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.