I Miss You

Sometimes you get lost in medicine. Lost in slides and sections, in cells and pathways, in diseases and pieces of parts of people until you almost forget what real life is. What your own life is. Patients you sort of expect to die. Knowing that it is coming doesn't always make it easier but you accept it as part of the job. When you lose people in your personal life however, it often hits you like a freight train, whether you expect it or not. As I sat down for group work this morning, I noticed an email in my inbox with an obituary update. When I opened it, I became cognizant of the date; today's date. I felt a sinking feeling in the pit of my stomach and I realized that I'd forgotten the two year anniversary of the death of one of the most important and influential people in my life--my cousin. One of the only family members I was close with aside from my parents -- a precious commodity for an only child. He took his own life after a long battle with depression and an obstacle course of struggles that had been placed before him. Life just wasn't fair to him.

In medicine, sometimes you spend so much time compartmentalizing things and being stoic for your patients and peers that you forget to be vulnerable within yourself. You forget how to be vulnerable period. Ironically, my cousin played a huge role in helping me learn to be vulnerable and helped me get to where I am today. He taught me how to ask for help, and more importantly, how to open the Pandora's box within yourself that you are afraid to see, and how only with that kind of introspection can you learn and grow.

No matter how busy you are with papers and patients, always remember to take the time to tell the people closest to you that you love them and appreciate everything that they do for you. Spend time with them because you never know when they will be taken away. And no matter how much you try to hide from loss by burying yourself in your work, like puddles to a hole in your boot, the pain will always find you.

A glimpse into the future

I almost watched a life leave this world last week. And it hit hard because this time next year the life of others will gradually become my responsibility. It was my first day of a desperately needed break, I was headed out to a night on the town. As I stepped off one bus and waited for another, I watched the commotion across the street as numerous firemen and paramedics struggled to save a life. One of the paramedics was vigorously performing CPR while another was attaching the defibrillator. They all stepped back as the machine did its thing and CPR was resumed. This repeated itself until a viable rhythm was restored and they began to load the patient into the ambulance. People around me also waiting for the bus watched with worried eyes and fidgety fingers. As we got on the bus, people turned to their phones and back to their own worlds but I could not.

Bit by bit, I can feel myself starting to assume that doctor role and all of the challenges that come with it. I have always been someone who has always appreciated the 9-5 routine; being able to turn off your brain as soon as you leave the door and go back to your personal life. That doesn't exist in medicine. Life and death wait for no one. Medicine isn't just a career, it is like a spouse. You gradually learn more about each other, grow together, fight together, cry together. You have duties to uphold 24/7. In the same way you make yourself available to your partner, you accept being on call and all that comes with it because the return is entirely worth what you put in, but that doesn't make it much easier. I can't even begin to imagine how I will feel in a year from now, but I feel like I'll be ready. 

The Miracle of Life

Earlier this week I had the privilege of being present for a C-section. It was probably one of the most existential moments I have ever had because I was a C-section baby and I was finally going to understand how I came into this world. As I stood in my scrubs and gown pretending to look important, I felt as if there was a blending of time and that there was no past present or future. Only heartbeats. When I shook the husband's hand I saw for a brief moment my father in his eyes. In his shifting stance and unsettled gaze, I pictured my own parents 26 years ago; what they must have been thinking and feeling.

The first and only time I had ever witnessed a birth prior to this experience was about 13 years ago, when I was at sleep away camp. As the free-spirited nature enthusiast I was, I ran away into the woods to escape the company of my fellow human counterparts. As I sat down by a tree, I noticed a deer approaching. The animal hopped around, haphazardly, with seemingly little coordination or purpose. I noticed a brown bulge emerging just under the animals tail and thought to myself jeez constipation in the wild is rough. As the bulge grew, my expression changed from amusement to awe as this once thought to be bowel movement took the shape of deer. This deer, a mere 15 feet away acknowledged my presence and continued delivering her baby. It almost felt like she wanted me to be there. I sat motionless, watching as mother nature unfolded her secrets to me. After a few minutes of straining, the fawn fell into the grass, the amniotic sac broke, and the small little creature uncertainly began moving, trying to stand. The mother licked the fawn gently until the little one finally made it to its feet and they both walked off into the forest like nothing had even happened. It was incredible. We as humans make such a fuss about having children, and this was just so natural and humble. The whole thing took about 15 minutes. I never thought I could find the same sense of peace in our man made world but much to my surprise, I had a similar experience standing in the OR that day.

"Alright we're starting," said the doctor to the team as the first incision was made. The room was calm, but not silent. Everyone was tending to their specified tasks, talking merrily as they went. I knew we were getting close when I was finally able to see tufts of black hair and with one good pull the head was completely exposed and shortly thereafter the baby was out. The climax of the event was when they removed the surfactant and the baby (and mother) began to cry. The baby was rushed off to be assessed, cord blood was taken, the placenta was weighed, and an inventory of all medical supplies was taken to make sure nothing was forgotten inside the patient. Surprisingly, it all felt so natural. I know we have been indoctrinated from such an early age that birth is a medicalized act (and almost all elements of society really). But amidst all the gowns and gloves and forceps and harsh lighting, the beauty of nature still came through. The miracle of life was no less incredible.

Surprisingly, the longest part of the procedure was suturing the mom back up, which again felt unusually natural and serene. Obviously this experience was a best case scenario and not all births go this smoothly. But as I stared into this tiny little face that had only been in the world a few minutes, I just found it so mind-boggling that life even exists in the first place. That we are here. That I am here. In the wild, I would never have made it for at least 20 different reasons, and yet here I am. And that one day, I will be reunited with the miracle of life when I have a child of my own.

The D Word: A Brief Moment in Palliative Care

It's time to talk about death. The elephant in the room. The inevitable fate of everything alive on this earth. Someone once said life is a sexually transmitted terminal illness. In today's visit at a palliative care unit, I had the opportunity to explore the edge of the universe, the end of life that everyone feels so uncomfortable talking about. It was beautiful, heavy, and made me look inside myself in ways that I never expected.

From the moment I walked in, I immediately felt this odd sense of calm and peace, and I certainly hoped that the residents on that floor felt the same way. The walls were pastel colors, decorated with art. The staff were jovial and smiley as they bounded through the hallways. As I made my way to the conference room, I  could see into the patient rooms that had the doors wide open. I passed by dozens of patients, mostly lying motionless in bed. Some had family members around them, tears streaming down their face. I tried to avert my eyes out of respect, and walked quickly to my destination and sat down.

Our preceptor arrived and began to debrief us on what is palliative care. And to know about palliative care, you need to know what health is. According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. But really, health is subjective; its definition varies from person to person. But from what I can tell, what health means in this context is giving people the opportunity to participate in as many activities that they find meaningful as possible. The goal of palliative care is to really give people the best possible quality of life during their last few moments by minimizing pain/symptoms, and giving people as much autonomy as possible. Non-pharmacological treatments are of utmost importance - you cannot use medication as a substitute for human care. It is really the little things, like having that cup of coffee every morning or spending time with a pet that play a critical role in helping patients die in peace. It is the one time where you really can't sweat the small stuff, because the small stuff is sometimes all you've got.

Fidgeting in my chair like an antsy child waiting for recess, I mustered up the courage to ask a few questions. What made you go into palliative care? I asked unblinkingly, my pen and pad in hand. Our preceptor said it was the honesty that captivated their interest, and the complete acceptance of death unlike in any other specialty in medicine. After my visit today, we learned that there are many positive things about death, namely that it is an opportunity to look back on your life and acknowledge everything you have accomplished. An excuse to resolve fights and salvage relationships with the people closest to you.

A lot of patients, unable to accept their own impending mortality put so much time and energy in trying to prolong life, that they miss out on really good quality time doing the things they love and making amends with the people they love. People who have accepted their fate may take the time they have left to fulfill things on their bucket list like skydiving. Towards the very end, they may have one last party with their loved ones and then die peacefully in the sleep, still with bits of confetti in their hair. Remnants of a life well-lived.

We were told that we were going to have the opportunity to talk with one of the patients dying of cancer. My heart sank. Of course it had to be a cancer patient. And of course the patient was dying of the exact cancer that I am at risk of getting, and have been worrying about the last few weeks.  It was time. My hands clenched and clammy, I entered the room and sat down in front of the hospital bed. The patient was propped up in bed, seemingly alert. Their voice was soft, their breathing labored, but full of life nonetheless. We were able to ask a few questions and get a sense of the shell of this person's life. Their sense of humor when answering questions was delightful and really helped calm me down and make me feel at ease. Laughter is the best medicine, even for ailments that one cannot cure. All in all, the patient seemed satisfied, accepting of their condition, and taking it day by day. We asked if there was one piece of advice for us aspiring young doctors, and we received the following: Live your life the way you want. Don't let anyone tell you what you can and can't do. The patient then asked us to turn off the lights and rearrange the room exactly as they wanted it. I couldn't help but smile; never too late to live life the way you want to.

When I got home, put my stuff down, calmly sat down, and burst into tears. Every fiber of my being was accepting that my death was inevitable. The tears of the realization of my mortality came splashing down onto my lap, rhythmically, like the labored breathing of the patient I spoke with earlier. As I sobbed, I felt consumed by loneliness and emptiness.  God I hope this isn't how I go, especially not in my early 40s or 50s. One can never really know when and how death is coming. Only that it is coming.

In medical school, not only do we have to come to terms with our own human weakness and the vulnerability of our individual self-discovery, but we must come to terms with our own death, and at a much earlier age than most. Before leaving the unit, I had asked our preceptor what helped them sleep at night and they said accepting that they too will die one day. Being fully accepting of their own mortality. I guess I have a little while to continue grappling with insomnia before I sleep easy. But when I do, boy will I ever sleep. 

The Origin and Insertion of Life and Death

I'm almost done classes in my first semester of medical school (hooray!). I have a few exams to get through before I am able to take some time off and decompress. I sat down at my desk, as often do, grappling with what to study next. I settled for anatomy. To brush up on things I may have forgotten, I started re-watching some cadaver videos and I felt the familiar sinking feeling welling up inside of me. A profound discomfort, like an elephant sitting on my chest (and not the angina kind). I should be desensitized to this, why do I still feel this "crainte"? Why do I still find it so uncomfortable to look at? Am I the only one who has this? I paused the video and pushed aside my oatmeal to really think about this. All that came to mind was "I'm staring inside a human". And then it dawned on me how detached we are from death in society. How non-normalized it is to see death, and even more, a dead body. We have become experts in the experience of death and loss, and grieving and all the customs and feelings that come with it; that is something we know.  But we never SEE death. Even at open casket funerals, the bodies are neatly dressed and wearing more make-up than a super model on a runway to look as much alive as possible (or as fake as possible). But there is still something eerie and raw about staring at a body. The terrifying serenity of just how still it is. How the chest doesn't rise and fall rhythmically and the fingers don't gently bob with each pulse from a vibrant beating heart.

I think what I hate most about anatomy is how it deconstructs you into parts, taking all the humanity out of you until you are reduced to nerves, muscles, organs. Until all your uniqueness is gone (aside from the occasional individual variation in positioning, size, and location of your components). How can people be so similar on the inside and yet so radically different on the outside? The same parts with a few alterations in the brain can change you from Mother Teresa to a school shooter. To want to save our world or destroy it. Even more terrifying, to think that these same parts are found with you and me, within people we love. That the diseases that won the battle against our donors could one day take us too. And that we all someday will look like the cadavers on that metal table. Exposed, vulnerable, and that spark that makes us us completely extinguished. I'm not sure what about peeling back the pectoralis major or staring into the left main bronchus brought about these feelings but I know one thing for sure from everything I've learned so far and that's how fragile and strong life is. How cruel and precious it is. And how often doctors and nurses and frontline healthcare workers are standing in that profoundly terrifying and humbling nebulous grey area between life and death. And hopefully with  a little more training (who am I kidding, A LOT more training),  I can give life a fighting chance. 

Why I had to fail before starting med school

Now this may seem like an odd title, but with a few months of medical school under my belt I can reflect on how things are going. I can check in within myself and see how happy and stressed I am. Overall, it is good news. I'm really happy (I can't remember the last time I felt this intellectually satisfied), have still kept up almost all the activities I did before medical school, and for the most part, am not too stressed (most of my stress in fact comes from things that have absolutely nothing to do with school).

A week ago I walked out of a midterm with that sinking feeling that I didn't do as well as I had anticipated, and maybe even went as far as failing. I later found out that I did just fine but at the time I couldn't shake the feeling of foreboding. Looking back on my high school and college self, who used to cry at any grade below 80, I've realized how far I've come to be very content with simply passing; a complete redefinition of success. During my undergrad, I encountered a few little speed bumps but still always pulled it together and never really had to deal with failure. It wasn't until I struggled with impostor syndrome in my Master's did I completely fall apart and put myself back together in a different way. A better way.

As a pseudo retired perfectionist, perfectionism is an ideal I strive for but within the realistic limits that life imposes on it. Instead of an end goal, perfectionism is now a driving force inspiring me to do my best, whatever that may be, and never at the expense of other important variables in my life. My strategy for exam studying is no longer to know as much as possible to get the highest grade I can, but to UNDERSTAND as much as possible and retain as much important clinically relevant information as I can that will serve me well in my future practice. I feel like this strategy has made these last few months more pleasurable. I take breaks, nights off, full days off, and sometimes even full weekends off if I need it. Self care is now more important to me than anything and even though I will forever be below the class average with this attitude, I'm more than okay with that.

Although I have had sustained academic success since starting med school, I have failed in other areas of my life, especially my relationships. When anxiety reared its ugly head in the face of a tsunami of tasks to complete, my relationships suffered until I adapted. And I know this isn't the end. I have many more things to fail at, especially before I make it onto the wards where I'm seeing patients and lives are literally in my hands. And even then, I will still fail at times and that's okay because I've learned that how you handle failure and learn from failure is a form success. And I've been feeling pretty successful lately :)

Hands

Med school does funny things to you, like make you think about the little things at night (like hands). I really hope I'm not the only one who has this. So far one of the many beautiful things I have learned about (and thought about probably too deeply) is the importance of hands.

Not only are they unique to each individual, but in my eyes are one of the most important components of a patient interaction. You shake a patient's hand to greet them when they step into the room. Simply observing someone's hands can tell you so many things about possible medical conditions they may have and give subtle but important signs about their overall health. The ridges, lines, calluses can you tell you about the kind of life they have lived and perhaps where they work.The rings they wear tell you where their passions lie. Hands can be used to tell you about a person's strength in all senses of the word. They communicate various feelings, thoughts, fears; people talk with their hands. And what better way to send a message than by holding someone's hand, bringing them comfort, and demonstrating compassion. Never underestimate the importance of hands.