Days 85-86: Extremis

September narrative medicine prompt: Write a poem about a patient you took care of in the ICU that was challenging for you, describe that experience, how it felt, images you saw.  Why was that particular case hard/challenging for you?

It was an elective surgery
Replacing a worn hip
So she could keep up with the grandkids.
She was a young 80-something year old,
The matriarch of her family,
So alive before her surgery.
When I first met her,
The tangle of cords and tubes
Shrouded her beauty,
No longer alive but not yet dead.
Waiting.
Waiting for family from far away
Wondering why they are saying good-bye.
She wasn't supposed to die.
She was supposed to go home the day after surgery
With a walker and home health.
Instead, she lay in the MICU with tubes
Coming out of natural and unnatural orfices.
How did this happen?
Surgeons claim aspiration pneumonia.
Op note is useless.
So many questions I couldn't answer.
I don't know why she didn't go home.
I don't know how she ended up with me.
Tuesday, post-op day five
The ventilator and pressors are stopped.
She was dead before the epi wore off.
She didn't go home,
She went to the ME
Because we still had no answers.
I listened to her silent chest,
Telling the family she was gone
Even though I knew she was gone
Before she came to the MICU.
I left for clinic,
Feeling empty
And useless.

Day 84: The End

She lays there
Unmoving,
Surrounded by cords, her halo.
Alone,
Her eyes won't follow you:
Unseeing.
She stands in the other world
Crying,
Tethered here by a trach.
Restless;
Why won't he come see her
Dying?
Why won't he let her go
Peacefully?
She no longer lives
Vibrantly,
Mere blips on machines
Marching
Across the blackness:
Vitals
Of a woman who has died
But keeps on living.

Days 80-83: Family

This coming month is going to be all about the family, and it started this past weekend.  My little sister is getting married next weekend which means I'm sweating bullets over the MOH speech I haven't written... It also means I get to spend a lot of time with my awesome family.  This past weekend, I got to be there for the final dress fitting for my sister and go to lunch with her, the moms, and one of her other bridesmaids.  We had so much fun despite the biker rally right outside the door of the restaurant.  Then it was running around getting all the various supplies for welcome bags and jewelry.  Saturday was spent cracking up about "deez nutz" and random scribbles on the backs of pictures.  It was so much fun.  What's even more exciting is knowing that Friday night will be all the siblings and their respective significant others under the same roof.  It is going to be so much fun.

I am thankful for the time I've had this past weekend talking with my little sister and my mom.  I miss getting to hang out with just them sometimes.  I can't wait until LOML and I have a house where we can have guest over to visit.  I want my family to be comfortable coming up to see us, knowing that they'll have their own space.

On that note, I am suddenly nervous about applying for my first job.  What if I'm not as good as I should be?  What if I get too easily distracted?  What if I'm not as competent as people think I am?  The impostor syndrome is kicking in again...

Day 79: Fear

Fear was a running theme today.  There was the family that was afraid of their loved one dying and hanging on to every last bit of control they might have over the situation.  There was the patient who was afraid of how her mother might do without her once she was gone.  There was the fear of admitting that I might have different ideas of the ideal job from what I'd professed even six months ago.  There's the fear that my CV and cover letter are not good enough to send out.  The fear of rejection.  Of not saying the right things at the right times to the right people.  There's the fear of not telling everyone flat out what my goals for my career are.  The fear of how it will be taken.  The fear of being cornered and pushed into doing something I don't necessarily think I want to do right now.  The fear of what expense comes with being true to myself.  The fear that I won't be supported by my mentors or will looked down on for not choosing what they want me to choose.  I am so afraid of not being accepted or being told that I'm turning my back on who I am.  I want to feel like I can choose my own path and still be loved for that, even if it's not what others had dreamed up for me.  This all compounds the fear that I don't take enough time to do all the work I need to do and haven't studied as much for my boards as I think I should.  I base my image of myself on my expectations of myself and am left disappointed when I don't reach the lofty goals.  I keep saying I'll do better tomorrow and then tomorrow never comes.

Days 77-78: In My Element

The last couple of days, I have been back at work on inpatient palliative consults.  I feel like I am back in my element.  I tend to do better when there is more going on, so I have enjoyed being busy.  Getting to spend my day talking patients and their family through difficult situations is something most people shy away from.  I really enjoy it.  Even when I thought I was semi-good at it as a resident, I feel better prepared at this point for the communication required to sit with people through their darkest moments.  I still have a ways to go from a growth standpoint, but I am closer than I was just a few, short months ago.  I feel more comfortable with letting the family lead the conversation which is completely different from how the conversations would run when I was in residency.  In most cases, I was given an agenda for the conversation, and that's what I would stick to.  Now, there is so much more I can do by simply following the patient and their family.  It feels less forced.  I will never be perfect or an expert, but I can certainly do the best of my abilities for my patients.  That is a good feeling.

Day 76: Inner Child

I have been channeling my inner child the last two days.  As mentioned in an earlier post, part of the curriculum this year is trying different self-care activities.  August was art therapy, and I have carried the techniques into my life away from the hospital.  I will have to post some of the more recent acrylic paintings later due to the recent paintings being presents.  What I can show is that I have finally mastered the "shaving cream art" technique.  I feel like it's the adult version of finger-painting wherein you don't actually use your fingers.  You start by spraying shaving cream onto a flat surface (I purchased cheap lunch trays like from elementary school).  You then use a ruler or some other flat edge (I use a large plastic putty knife) to flatten out the shaving cream and make your medium.  Then put drops of color into the shaving cream (gel food coloring for me) and swirl it around with a skewer.  Once the colors are swirled to your satisfaction, you firmly press a piece of cardstock or watercolor paper (must be heavy paper) into the shaving cream and let it sit for about 30 seconds.  Flip it over and scrape the excess shaving cream off the paper.  I also blot the paper to remove any residual shaving cream and wet food coloring before letting it air dry overnight.  What you get is something that looks like this:

  

There were others that I did that weren't as good as these, and there is still room to improve.  It definitely lends itself to more abstract art, but it is so soothing to swirl the colors in the shaving cream to create the images.  Each one is different from the next.  I am enjoying this little piece of relaxation along with the writing and occasionally reading.

Days 74-75: Imperfection

We, as humans, are imperfect.  Our bodies are not meant to last forever.  Disease and aging occur whether we want them to or not.  Our minds are only able to show us as much as we are able to comprehend.  When bad things happen, we either project inward and wonder what we did wrong to lead to the event or we project outward and wonder how others could have done what they did to us.  We try to find blame, and sometimes even wonder if God, or a Higher Power, truly exists, and if so, how they could let such travesty befall us.  We wonder how a Being that is considered so loving could betray us and turn on us.  I, for a long time, have felt that there is no way some Higher Power could exist, especially after the things I was asked to do in the name of love as a resident.  It is truly difficult to understand how a person can, in the same breath, say that they leave it all to God and then ask us to resuscitate their 90+ year old loved one.  It seemed like abuse and a contradiction.

I have been thinking about imperfection.  My imperfections, my defects, the things that I wish I did better or had more control over.  It wasn't until the last couple weeks that I started thinking that the imperfections of humans, our toils, wars, racism, hate, and diseases, could exist in the same universe as a benevolent God.  Then, a few weeks ago, when going on home visits with one of the hospice chaplains, I realized that they can exist.  The chaplain was talking to a man who could not understand how his doting wife could have come down with a neuro-degenerative disease that left her unable to talk or care for herself.  He was angry at God, but felt guilty for that anger.  The chaplain's response was that God did not cause or allow the disease to happen.  He said that we were all made from clay, and clay is imperfect.  Therefore, we are made in the image of God but because we are formed from an imperfect medium, we cannot expect ourselves to be perfect.  He went on to say that because we are formed from clay, our bodies begin to breakdown, to return to its natural form.  Thus, we develop diseases; we age; we die.  It was a revelation for the patient's husband as well as for me to hear the chaplain talk like this, to say that the miracles of healing may not look like what we are wanting or expecting, for in death, we are cleansed of all our imperfections and our souls return to their Creator.  It was a revelation to hear that the things we do to each other are because we are made from an imperfect material and are prone to making mistakes, for doing things that are not always good.  It's in our nature to be imperfect, so why feel like a failure when perfection is not attained?  This does not mean to lose all motivation, but instead, continue to follow the rule of "love thy neighbor as thyself" and "do unto others as you would have them do unto you".  God made us in his image.  If you work everyday to do your best to meet the Golden Rule, then there is no failure for you have done the best with the imperfect material from which you were made.

Day 73: Procrastination

I have spent the last couple of months procrastinating on coming up with a hotel block for the wedding.  It seemed like a tedious task to get bogged down in, so I conveniently forgot about it until I had to actually get something done.  So my plan for today was to start calling a couple places to see what I could get, only to find out that there is a group that is partnered with "the knot" that negotiates the price for the rooms and gives you a list of bids for the hotel block.  If only I'd taken the time earlier on to find this, I would have saved myself a lot of anxiety over what turned out to be a simple task.  I also got a picture on the wedding site and made a registry.  It was relatively painless and quite a bit of fun.  Now to wait to hear back from all the hotels before making a choice, but it's possible even that will be done before next week which is a relief.  We're left with a few other details, but most can wait until after my sister's wedding in 2 weeks!  Overall, a good day of making up for months worth of procrastination.

Day 72: Euphoria

This is the late entry for Thursday.  It was such an emotional roller coaster of a day, I needed the chance to sleep on everything before thinking a touch more clearly.  I am still in disbelief.  I got my first true job offer yesterday.  I am beyond excited, too.  I still feel like I should interview a couple other places, but I so love the team where I am that it would have to be a "too good to be true" offer from somewhere else to tear me away from Winston.  It's a little overwhelming right now thinking about my sister's wedding in a few weeks, LOML and my wedding in a few months, interviewing for jobs, contract negotiation, etc.  I feel a little more confident in myself, but I think it's going to be quite some time before I feel completely settled.  I am glad to have LOML by my side through all this.  I am thankful that we have somehow balanced out when each of us are stressed so that we're not stressing out at the same time.

I also talked with the counselor at group about my worries from my last post.  He referred to my concerns as "signs of growth" and that I was the only person who had truly kept coming back to continue to grow.  I will likely finish out the month, if possible, with going to group weekly, and hopefully by that point will have completed the extra training in addiction medicine treatment that I am doing.  I am honestly not sure how I will use it at this point, but I will see where the road leads me.

Currently taking things one day at a time because there is so much that I need to do.  As they saw, onward and upward.

Days 70-71: 10 Weeks

I have been the hospice and palliative medicine fellow for 10 weeks now.  I have so much left to learn and so little time left to learn it all.  I have a research and an education project.  Surprisingly, one of the areas of interest to me is determining how to best care for patients on hospice who have concomitant substance use disorder.  I did not think this would be an area of interest.  I thought I would spend my life trying to fend off individuals with chronic pain or substance use issues.  There is this mentality that they are headache patients, difficult to care for, and uncooperative.  I can imagine when practicing outside of hospice, it is hard because the data points against the use of opioid medications for chronic pain.  Many doctor shop for the ones that will give them what they want.  It is not always an easy group.  But there is still the possibility that these people will end up with a terminal disease or cancer and potentially getting referred to hospice.  Right now, there is little data and even less infrastructure in place to address the best way of caring for this population on hospice.  Here we find ourselves in a situation where the best treatments for pain are narcotics, and the likelihood for developing pain is high.  Hand-in-hand with caring for a patient with addiction is the concern for family or friends diverting medications from the hospice patient.  How do we make sure undue suffering does not occur at the end of life?  How do we best address the issue compassionately and safely for all involved?  While the numbers of patients we will see that fall into this category are low, they don't deserve to suffer anymore than anyone else.  There is a lot of information that outside of the fleeting euphoria that comes with using, most of the time is spent feeling alone, depressed, and craving the drug of choice.  It is not a happy or peaceful life and compounds the suffering of dying.

I have to admit that I was jaded by my residency.  Many of the people I saw with addiction were not in treatment.  They were angry at the world, and more specifically me, because I was the one who was refusing to feed into their addiction.  I modeled those I worked with who typically took the strong stand of not prescribing any opioids.  Harsh words and curses from the patient were met with the strength of the offensive line in football.  Neither side would give and no one was happy with the situation.  It will harden and embitter anyone.  My hope is that with new training in compassionate communication, I can at least bridge the gap, show empathy, but still be firm in the limitations we define for the care plan.  My goal is to not let someone suffer in their last days, but at the same time finding safe ways to provide them appropriate treatment for their end of life symptoms.  I don't think this is something I am going to figure out in the first five years of my career.  I hope I don't become jaded again.  Addiction is a disease not a choice someone makes on a whim.  Most don't have control over themselves.  It needs the same steadfastness and care as any disease we can tangibly see or test.  I hope I continue to remember that when faced with the devastation of the wake from the disease.

Days 67-69: Work from Home

I am infinitely less productive when I work from home.  Between the animals and chores around the house, there is always something to distract from the work that needs to get done.  Fortunately, I left wiggle room on Tuesday and Wednesday so I can make up and get back on track (only to end up behind again).  This week is my last week of the research rotation for this half of the year.  I am going to miss the extra free time to do things when I want to do them.  I wish I had more time like this.  Sadly, this is not real life.  I have come up with a quality improvement project.  I am not to a point where I am ready to discuss it here, but I am glad I figured one out, and it is one that I had thought of, not someone else.  I think despite it's seeming simplicity, it will likely be more complex than I think.  It will have to be done in pieces.  I also need to get the ball rolling on applications.  I need a couple more people to review my CV and cover letter.  I am nervous and excited.  I feel like there are so many things I need to work on and next to no time to do so...

Day 66: Storm Prep

Hurricane Irma is heading for the east coast, starting with Florida.  While it is unclear what the course will be after landfall, there is concern for lots of rain here.  Fortunately, I feel quite prepared with my "raining cats and dogs" umbrella.  While our likelihood of losing power is low, LOML and I have stocked up on essentials.  We have enough nonperishable food to last us about 3 days, water for us and the animals, and food for the animals.  We've filled up the gas tanks to get into the following week.  It's probably overkill.  The important part is knowing that I am stocked up for working on my hobbies when I'm stuck at home.  Or mentally preparing myself if I'm somehow needed for extra staffing at the hospital should we become part of the evacuation strategy for other hospitals.  I'm banking on the former.  This coming week is going to be very interesting...

Day 65: Higher Power

Today, I think a Higher Power took hold and put me where I needed to be this evening.  I have been in a funk, worrying that I've said the wrong things at the wrong time to the wrong people and completely ruined any chance of getting a job doing what I love in a place I love.  So after getting myself all bent out of shape this afternoon, despite most things pointing to the contrary of my current thought trail, I was contemplating forgoing group this evening.  It is the first time in the last three weeks I hesitated when leaving the house to head out the door.  But I figured nothing would be lost in going.  The caveat here, is I am going on an invitation after my week of addiction medicine.  I am apparently the first person who has taken them up on the offer.  I find it to be my moment of peace in a busy week.  I don't have to be on my phone.  I am present.  There are no expectations, although, I have spoken up the last two weeks.  I get seriously nervous doing it.  But I do it.  And tonight was the first time I really felt like I made a difference for someone.  Someone who was adding to the grief of losing a loved one to dementia.  It was something I could speak to, I could support through naming the guilt and fears, showing a deep respect for the time it takes to care for the loved one, for the strength it takes to be that person's voice.  I could give hope that the person did everything in the best interest of their loved one, and hopefully be able to see that when the darkness of grief had parted.  It was the proverbial 2x4 from the Higher Power that my calling is caring for dementia patients.  That this is where I can do the greatest good for the world's greatest need.  It is such a difficult, dark place sometimes, but to be able to have these moments of deep connection.  The opportunities to educate and support abound.  My sense of self-deprecation and doubt was gone.  The anxiety of the nebulous "I can't do anything right" was replaced with the nervous of speaking up in a group of strangers and yet doing so for something I am so clearly compassionate about.  In the same breath of saying I hate giving the diagnosis of dementia, I could be finding ways to provide hope.  It's hard to see that in the moment of taking away someone's identity and independence, but there has to be some way to shine light in the darkness.  Even if the light only comes from the smallest of candles.

Day 64: Success

This is how I feel right now.  I feel like I can't keep up with all I need to do.  Fortunately, I think if I just start doing what I need to do, and doing the best I can, I will succeed.  I just need to get  into the right mental space.  I'm at the point where I am second guessing my every move.  This happened during geriatrics fellowship, too.  I think it's more pronounced this year because it is the last year of training before I'm set free on the world.  That is the most exciting and most terrifying thought there is right now.  Part of me realizes that there will still be oversight and people to talk to about difficult situations, but there is still a level of gravity to the knowledge that it won't be the continued direct supervision.  I feel like I will never know enough.  Blessing and curse.  Blessing in that a small level of discomfort will keep pushing me to provide the best I can for the people I'm caring for.  Curse is that I will be in a position to potentially never overcome the constant self-doubt.  I need to find a happy medium between constantly tearing myself down and pushing myself to do the best I can.  Until then, I will just keep at it.

Days 60-63: Where Do I Belong?

This weekend was a wonderfully relaxing weekend.  I was able to spend Friday helping out my family when my baby brother's girlfriend developed appendicitis and he needed all our support.  I spent Saturday with my grandparents which I enjoy doing, especially since it's hard to know how many more times I'll be able to do that.  Sunday, LOML and I hiked Pilot Mountain which was a fun little adventure for the two of us.  Monday was spent doing some work and then painting the evening away.  When I was in high school I used to paint spiderwebs on the backs of the AOL CDs.  This time around, I painted a stained glass window which looks similar to the spiderwebs I used to paint, expect the stained glass window is a little more detailed.

It was definitely fun painting it.  I have so many ideas for other paintings to do.  I wasn't sure how it was going to turn out, but am glad it turned out decently.

As for today, well, it was a bit difficult.  Clinic was busy, as usual.  I had to leave early to spend time with an interviewee.  Then went to drinks with some of the faculty which was a little uncomfortable being the only one there that wasn't faculty.  It was another moment where I felt out of place, like an outsider.  I didn't quite feel like I belonged.  I don't know if part of it is the fact that I'm a fellow and not privy to much of the faculty stuff or if it's  something to actually do with not fitting in with the group in general.  As my best friend from college says about her post-doctoral program, got to take it one day at a time.

Days 57-59: In the Shadows

The last two weeks has been spent shadowing the other members of the interdisciplinary team of home hospice.  Nurses, social workers, case manager, chaplain, admission team members, and nurse practitioner.  Each with a different piece of the puzzle of a patient's care team.  Each working together to better serve our patients.  There were some experiences that I had not had before and truly enjoyed.  From getting to sit at the bedside of a patient who was dying and coaching the family on how to provide medications for care.  To the continuous care patient and watching how the nurses and family surrounded her with infinite love and support.  To learning who helps decide if a patient is eligible for hospice and then the admission team who talks with the family about what that means.  Each person works together to keep a seamless level of patient care available.  It was wonderful being able to see it in action.  I can't wait to come back and work with the home teams more over the coming year.