Impatience

The cognition was fading, more rapidly than anticipated.  An intervention that would likely prevent it was not what the patient wanted after watching a loved one die of the same.  The primary team called an emergency family meeting to get a decision made.  The patient refused to let anyone make decisions except them and yet, they could not follow the conversation.  The family was afraid to make decisions because of past history of animosity and anger if things didn't go the way the patient wanted.  The onus was put on us to get a decision made.

It's amazing how easy it is to feed into that sense of impatience.  I felt like I didn't get to do things the way I prefer to - get to know the patient, figure out what's important to them, determine what treatments they for sure knew they did or did not want before being thrust into forcing the patient's hand on a decision.  Instead, the rapidly fading mental capacity of the patient led to a hard push to try to get a decision made, and it ended in the patient's family getting the silent treatment.  That, I felt, was my fault for not doing things the way I typically do them.

Today, we got nothing from the patient.  The chemicals in the blood already having their affect on the clarity of consciousness.  The edge that was present yesterday, was gone today.  The patient is rapidly becoming a shell of themself.  The family is still paralyzed by the patient's previous indecision.  The team was impatient, angry that we hadn't "made the patient hospice" so they could get rid of them.  It was heartbreaking.

How do you balance doing what feels right for you when it comes to setting up the conversations at hand with the expectations of the primary team and the abilities of the patient?  Knowing that this patient wanted to make all of their own decisions without family intervention makes it harder now because that's not possible.  We have no information on what the patient wants us to do beyond the things they don't want.  How do we proceed.  We know the patient does not necessarily need to be in the hospital, and yet the family is saying they wouldn't want multiple other options that would be supportive of the family.  Where do we go from here?  How do we support the family into inertia to make a decision?  How do we block them from the pressure of the impatience of the primary team?  How do I keep myself from also giving into the pressure of external impatience in the future?

My Birth Story Part 2

The actual birth of my son was as unexpected as I'm sure most births typically are.  My blood pressure decided to go up around 38 weeks.  In retrospect, what I should have done was wait it out as it was a particularly stressful day at work.  However, as a new mom, I did what my OB recommended which was come in for an induction.  Now, for starters, most inductions are scheduled to start in the morning.  Mine, with being done at a new birth center, was scheduled to start at 5 PM on Tuesday, January 28.  I thought nothing of this until the OB on-call slept through his alarm to come break my water at 1 AM and instead showed up at 3 AM.  I had been on increasing doses of pitocin since 7:30 PM, and learned at 3 AM that it hadn't done anything.  Once my water was broken, everything seemed to speed up and slow down at the same time.

I have now also learned that I need an epidural before my water breaks.  I am a wimp when it comes to that level of pain and waiting 2 hours for anesthesia to finally come in was brutal.  I am shocked my husband doesn't have PTSD from not being able to do anything for my pain during the wait.  Once that epidural was in, it was fantastic except for the hip flexor pain that I think was probably triggered by the fact that my son came into the world facing the wrong direction.  In other words, when babies are born, for them to more successfully pass through the birth canal, they should be facing toward the ground if mom is lying on her back.  This makes it easier to pass under the pubic bone.  On the other hand, my sweet little boy came in looking up (and hasn't stopped since then, wanting to see everything) which meant his sweet little top of his head was bruised and raw from smacking into my pubic bone instead of passing underneath it.

I think if I had waited it out, my blood pressure would have dropped, and my baby boy could have had a little more time to get into optimal positioning.  And yet here we are, happy and health.  He finally arrived at 2:04 PM on January 29 at 7lb 10oz.  He is precious and sweet and I don't think I knew how much I could love another human until he arrived and that was after 3 hours of pushing...

My Birth Story, Part 1

It has been almost a year since I last published.  At the time of my last post, there was so much going on.  For starters, in January of 2019, I was told that if I wanted to have children, I needed to start sooner rather than later because my ovaries "weren't getting any younger".  See, at the time, I had gone over a year without a period.  I now know this is because of PCOS, and at the time was also fairly certain of that.  However, there's nothing like your GYN making the above comment to get your biologic clock ticking.  With little support from said doc, I turned to my internist to get the necessary labwork to show I had PCOS (with the help of a friend in endocrinology to tell us what to order).  I will say, the average time to diagnosis for most women with PCOS is several years with visits to several different specialists.  I was beyond lucky to have a wonderful primary care doctor who was willing to do what needed to be done.  I also was fortunate to have bloodwork that shows that my ovaries are doing just fine for their age.

With the diagnosis in hand, we turned to a local reproductive endocrinologist to help figure out just what needed to happen to trigger ovulation for me.  Fast forward to April, and we were talking about using pulse dosing of Femara (typically used to help keep breast cancer in remission when taken daily).  The idea is to mimic what typically happens for egg maturation.  Estrogen levels drop with the Femara which triggers an increase in follicle-stimulating hormone which causes an egg to mature.  It took two tries to finally get egg maturation kick-started and then the use of a trigger shot to cause ovulation.  The next few weeks of waiting to be able to take a pregnancy test were really tough.  And when I could finally take one, I took 6 just to make sure I was, in fact, pregnant.

I had pretty bad nausea during the first trimester, and developed several food aversions that stuck around for the entire pregnancy (I can thankfully say that they are over and done with and I pretty much eat anything in sight at this point).  Pregnancy (like motherhood) is a mix of joy and anxiety on a regular basis.  I felt paranoid at times because I felt like any wrong move would be the end of my little nugget.  I worried about everything I ate, how much I slept, the exposures at work while at the same time being so incredibly thankful for the ability to carry and grow and protect my little one.  It's an incredible experience knowing that I was and still am a safe haven for my sweet little boy.

Speaking of which, little man is needing my attention. Until next time.

Spirituality

I have been thinking a lot about spirituality and the interconnectedness of every living creature.  One of the things that I have been thinking about is "why me? why this?" especially in relation to my career and what I do everyday.  I was talking to a colleague about how so many times I am in awe and completely humbled by how the people under my care or so willing to open up and let me into the most intimate moments in their lives.  People share their worries and fears, their greatest hopes and the wonderful lives they've shared together.  I become a thread in their life tapestry, and am the guide through their last moments on Earth.  It is absolutely incredible that I am allowed into these spaces with these people who I am a complete stranger to.

And, they trust me to the point where some want to confer with me on incredibly huge decisions for their loved ones before they make the choice.  This was especially poignant for me in a recent encounter where I had really only spoken with the family on 2 occasions for less than 10 minutes each, yet when they were asked by another team to make a big decision for their loved one, their first thought was to ask for my guidance.  They trusted me enough, even in those few moments we had talked previously, to request my recommendation.  They had faith that I would help them reach the best possible decision for their loved one.

So many times I want to look at the people I am talking with and say, "do you realize that I have only been doing this on my own for 9 months?".  Yet, that falls into the category of proclaiming my step or shelf or board exam scores.  In that moment, they don't care.  They don't care that sometimes I still feel like I am a baby, that I am just learning how to walk and talk.  They don't care about my insecurities.  They care that I show up, I am there for them, I care about them and their family members, and that I am honest and kind.  As the saying goes, most of all kind.  

Many times over the last two years I have wondered if this is really what I am supposed to be doing, if I really have the intestinal fortitude to be a doctor.  And then I have days like today.  Days where I truly feel like I am where I am supposed to be, caring for the people I am supposed to care for.  I was set on the path of these people's lives for a reason, and they were set into mine.  We are each adding a thread to each other's life tapestry.  Because of that, our tapestries are connected and more beautiful for it.  Even if I am meeting that family at their darkest moment, I am the safe haven where they can drop their guard and let me be the strong one for a moment.  I am the one who listened.

Many times I wonder about what would have happened if I had ended up somewhere else other than where I am today.  While I can imagine I would still be successful and know the people I care for would be equally well cared for by someone else, it would have been different.  I am still exploring my spirituality.  I do know that I was set on this Earth to be with the people I am with, do the job I am doing, and because of that, I am there for the people who most need me when I am supposed to be there.  Even when those cases stick to my heart permanently, I learn to dance with the limp and use that growth to provide for others.  As harrowing as the cases can sometimes be, I still cannot imagine doing anything other than what I am doing today.  I have one life to live, and know I am living it with using my gifts for the purpose they were given to me.  I am forever thankful for this opportunity.

Check-In

The last six months of work have been a roller coaster.  I have had periods of feeling like I'm really making a difference and periods where I feel like an impostor.  I have been told on several occasions to just get over my impostor syndrome, that everyone feels this way, and there's no reason why I need to feel this way.  I have felt like few of my own family even understand the emotional strain of what I do, and there is family who really doesn't understand what I do.  I feel like I am immature, that I can't stand up and fight when I need to, I'm too much of a people-pleaser, and I can't get out of my own head enough to help others.

Then there are times where I really feel like I helped a patient, even if it was only to hear them out.  I have sat by people, cried for people, listened to people vent.  I have been the person others turn to for support, and celebrate the small victories with.  I have helped streamline communication between the patients and teams.  I have come up with ideas for education.  I have built a new curriculum for narrative medicine.  I have taught residents about what I do.  I have turned to the people I work with to help me.  I have learned that I am not always a lone wolf.  I have stood up for myself when I need to.  I have been a team player.

Today, I feel like I have not done any of the things in the second paragraph, and have fallen into the first.  I feel like I made communication worse rather than better, even though I had only met the patient once, and never met the other family.  I have taken the fall for miscommunication I didn't realize existed.  I feel like I haven't been as professional as I need to be.  I have acted immaturely and been scolded for it.  I feel like I'm not really ready to teach fellows since I'm only six months out from fellowship.  I don't feel like I know what I'm doing.  I can't seem to make anyone feel better, and seem to only make people feel worse.  While part of me knows this is a gross over-exaggeration from the events of today, I beat up on myself for feeling like I've messed up.  While most people would have looked at what I did and call me normal, I hold myself to unattainable standards.  I need to cut myself some slack.

I had been so calm and had just enough confidence to be able to carry on without falling apart at every negative encounter.  Today was one negative encounter after another.  There was no stopping.  I got caught in the rip current of negativity, forgot to swim with it, and was swept out into the ocean to drown... or be eaten by sharks.

I feel like the moment I start to feel like I am settling in, finding my groove, on good standing with the rest of my team, the sand shifts and I realize there wasn't actually solid ground underneath me.  Sometimes I wish that I had a lower stakes job, that I wasn't as driven to go into a career that required other to depend on me as part of their healthcare team.  I wish I believed that I was really cut out for this.  I wish that one day of constantly feeling like a disappointment didn't knock me down to zero so quickly.  I wish my self-esteem reserve was deeper and more full.  Instead, I crumble the moment I feel like I've done wrong by a patient or their family or have let them down.  Even if I am not the direct reason for the letdown.  Even if I am not the one fully at fault.  Even if I'm working against a disease that is robbing a person of their essence.  Somehow I am supposed to take away from their oppression, not add to it.  I feel like I added to people's issues, not took some of the pressure away today.

I beat myself up over every little thing.  Every word I say.  Every recommendation I give.  I feel like a failure when I think I did things wrong.  I feel like I am the only person who ever flubs up an encounter.  I don't know the right words to say.  I don't have anything to provide to alleviate the physical pain.  I don't even know how to sit in the emotional or existential pain anymore.  I feel like I have nothing to offer, and anything I do offer is wrong.  Completely and utterly wrong.

Maybe tomorrow will be a better day and I can pick up the pieces so the patients don't see my lack of self-esteem...

New Year's Resolutions

Last year, I set what seemed like a simple resolution.  I would do one thing for my own self-care everyday.  While I did a great job posting my self-care up until mid-March, for the most part, I was able to stick with it.  Some days were less active forms of self-care, and others missed the mark entirely.  However, I am proud of myself for taking the time to focus on my personal growth and emotional stability.  I still have a long ways to go, especially with being a people pleaser and focusing more on how others view me than my own internal moral compass.

This year, I am continuing last year's resolution and adding on.  This year, self-care will be a more active self-care.  I will continue going to pure barre regularly because I love the physical activity and knowing that my body is stronger because of it.  I am also going to do a 6-week course in "Healing through Mindful Movement" which is a 6-week yoga counseling workshop on how "mindful movement can help your body heal your mind".  I enjoy yoga and am always looking for novel ways to help keep me physically, emotionally, and psychologically balanced.  Along that same vein, I need to start doing mindful meditations again with the Calm app.  Finally, my goal is to focus on some of my hobbies: sewing, knitting, crocheting, painting, writing.  I want to have time to do each of these in order to find ways to expand the more creative side of my brain.  I find it helps me think better on my feet.

One of the additions is now continued development of my career.  I have several lectures I am giving this year that need to be developed.  I am applying for a curriculum development scholarship.  I need to build prompts for the narrative medicine curriculum for next year.  It's amazing how little time there is in a day for all these things.  Some will carry over into time at home.  However, I strive to keep the first resolution above at the forefront outside of the hospital.

Even higher than the previous resolutions falls the one to find ways to focus on continuing to improve my relationship with my husband.  Sometimes, this focus can be simple.  Through the Gottman Institute, we have twice weekly marriage minutes to discuss, we have stress-relieving conversations we can have over dinner, we have card decks that we can work through to deepen our understanding of each other.  I want to be more intentional in the energy that I put into the relationship.  My sweet husband has done such a wonderful job of keeping us both buoyed.  I could not imagine having a better life partner.  I want to make sure I devote ample time to showing him my love.  An added bonus is the fact that it will only improve our relationship.

Finally, one of the words that I want to meditate on a little more this year is 'expectations'.  Expectations I set for myself, what I expect of others, work expectations, patient expectations, and so on.  I want to be more thoughtful about which expectations and which are harmful.

I am excited for 2019.  Let's see what the year holds.

Silent No More

"Fear is the path to the dark side.  Fear leads to anger, anger leads to hate, and hate leads to suffering" -Yoda

We put too much stock in blaming inanimate objects or other people or oppression or [enter whatever you want here] as the reason why hate toward others is still so prevalent.  We blame guns for deaths and statues for racism.  We focus on the thought, "if we just tear down x it will make the world a better place" or "if we just control y it will change everything".  Why don't any of us stop and realize that it's our own internal fear that drives the interactions we have with others?  It's fear that leads to "us versus them" mentality.  It is fear that is truly the path to the dark side.  Fear deafens us.  We all scream and shout at each other thinking that if our voice is heard the loudest we'll change other people's beliefs.  Just stop talking!  Stop shouting!  Stop silencing everyone around you!  LISTEN!!

First, listen to the silence.  Listen to what can be heard when you aren't ranting.  What does nature sound like?  What is the Earth telling you?  What sensation does this cause?  Does the silence make you angry?  Does it bring you peace?  Do you feel like laughing or crying?  What is the message in between the silence?

Then, turn to the person you have been shouting over, the people silenced because they are afraid of speaking over you.  What do they have to say?  Learn what is important to them.  We all have something that makes us feel important, that is more valuable to us than anything else.  We all have hopes and dreams and fears.  We all have worries.  We all have a purpose.  What is the purpose of your interaction with the person next to you?  What makes them who they are?  And when you are done with this listening, realize that you only know that one person.  You cannot generalize what you learned from them to anyone else.

Now, listen to the next person and the next and the next.  We are all connected to one another in one way or another.  We all have families, we all have dreams, we all have hopes for the future.  If you think that tearing down one statue or removing all guns from non-military/non-LEO homes is what will change the story-line, then it will be a long road ahead.  You have only asserted your beliefs.  You have done little to hear the beliefs of the people around you.  You may be contributing to the fears of those around you, and that does not make you any better than what that statue stood for or what guns can do if used carelessly.

I applaud people who are willing to stand up for what they believe, but blaming today's bigotry on a statue from 1913 does not really make any sense.  Whether that statue is there or not, the history of the university has not changed.  You cannot change the past.  You cannot change history.  By trying to ignore history, you run the risk of repeating it.  What matters now is how you decide yourself, today, to make the world a better place.  Keep in mind, that world may just be a small piece of the planet we live on.  It may only be the few people you touch in your lifetime.  How are you going to make things better for that small sliver, and how are you going to show them how to pay it forward?  What is more important for your future children: telling them you pulled down a statue once and continued your life as it was or show them how you cared for other people throughout your lifetime?  What is going to have an indelible mark on them: a one time instance of disrespect for public property or a continual show of love toward others regardless of how society sees them?

I choose the latter.  I want my children to see me truly love my neighbor as myself.  I want them to see me sit with other people in their suffering and hear their story.  I want them to know that judgement was set aside, and true compassion for human life shown through.  I want them to understand that we are all equal, that we all experience joy and pain and sorrow.  I want them to know we all laugh and smile the same, we all seek comfort when we are lost or hurt, we all cry in the face of deep sorrow.  I want them to know what anger feels like and know that it is okay to be angry, but that it should never be directed toward another person or creature.  I want them to be curious and have a thirst to better know themselves and their world on a grand and small scale.  I want them to know love, deep passionate love, the love of the simple things in life, and the love that makes us want to care for others.  It doesn't matter how we look or act, we are all part of the same family.

Keeping that in mind, how can you change the world today for the person sitting next to you or in front of you or behind you?  You can listen to the story they tell and know that it is a beautiful thread in the cloth of humanity.  You know where that thread is and can marvel in its beauty.  You can let them know that you have seen and heard them and love them for who they are in whatever way you are capable.  This is what I want my legacy to be.

Days 356-362: The End and The Beginning

June 29, 2018 was the official last day for my hospice and palliative medicine fellowship as well as my status as the trainee.  In August, I will start as the trainer.  What a daunting task.  Sometimes, I'm not sure I'm ready to be in that role.  I feel like I still have so much to learn myself.  I realized that there is always going to be this sense of need to learn as much as I can.  I am excited for my new role and to know that I am not going to have to do too many weeks of back-to-back consults.  I will have medical students, residents, and fellows working with me.  I will be working to make the home calls a more cohesive group.  I will be working on my narrative medicine expertise as well as my role as a mentor.  I will be teaching bioethics for the brand new medical students.  I am nervous and excited.  Before I get too far ahead of myself, though, I have six weeks of rest and relaxation.  Or at least not going into work and packing to move to a new house.

Days 331-355: An end and a new beginning

Today marked my graduation from my hospice and palliative medicine fellowship and the end of my time as the trainee.  In one week, I will be officially done with fellowship.  I get six weeks off before starting as faculty, the moment I have been waiting for since I was a medical student.  In the meantime, I will be packing since LOML and I will likely be moving into a new house before I start my new position.  It's been quite the crazy series of events to get the house we are currently under contract on.  We looked at a group of houses in the neighborhood where we thought we wanted to buy, only to find that the layouts of the houses were not what we liked.  When then started again with a new search, and had two houses we liked at the end of the day: newer construction with vinyl siding and an all-brick house with great updates but on a septic tank.  We went with the newer construction, had everything ready for the offer, and were told it went under verbal contract.  So we looked at another house in the same neighborhood that was the plan we liked.  We put in an offer, only to have the sellers back-out and decide they didn't want to sell.  Finally, I convinced LOML that we really did want the all-brick house because it had everything on our list other than a screen-in porch.  We put in the offer, and it was accepted immediately.  We are now getting the inspections and appraisals scheduled, and will hopefully close the beginning of August.  We've shoved as many big events into one year that we can.  We are excited.  I can't wait to start my new job as daunting as it feels.

Days 318-330: Silence

I have forgotten to focus on my own self-care recently.  I have spent so much time trying to do so many things, I have forgotten about myself.  I have not exercised.  I have not blogged.  I have not written for fun.  I have not painted, meditated, knitted, crocheted, or sewn anything.  The last thing that resembled self-care that I did was the honeymoon.  Prior to that, it was almost back into February, maybe March.  Even then, it was just exercise for maybe 15-minutes first thing in the morning.

When I don't take care of myself, I don't have the energy for pretty much anything else.  I never feel refreshed.  I don't have the tolerance for BS that I normally do.  I barely have the ability to keep it together for a patient visit.  I lack my normal, bubbly, positive personality.  I can't remember the last time I felt care-free.  I can't remember the last time I didn't care what other people think of me.  I constantly second-guess myself because I don't have the energy to overcome and maintain my self-esteem.  LOML is the only person I feel normal and safe around.  He's the only one that I feel is 100% supportive no matter what the situation.  He is simple in that, as long as we are together, that's all that matters.  Even when I lack the ability to show my love as well as he shows his, he knows that we are a team and supportive of each other.  I love him more than I will ever be able to say or show.

My sensitivity level is way too high right now.  I take any comment or critique that could possibly be construed negatively as such.  The general feeling is that I cannot do anything the way I am supposed to.  Even though it shouldn't really matter what anyone else thinks (so long as I don't cause other people physical, emotional, or psychological harm), I feel like I have obligations I am not meeting.  I want to get to a point where I am not phased by what other people think about me.  I want to not care about it.  Certainly if it is going to cause harm, I would like to know, but otherwise, I want to be able to feel like I have support for the decisions I make.

Days 300-317: Absentee

I have not blogged in a long time.  I haven't had the energy to.  The wedding on April 29th was picture perfect.  The weather was amazing.  It was a full moon.  Everyone is still talking about how much fun they had.  The honeymoon was more than anything I could have imagined.  LOML and I hiked every day, explored the upper part of NC and the lower part of VA.  I can't wait to disappear into the mountains with him again.  It has been tough to try to get back into the swing of things at work.  I am emotionally exhausted from the wedding and it's myriad emotions, the deep relaxation of the honeymoon, and then a week after getting back from the honeymoon, on a plane to my grandfather's funeral.  I thoroughly enjoyed getting to see all my family.  I was glad to get to speak at his funeral when I wasn't able to go to Grammy Lou's funeral.  I got back Sunday, and turned around on Monday to start on the palliative care inpatient consult service.  While I realize from a billing standpoint the attending can bill more if they are with me, but it also doesn't make me feel like I am actually ready for faculty if I have to have the attending with me on everything.  Some attendings are better than others at allowing me to continue to run the conversation, but the particular one that I am with is not.  She is well-meaning, but sometimes she cuts in while I'm still thinking about my next move.  It makes me feel like I look like an idiot to the patient.  I'm sure that's not the case.  It probably doesn't help that I haven't emotionally recovered from the previous two weeks.  I'm hoping I'll be in a better place mentally next week after a weekend off.  Unfortunately, it is my last weekend off until I finish fellowship.  Granted, then I have six weeks to get mentally ready for faculty.  I'm excited and nervous for that time.  For now, to make it through the next week and a half...

Days 283-299: Celebration and Sadness

Today is the day before LOML and I get married.  It has been a frenzy of activity leading up to today.  There has been some stress.  Family dynamics are always interesting when you add stress to the mix.  I am trying to stay calm, and I am trying to get excited.  I know this is monumental and a wonderful event in LOML's and my life.  I just hate that I'm stressing out about everyone else behaving.  I need to just let it go and enjoy each moment as it comes.  Tonight is the rehearsal. Tomorrow is the wedding.  I wish, sometimes, that it was just LOML and me.  I know the family is excited to be involved.  I need to get some of that energy!

I also can't believe that I will be at the two month mark for the end of fellowship the day after the wedding.  

Unfortunately, some of the excitement is tempered by the loss of my grandpa Jack.  He had been suffering from dementia for several years now.  I am glad he is no longer suffering.  I have not had time to fully process the loss, and likely won't until after the wedding and honeymoon.  I will be able to go to the funeral and am glad that we can remember him for the good times.

Days 265-282: Humbled

Today during debriefing, the facilitator made a profound comment.  He said, "the healthcare providers with the highest emotional intelligence hold a double-edged sword.  They have the highest work satisfaction and are the most likely to have severe/catastrophic burnout.  It's the difference between PTSD and PTS growth."  This came after my presentation of a really tough situation I've been managing (almost completely on my own) since Monday.

Before we go there, the facilitator is amazing.  He is joining the palliative care team in May that I will be joining in August.  He is a surgeon from a former life, converted to palliative care, and also has his MDiv.  He is an incredibly positive person, and is good at instilling confidence in the people he works with.  I almost want him on my mentor team just for the continued confidence boost I would get.

At any rate, I have had a really difficult case that I picked up on Monday.  The family requested transitioning to a focus on comfort.  The caregiver that had been living with the patient for the last year was concerned that the family was forcing the patient into an earlier death than she would have naturally had.  The anxiety levels and lack of sleep led to an incredibly frustrating night and early morning for them on Tuesday, which resulted in me being blamed for the situation because I had not put in enough medication to manage the patient (despite the fact that I am in training, and should have someone to double check my orders as part of education to provide feedback).  I felt terrible because I felt like I had let the patient, the family, and the team down by not asking for recommendations on medication management.  We got the patient on a PCA which significantly helped her pain and the family's anxiety, along with my staying with them to observe what she was doing that was concerning and provide guidance on what to look for.

This morning, the patient was more alert and comfortable.  Her caregiver was in a better place.  And then the surgeon came in upset that this had transpired, and didn't understand why the family had been allowed to do this.  This got the caregiver riled up again about how things were moving too fast, and the children were forcing her death too early.  I was brought into the meeting between the surgeon and the daughters.  The daughters explained their position.  The surgeon backed down and apologized, and then continued to pour his heart out.  He reported his stress over whether the surgery should have even happened.  He felt such remorse, and was looking to the grieving family to help him work through his existential crisis about his career as a surgeon.  It turned out he had several recent surgeries that had ended similarly.

The facilitator was able to note that for many surgeons, their excellence in their career was intimately tied to their identity.  The second was that I was looked on as the expert in communication, and was needed to validate the emotions in the room while delicately moving the focus forward to future care.  The facilitator was in awe at the amount of genuine care I had for the patient, her family, and the surgeon.  Despite my frustration in the room, I was able to step back afterward and see the situation for what it was.  I now have the chance to hopefully reach out and try to support a colleague who is going into a tail spin and looking for someone to provide a parachute.  I hope I have the strength to do what needs to be done to acknowledge the surgeons suffering.  I hope I can see when I reach a point where I might end up in a tail spin and know how to reach out to my colleagues for that parachute rather than the patients and families who are already in their own grieving process.

259-264: Exhaustion

This week has seemed so long comparatively.  It probably doesn't help that it followed the conference in Boston last week.  It also probably doesn't help that it's the first time I've really worked since January, other than my one week on hospice back in February.  Between both my and the attending's crazy schedule, I have felt that I can be more efficient than I give myself credit for.  To see 4 people between 11 and 3, get notes done, eat lunch, and get stuck in an elevator for 20 minutes on Friday, I might be able to be an attending in September.  Am I intimidated? Yes, but I will be able to do it.

This week has seen a full clinic on Tuesday, academic half-day on Wednesday followed by Boris's appointment at the vet, taking Boris back to the vet on Thursday morning and acupuncture in the afternoon, and food tasting on Friday for the wedding.  We will dissect the parts that are important.

First, Tuesday's clinic.  We still finished at 1.  We still had 2 no shows.  The difference was we were double booked for the schedule, so usually we are seeing 4ish patients.  Tuesday, we had 6.  I saw both news, and two of the follow-ups.  I am trying to do better about not spending too much time with the patients to hold us up.  It hasn't helped that people are showing up or getting roomed late.  When we start 30min behind in a palliative care clinic, it's near impossible to make that time up.  But I feel like I'm doing better with what I have some of the time.

Wednesday academic half-day was interesting.  Part of it was supposed to be an hour discussion of "what we learned at the AAHPM conference".  It turned into a 50 minute presentation of what the program director learned with 10 min for me to present.  I didn't present much because I still had to check-out with the attending I was working with and then leave in time to go with LOML to take Boris to the vet.

Boris is my oldest cat.  He will be 12 in June.  We have been through a lot together with his dietary restrictions and weight issues when I first adopted him.  A couple weeks ago, he developed a swelling on his chin.  We thought he had been bitten by Alex, but the vet was concerned about cat acne.  We changed out the bowls, as recommended, and used to wipes as directed.  Unfortunately, his chin worsened.  On Wednesday, the vet couldn't tell the extent of the mass.  He went back in Thursday for his dental and a more in-depth evaluation as well as a biopsy.  The vet felt like the mass only involved the dermis, and did not extend into his mouth or jaw.  We won't know the results of the biopsy until next week.  We are switching him back to the food he used to eat out of concern that the new food is triggering the reaction.  It seems to be mildly better at this point, but still swollen.  Our hope is that it isn't cancer.  It is reassuring that it is not effecting his eating in any way, and he hasn't lost significant weight (even though he needs to).

Acupuncture was interesting.  I spent the better part of Thursday telling myself I would believe in its ability to work.  I went into the office (which is a doctor's office) but the room is set up like a massage spa.  We talk, and I explain the areas of concern, and then was told to strip down to my undies and get under warm blankets.  Next, sewing needle-size needles are placed along appropriate meridians: ear for relaxation, wrist for sinuses, back and feet to help with my neck pain.  A heat lamp was placed over my upper back, and I lay there for about 20-30 minutes.  I was unable to move due to concern that the needles would dig in deeper and cause pain.  So all you can do is listen to the calming music in the room and rest.  I think that may be part of why it works.  It doesn't completely explain why the knots I've had in my neck for the last 3 months are gone.  That was really nice.  I realize that there is more to acupuncture, and I would likely do it again in the future.  It helps knowing that our patients have to be able to lie there for 20-30 minutes to be able to reap the benefits of the procedure.

Friday was interesting for two reasons.  The first was getting stuck in an elevator.  My attending and I were on the 8th floor in one of the hospital towers and trying to get to the 4th floor.  We got on the elevator along with two med techs who were going to the 7th floor.  The elevator doors closed and then momentarily, we sat at the 8th floor before going to the 7th.  The med techs got off, and the doors closed and then reopened.  That should have been my cue to get off, but we didn't.  As the doors were closing, the buttons wouldn't work, and I knew we were in trouble, but it was too late.  I thought maybe it would start again, but it didn't.  We sat for a minute, I told my attending that I didn't think we were going to get out without help, and I called the help phone.  The help phone, coincidentally, connects to the 911 operator, so imagine the joy of telling them I was stuck in an elevator in the hospital.  I'm thankful it was during normal working hours.  Security got there relatively quickly as both my attending and I talked about our issues with claustrophobia before talking about the wedding.  They were able to finally get us out without the elevator becoming the "Tower of Terror" ride.

The second thing that made Friday interesting was learning that LOML and I had been shuffled on to our third event coordinator at Graylyn.  It explains why we had so many issues with communication with the second coordinator as "life was taking her other places" despite her thinking she would be at Graylyn long-term.  Needless to say, the current coordinator is very on top of things and great with communication, so I'm hoping we keep her through our wedding.  The food for the wedding was delicious.  I am very excited for that.  We also did a quick walk-through with just the three of us before the full walk-through with everyone tomorrow.

We met with the DJ today who I am very impressed with.  He has a calm demeanor, and seems very dependable.  He met us when he was coming in early for a wedding reception he was doing, and was worried about the weather.  He also is very receptive, and is going to be very good with helping to keep everything moving smoothly.  I am thankful to have a strong team working with LOML and I for this.  It is helping alleviate some of the stress, even if there is still some to be had.

Obviously, the week has been eventful.  I don't foresee quieter weeks any time soon.  I am looking forward to the honeymoon when we can relax for a little while.

Days 245-258: Compassion Refueling

I have not had the desire to blog in quite some time as noted by only posting about once a week until the two week hiatus.  I was tired and stressed.  There has been a lot going on, and not all of it super positive.  I got to hit the reset button last week at the AAHPM annual assembly in Boston, MA.  The annual assembly is the yearly conference for hospice and palliative medicine practitioners.  I say practitioners because it is more than just doctors.  It's social works, NPs, PAs, RNs, chaplains.  Anyone who has an interest in HPM.  I think having the interdisciplinary approach improves the conference greatly.  You get a variety of perspectives and approaches to the care provided to our patients.  There also is an understanding that to provide great care, you have to foster the creative side of each of us.  I got to color with crayons, play with therapy dogs, write poetry, go to book club, escape a room with a team of other HPM practioners by completing many different puzzles.  It was the best conference I have ever been to.  There was a perfect balance of education and wholesome fun.  We laughed and learned together.  It was a sharing of ideas across disciplines that allows for a more holistic approach to patient care.

It also gave me a break from wedding planning, trying to figure out taxes, and the drama that comes out around the time of a wedding.  It was a welcome break.  I have been stressing about how I was going to get my taxes done because I have additional taxes thanks to my moonlighting.  There are several forms that I have needed to complete in preparation for the wedding.  We haven't taken the time to complete any of them, and then the number of emails to keep straight has been unreal.  I got to forget all of that for a little while.  I got to refuel for my job.

Today has been spent listing out what I needed to get done now that I'm back in Winston.  LOML and I are at the 6 week mark for the wedding.  We finally submitted the form for the ceremony musicians.  We emailed the DJ about dates to meet but are still working on the plan for the reception.We have completed the form for the photographer but need to send the picture planner and the timeline.  We have a tasting date, but need to double check the date for the walk-through.  We are still waiting to hear back from the officiant regarding the ceremony LOML and I created.  It's so funny how the little details take over at the end when LOML and I should be focused on supporting each other as we prepare to become man and wife.  I am so excited to be his wife.  I have to keep focusing on the importance of that statement.

Days 240-244: Dysfunction

Today was a day of interesting encounters.  The first was of a lady who used to be quite ornery until she declined and became non-verbal.  She still wasn't very happy with us today as we moved her around to complete her exam.  She is dying, and while she has very loving caregivers, they aren't able to give her medications if she can't swallow.  We ended up having to move her into the hospice facility to be able to receive liquid, oral medications for symptom relief.

Next was the patient who just wanted to stay in her room.  Her family kept talking about how crazy she was.  She was the most sane of the group.  She clearly was not in a happy marriage.  The nurse and I listened to a sermon from her husband, who then had the audacity to tell her, "you may be good but you sure aren't pretty" when she responded to the nurse's question about how she was doing with a "pretty good".  The daughter did not stop talking, and did not want to rescind control of the patient's care.

Then we went to the top of the mountain to see a third patient whose symptoms are worsening as his disease progresses.  His wife needed coaching on medication administration, but was kind and present for her husband.

Finally, we had the guy who was actively dying, and had a sweet and doting family who had really helped provide the best care possible for him in his situation.  They asked questions about his presentation, if he appeared uncomfortable, and what the best options were for his care.  It really was a good end to an interesting day.

Days 230-239: 8 weeks, 4 days

I am supposed to be writing about experiences with patients that have deeply affected me.  While there are many situations that I have had wonderful experiences with patients and their families, most of my time and energy is devoted to the wedding.  I had fun today at a little shower at work with everyone.  Then, the handles broke on one of the bags of gifts, so I awkwardly carried them to my car.  It's one of the few times I was a little disappointed that I had to walk across the entire hospital just to get to my car...  My biceps asked that I not make them lift weights tonight.

I've also had multiple people say that I need to add more things that I "want" to the registry, not things I "need".  LOML and I do not really have a lot of stock in material things.  We keep it simple.  We don't want or need many things.  The original items on the registry were the things we wanted.  We can add a bunch of stuff, but then there's also the issue with not having anywhere to put it in our tiny house...  And the fact that we are likely going to end up having to buy the stuff for ourselves over the next couple of years because not all of it is going to be given as presents.

I probably am not going about this the right way, but in my mind the gifts are superfluous.  Everyone is already having to pay to come celebrate with us.  It's going to sound cliche, but getting to spend time with friends and family is far more important than anything anyone buys for us.  There is nothing on that list that we need right now, and sure the stuff is fun, but it is just that.  It's stuff.  I appreciate everyone's desire to give gifts, but really, I just want to spend time with people and enjoy their company.  I don't want to keep being told that I'm not materialistic enough for everyone else...

Days 220-229: Planning

I really have done a horrible job of blogging each day.  During the past week, we have worked on wedding planning to the point where I'm not having regular nightmares about the day of.  The first nightmare involved me running around the venue doing all the last minute planning.  I'm in my wedding gown, and freaking out about LOML seeing me in my wedding dress.  I even have my sister and brother working to try to keep me from being seen.  I have no idea what I thought I needed to do the day of my wedding.  I woke up panicked that LOML saw me in my dress.

Two nights ago, I dreamed that the hair and make-up crew showed up late, we had to set-up in this huge covered porch with large sheets so that no one could see us.  Then, right before I was supposed to start my hair and make-up, we realized the photographer wasn't there.  He was at the door, really upset that he couldn't make it because his daughter had a play he'd forgotten about when he said he was available for our wedding.  He said a back-up was on the way but couldn't guarantee when the replacement would arrive.

These dreams are strange, and I figure they will continue to worsen over the next 10 weeks.  I can't believe it's 10 weeks away.  We have the invitations done for the wedding.  The rehearsal dinner invitations are ordered.  My mom has finished the numbers for the tables.  I have completed the ceremony script.  We still have to complete the forms for the ceremony and reception music, but have at least talked through them.  I have babysitters lined up, but need to get them the information about the number and ages of the children.  We have our food tasting on March 12, and have picked out the food we want to try; we need to figure out the pricing based on the number of children, etc.  I don't even know what else we need to work on.  I think the photographer and day-of coordinator both have forms for us to complete at some point.

I feel like I live and breathe wedding planning and am not doing a great job at it right now.  I can't seem to shake the feeling that I am inadequate at this.  I feel like I am not keeping up even though I'm relatively ahead of schedule.  I am not maintaining the family relations I need the way I need to with fellowship, the cats, and wedding planning.  I feel like I'm failing on all fronts most of the time.  Even if I'm not, I feel like I am, and when everything calms down, I'm going to realize that I don't really have anything left.

Day 219: Blessed

I am so blessed to have the support team that I have and keep expanding.  I am a firm believer that if you are humble, if you are willing to be vulnerable, if you are willing to let others help you, you will overcome any difficulties.  This isn't asking those people to take the burden of the challenge and carry it for you.  That is not their cross to bear.  Instead, these are the people that will help you with her comfort in facing the challenge and provide the strength to continue through it.  It's not about pushing the work off on others, but finding ways to support each other in life.  Life is not easy.  It is not supposed to be easy.  If it's easy, you're not fully living.  I didn't adopt all my little creatures thinking their care would be easy.  I have LOML to help me.  He is willing to hold me when I feel like I've failed at caring for the animals.  He helps in getting them medicine and dealing with the crazy diets.  He is supportive despite the fact that he sort of fell into their care.

Yesterday, I got to talk with the team that cares for children with chronic diseases or genetic diseases.  I talked about the hardship of feeling like I was a terrible parent, and how we sometimes look at the parents of these sick children the same way.  About how they could allow their children to get into certain situations or that these children appear to be suffering.  We can say the same of the children of the adults we take care of on the other end of the age spectrum.  It was refreshing to talk with people who didn't look at my like I had lost my mind for the things I try to do for my animals.  It helped having someone in the room who had a cat with diabetes and understood the hardship of caring for an animal with a chronic disease that requires constant monitoring and management.

It's also been really helpful having my mom.  She used to work in pediatrics, and her describing Julia as a baby with asthma was helpful.  She would see so many babies in the ED on bad weather days because their asthma would flare.  There was nothing the parents did that caused the exacerbation, and there wasn't a lot that they could have done to prevent it from occurring.  She was so reassuring and supportive.  It was so nice having her and LOML saying that I was doing a great job with caring for Julia.  Even when I took Julia back to the vet yesterday, hearing the vet say that I had done the right things in the situation we were in helped reassure that I knew how to take care of my sweet girl.

I think that's the hard part.  If it's obvious the medical team trusts the family's judgement, that bridge of mutual respect and team building is there.  Each can support the other in coming up with a plan that is beneficial and manageable.  If it's obvious the medical team feels the family can't manage the care, then the family goes on the defensive.  They feel belittled and demeaned.  They lose their trust in the medical team because they feel like it's an us v. them situation when it shouldn't be.  We all have the same goal.  We all want the sick patient to get well.  At the end of the day, we want to do the best we can on that team in caring for the loved one.

Days 211-218: Feline Asthma

One of the most terrifying things is having a sick child.  While I do not have any human babies, I do have several animals (who have been referenced in past posts).  For the most part, they are healthy.  LOML and I do what we can to make sure they get what they need.  Julia, our only little girl kitty, has feline asthma.  While we don't know why or what the original trigger was, for the most part, she has done reasonably well until the last couple months.  The first trigger in January was the heating system breaking.  The more recent was likely the use of pine sol to clean the floors and the terrible weather.  Now we're in the cycle she was in when she was first diagnosed where it took several rounds of IM and oral steroids and bronchodilators to finally smooth things out.  Unfortunately, it is stressful for her to go to the vet, and the stress doesn't help her breathing.  I hate seeing her so tired out, struggling to breathe, and not herself.  It makes me feel like I'm letting her down because I can't seem to get her feeling better.  It's also really scary to think that she might not survive each subsequent cycle of exacerbation.  I feel helpless and sad.  She doesn't deserve to suffer from this disease, and she really does well in between.  Unfortunately, the vet has never seen her when she is doing well, so it looks like LOML and I just let her sit and suffer all the time at home.  That's hard feeling like the medical team looks at you like you're horrible parents for letting your child suffer without receiving medical attention.  The thing is, we don't.  If we didn't care, we wouldn't bring her to the vet when she's acting uncomfortable or can't breathe.  We do our best to follow the instructions we're given for her care.  We really do try to keep her as happy and healthy as we can.  We're just in a bad cycle right now.  The sense that we are being looked at as animal torturers is hurtful.

I realize that there are situations where, in the medical field, we look at patients and families the same way.  How could they allow x, y,or z to happen to their loved one?  Why didn't they bring them in earlier?  What kind of life do they allow their loved one to have at home?  It's condescending and does not allow for the partnership that is needed to care for the very sick patients we are seeing.  Everyone hopes for the best, that the bad parts will pass, and the sun will come out.  The disease that is attacking their loved one is really only a virus, a cold, that will pass.  No one wants to think that their loved one has cancer or something equally bad.  What would be different if, instead of thinking to ourselves all the bad things that come to mind when faced with a critically ill patient that has been sitting at home just as sick, we try to put ourselves in that family's shoes?  What if they thought it was something simple that would pass?  What if they didn't want to see the red flags because they knew it was something bad but wanted to hold onto the hope that it wasn't as bad as they thought?  Don't we all do that at some point or another?  Instead of thinking that the family is neglectful (unless there truly are signs of neglect or abuse), show compassion for them.  It is hard trying to deal with as foreign an area as medicine.  We use language that isn't fully English but say it in a way that people feel even smaller because they don't understand what we're talking about.  They may have had a horrific incident in the past with the medical field and are reluctant to use it.  They don't know all the options, and sometimes the options are presented in a way that makes them feel like their loved one isn't getting the expert care they deserve.  There are any number of reasons why people may avoid the healthcare system until it is far too late.  So instead of belittling them, align yourself with them because you never know when you'll find yourself in the same situation and realize the fear of not being able to care for those you love most.