of older patients that come in because of an incident (such as a fall or an acute pneumonia or even caregiver burnout) that has left them in a state of health where they can no longer return home to their primary residence. They are then stuck in a difficult position of being in the hospital (when there may no longer need medical management) awaiting placement in a rehab facility or group care home. It's a phenomenon I expect to become increasingly prevalent with the aging population. It's difficult to manage on a systems level because there simply aren't enough resources and beds out there for our patients. We can't send patients in this condition home because it isn't safe, but then we also have people stuck in the ER who need to be admitted for care but can't because there are no available beds. This also leads to congestion in the ER, increased wait times for a bed, and undue stress on both the healthcare workers and patients alike.

I was also stunned to see how complex the doctor-patient relationship can be and how it can evolve as the disease process evolves, and as the patient nears discharge. I had a patient who started off very cooperative and pleasant. We had a good trusting doctor-patient relationship, however, as we got ever closer to discharge, most likely out of fear, this patient began to be more belligerent, angry, and even started sharing with me racist sentiments about other colleagues. Soon I became one of the few people this patient would be compliant with and it was very difficult for me to balance continuing to nurture this relationship while standing up for my colleagues and team members as they were the subject of discriminatory discourse.

Lastly, I did not expect to have as many palliative patients on our floor as there are. I have seen about 3-4 deaths in the first few weeks. You come in one morning and you see their room being cleaned and you just know. What I find hard compared to previous hospital exposure is it's not just one short encounter with these patients. You are seeing them, deteriorating slowly every day, sometimes for weeks. I find it harder to not feel as emotionally connected, I mean I see these patients more often than my own family. Names in the obituary column of the newspaper that were once strangers are now names that I can put to a face, whose journey I know all too well. For the first time in a long time, I find myself lying awake at night thinking about some of the stressors of work and the difficult patient encounters I had that day. I think it will take a bit of time to adjust and be able to sleep more peacefully. But for now, thank goodness for friends and exercises - my two pillars of support. 

And So It Begins

Tomorrow. Tomorrow I am officially in 3rd year. I will have responsibility for patients. I know I will be supervised, but still, they will be MY patients. I'm both excited and terrified. The learning curve is going to be steep and although I know I am prepared for what lies ahead of me it's hard to feel like I am actually prepared. As of tomorrow, I will be working about 12 hours a day in hospital as part of a team. I can't remember the last time I truly felt like I was part of something greater that really made a difference in peoples' lives. I look forward to experiencing everything that this new life will have to offer, both the beautiful and painful moments.

To my friends and family reading this, you knew this time would come. No matter how busy I get, you still hold an incredibly important place in my life. I wouldn't be here without your love and support. I'm going to need that love and support more than ever. You know I've never been the most confident person but having you all in my life has helped me find muster up enough confidence to move forward. You have helped me regain my footing when I feel like I have slipped and am falling uncontrollably. I am so sorry that I will have to miss important life moments of yours. Parties, weddings, etc. I'm sorry I won't necessarily have the same amount of time to give to you as before. Please understand that I do not value any less our relationship and that if you really need me, I will find a way to be there and make time for you. It may be at some weird hours but I will find a way.

To my colleagues, now we are going to need each other more than ever. We will all be in the trenches together; fighting for our patients, fighting against the negative aspects of the culture in medicine, and growing into the professionals we all want to be someday. I look forward to getting to know so many of you in a greater capacity and learn from you. We are all in this together.

The house is almost clean, the laundry is almost done, all food for the week is almost ready. I stare at my freshly washed white coat, still pristine, white with inexperience. Never in my life have I more looked forward to wearing out a piece of clothing.  

Selflessness vs. Selfishness: Where to Draw the Line?

Nearing the end of my five months exposed to the clinical environment, this theme of selflessness has come up in almost every rotation. "To be a good doctor, you need to be there for your patients 24-7" my surgery mentor had said to me. This resident sleeps about four hours a night for the last four years, surviving on four large coffees a day and two large meals. They explained to me that only when you are are there almost all the time can you truly monitor your patients' statuses and capture deterioration early. But what about their health?

During neurology I watched in awe of an incredible, compassionate doctor that was there for their patients at least 12 hours a day and took money out of their own pocket to open their own clinic to care for even more patients. Despite unimaginable hardship in their personal life, they handled it with grace and continued to give their patients exceptional treatment. But what about their health?

In my rotation through ophthalmology I watched numerous doctors push through 60 patients in one day when they were only supposed to see 40. Between emergencies and other people handing off patients, the workload was insane. To accommodate everyone, the average appointment time was between 2-5 minutes. Even with these short appointments, most patients wait between 5-6 hours for to be seen because of delays. The regulars know to bring books and food to last them the day. For the doctors, it is the norm to start at 8 am and not get to eat lunch let alone use the bathroom until 4pm. When I asked one physician why not just cut spots to plan ahead for emergencies, they replied: "I could cut spots but then these patients wouldn't get seen. Some of these patients have glaucoma and need regular follow up. If they can't get an appointment, they get lost to follow up and without proper care could go blind. I could take my lunch for 30 minutes at noon but I can't bring myself to do it knowing some of these patients have already been here for 3 hours". Many of these delays are due to failure in equipment - scans not working, instruments being out batteries, etc. With budget cuts they are not allowed coloured printers to so they cannot make copies of patient scans (and they do not have scanners). What about everyone's health here? I asked what the biggest issue was and they said a lack of staff. However, no one wanted to take a paycut to hire another staff member.

We know the system is broken. But at what point should it become an individual doctor's responsibility to compensate for it? The lengths they go to for their patients is incredible but at what cost? To what point should we praise people for sacrificing their own health for the good of others?

When I think about that lifestyle and making those kinds of sacrifices, I don't know if I want to do that. Does that make me selfish? Heck I don't know if I can do that. Is it wrong to want to give 110% in every interaction but when I need to eat lunch, stop for a 20 minute break leaving my patients waiting? Or would that make me less of a good doctor? As a young medical student preparing to enter clerkship I am scared of this choice that I will inevitably be facing; who is more important? Them or me? I suspect the answer is some sort of middle ground, but will the culture even allow me to make that choice? Even more worrisome, will I be penalized for it? For the time being, as I sit surrounded by textbooks and notes, I will stop everything and enjoy my dinner. Savour every bite, every spice, and try not to think about it.

Just like real doctors

As I look in the mirror of the hospital locker room, the figure adorned in a white coat, stethoscope, and more IDs than boy scout has badges stares back at me. Pens and granola bars are shoved in every possible pocket, bulging in all directions. I feel like a child trying on my mother's high heels and dress; it is almost comical how much growing there is left to do before these will fit properly both inside and out. After getting lost in the dimly lit labyrinths of the hospital basement for 10 minutes, I finally find my way to emergency room and spot the top of my attending's head above a pile of charts. Hurriedly I rush towards him and he says "Neurology consultation, room 7. Go!" and hands me a chart. All that is written is "40 year old female with headache, blurred vision, and difficulty speaking. Please assess". A fellow medical student and I approach the ER waiting room and call her name, beckoning her to follow us. Just like real doctors.

The conversation begins as always: "What brings you here today?". As the story unfolds, I jot down everything that could potentially be relevant to the diagnosis. Facial pain, ear pain, no nausea/vomiting, so on and so forth. Thoughts and questions to ask appear like birds flocking to a pile of breadcrumbs; uncoordinated and chaotic. Did I forget anything? What else am I missing? We complete the neurological exam to the best of our abilities. Neither of us could elicit reflexes in the left knee or ankles. Is that just us? Or is there actually a problem there? But how does that relate to headaches? Think brain, think. We finish our examination and run back to find our attending.

He carefully sits down and reads through our chart; I'm happy to see we made less mistakes than yesterday on our first day. "Did you ask about a history of migraines?" Crap. I knew I forgot something. "What was her blood pressure? Always important to note the blood pressure when someone comes in with headaches". Where in their chart did it say her blood pressure? I can't remember. I jotted down a few more things to on my already exhaustive list of "things to read and study tonight".

We are babies taking our first steps into the medical world; surrounded by padded mats and watchful doctor parents excited to see our progression. Knowing all of this exists doesn't make it feel any less scary. Falling is just as scary when you can't fully see that the padding is there to catch you. Almost overnight I've gone from sitting in lectures learning about the different anatomical structures to looking in eyes and ears and suggesting tests. It's exhilarating and exhausting to be the newbie thrown into a sea of experts. But the good news is you learn how to steer that ship pretty damn fast and, most importantly, you learn to watch out for icebergs.