My Drowning

Today is Tuesday. It happened on Friday. Usually I use writing as a tool to think about what I've seen, make sense of problems, and move on. I am writing today because it has taken me this long just to sort out this situation well enough to write about it.

A four year old boy drowned. In a pool, in the middle of winter. He had been dead, was resuscitated by the paramedics, and was brought to meet me and the attending pediatrician in the ER. As I put the bagged oxygen mask over his mouth, I wondered if he had been eating a blue popsicle before drowning? No, I realized, his tongue was that color because he was so cold. Reaching out to touch his baby hand was like holding a refrigerated chicken wing. His eyes were brown, dull and unseeing, under his closed eyelids. His temperature was 85 degrees, and his lungs were filled with water. Listening to them was like ascultating an aquarium. He wasn't getting enough oxygen, even with the bagged oxygen mask, so we needed to intubate him. The ER doc tried first, pushing the tube down his throat. As the ventilator was turned on, his stomach distended with air. His heart rate dropped down into the 30s, and bagging was resumed. However, the bagged oxygen mask was now cracked, and he was losing oxygen and his heart rate was falling. The doctor gave the laryngoscope to me to try, and I opened his mouth, visualized two tiny vocal cords, and pushed the tube in. Pool water sprayed out, soaking my shirt and face, and the monitor alarms went off. In the few moments it had taken me to intubate, he had gone into asystole.

Asystole. Pulse zero. Respirations zero. These are all medical terms to describe death. The death of a kid that had been a normal little boy a few hours ago, and was now cold and lifeless under my shaking hands. The doctor shouted, "He's going to die!" and my stupid brain wondered "Isn't he already dead?"

The attending and I talked with his parents, explaining what had happened, and invited them to come see their son. As I watched mom kiss around the intubation tube, and dad touch his son's cold, dusky feet, my heart broke for these parents that turned away from their child for a minute and will now live with a lifetime of guilt. A couple of tears slid down my face as I watched these parents desperately try to reach their son, and grapple with the realization that he was not there.

My lungs were clear, but my heart was drowning. How long would it be before I forgot the sweet detail of this child's face? How could I not wonder if I could have done something better? When would I see other children as they are, rather than thinking about how they would look drowned like this little one? After all, he was a healthy boy a few hours ago, with a chest that heaved with exuberant play instead of the force of a ventilator. Why was I the only one that seemed to be bereaved by the loss of this child?

My friend June, who has been a wonderful nurse for longer than I've been alive, offered some perspective. Some doctors build protective clamshells around themselves, shielding them from experiencing patient pain. Sometimes this dissociation is necessary in order to care for someone in great distress. But to be too far removed is a disservice to patients and their families; patients need doctors who are there for them in the most difficult of times. She also reminded me to be gentle with myself. All of the distress and grief I experienced over the loss of this child are some of my best attributes; they indicate a caring and empathetic nature that ultimately will benefit my patients. It also indicates that my self-awareness is set correctly, because questioning and analyzing situations like this is the way to maintain a humble and teachable spirit. However, that does not mean that these situations are easy on me.

This is not an easy job. I never want to wear those chlorine-soaked scrubs again. Suddenly I don't like my stethescope, because it allows the amplification of human suffering into my ears. I don't know how to move on and forget about this kid that was the most awful situation I've ever seen.

All of these events form a collage of who I will be as a physician. With experience, I'll learn how to reach an equilibrium where the pain and triumphs of my profession are balanced with the rest of my life. And I'll know that while this experience will stay with me the rest of my life, there is a new patient outside my door that deserves every bit of the best care that I tried to give this little boy. It's not right for grief to cloud my focus on the next patient, because there is always more need to be met.

People say medical school is hard. What they don't say is that the academics are extensive, but attainable. What you really wrestle with is the ability to develop meaningful doctor-patient relationships. To emotionally engage with someone that is in pain is burdensome, but a privilege. Doctors have the unique opportunity to be part of peoples' lives in exquisitely intimate moments. I think most people would say that they go to medical school to "help people." This is probably partially true, but I think it goes beyond this. I think the desire to become a doctor stems from a deep yearning to offer people a part of us; the ability to treat illness but also relate to them in a time of difficulty, to meet needs that are seen and unseen. And I think if you do it right, you come away with more than you ever gave.

Pediatrics Warrior, not Prisoner of War

I was dreading my pediatrics rotation. From what I could see, it involved barfy, sniffly, whiny, drippy, crying, germy children whose little ear canals are impossible to examine and whose heart and lung sounds are indistinguishable from their wailing. I figured that February 8-March 7, 2010 would be a black hole in my medical schooling; the doctor equivalent of torture training by the military for the possibility of being a POW. And that's what I would be: a POW in the pediatric community clinic.

What I learned today is that this is the picture of outpatient peds. Inpatient is different. And I LOVE it.

It was exciting. Pediatric consults in the ER, waiting for the product of a difficult delivery, kids in the NICU and pediatric ICU, one room with cribs stacked side by side filled with babies with respiratory syncytial virus, all waiting with no pretense for the care of a quick-minded physician. It was just my first day today, but I saw more of a gamut of problems than I had ever expected; things that I figured I would read about but never see.

There was one little guy in the ER with a history of imperforate anus and dependence on saline enemas. He was backed up to the small intestine, with his large intestine so distended that it was putting pressure on his lungs. Looking at the xray, I asked "Does he have Hirschsprung disease?" The attending looked at me and said "You know, I think you're actually right. I can't believe no one has diagnosed him with that." He saw a pediatric gastroenterologist that afternoon and is now being treated. I was pretty proud of that (and glad to make a decent impression on my first day).

There was another little baby with Down sydrome, sick with pneumonia. He was cute as a bug, with a mom who was only 15 but really trying to do the right thing. One kid we saw today was in the ER with pneumonia, but I thought that I heard a heart murmur along with the junk in his lungs. On the xray, the little guy's heart was dilated to the size of a grapefruit, with a nice patent ventricular septal defect. There were a set of twins born at 25 weeks, that the 14 year old mom had gotten pregnant with them when her first child (a preemie born at 30 weeks) was still in the NICU! There were a set of parents in the ER with a kid who didn't look too sick, but on further questioning revealed that they had a three year old that had died the year before after being sent home with a respiratory illness, so were understandably anxious. Besides that little guy, there were another two dozen with respiratory illnesses (RSV) sick enough to be hospitalized. The pediatric ward was full, so kids were spilling out into the postpartum ward, the L&D, and even adult med-surg. One scene reminded me of third-world medicine: because of a lack of beds, they had put makeshift cribs in one room and clustered several babies with RSV in there. We rounded on them one right after the other, talking with different families, in different languages, but about the common illness their kids shared.

One kid was a particularly interesting case. This kid was about two, and had been born with hydrocephalus. He was followed in the NICU, and then discharged. Since then, he's bounced from PA to physician at different clinics, and NO ONE has addressed (or even mentioned) the fact that this kid's head can't fit through his shirt. He's now got a sodium level of 120, probably from a mass effect on the hypothalamus causing a SIADH syndrome. And yet, when we looked at the CT read in November, the radiologist said that is was unremarkable. Um, hello? This kid looks like he was fathered by the Elephant Man. His ventricles stretch almost the longitude of his midbrain and the hemispheres are asymmetrical. I'm a student, not a radiologist, and I could see that. The pediatrician called up a buddy he had in San Diego that was a neurosurgeon, and asked him to reread the CT as a professional favor. He needs a shunt, so he'll get connected probably with Stanford Children's Hospital now. I hope he gets taken care of.

Another interesting kid was one that both she and her mother had coded (died) during delivery. Both were resuscitated. Mom was okay, but this kid is completely vegetative. She's graduated hospice twice now (does that get a cap and gown?), and her life consists of just hanging on between infections. However, her parents are fighting about the DNR order, so right now she's a full code. Dad says it is against his religious beliefs to let her die; mom thinks it is kinder to her daughter to let her escape this medically sustained life. Interesting, the ethical dilemmas that come up in medicine.

I think this is a very different picture than I might get in another hospital. Sometimes the negligence of care is shocking. Other times, the care is good but the facilities are lacking. In any case, this is an area of great need. The doctor I'm with says that he sees things here that statistically he should only see once or twice in a career, and yet he has had several cases in the last few years. Kids with Edward syndrome (trisomy 18), DiGeorge syndrome, one rare metabolic syndrome (there are only 5 documented in the world), high rates of acute leukemia, and others that are considered medical "zebras" but somehow become "horses" in this community. He thinks its because of the generations of farming pollutants. Sounds reasonable. I don't know. Either way, I'm grateful for the experience here. And I'm very grateful to have discovered a love for sick children that I didn't know I had.

Poverty Is...

I grew up in Orange County, CA. From there I moved to San Luis Obispo. I always had (more) than enough to eat, school supplies, and clothes that were not only warm but reasonably in style. I had never experienced poverty. Sure, I volunteered at the food bank, collected toiletries for the homeless, filled school backpacks with supplies and send toys overseas, but poverty was not part of my existence.

As a senior in high school, I went on a mission trip to Mexico to play with kids and build a house. My classmates were happily kicking around the soccer ball and drilling nails into a framework, but I remember watching all those kids running around barefoot in a field with rusty nails, and thinking that what they really needed was tetanus vaccinations. It was my first real glimpse into poverty, and gave me a sense of purpose for my future life as a physician.

Fast forward six years. I am now a third year medical student stationed in the central valley of California, my task to learn medicine while providing services to the underserved and poverty-stricken population here. What I've observed is a lot different than what I expected. I had thought that my time here would be a similar experience to that time in Mexico- working hard to provide something good for a family who would otherwise go without, and the people would recognize the service and be thankful. Instead what I've seen is two types of poverty. One is heartbreaking, one is frustrating.

Probably the worst representation of poverty that I've seen here is the car washes to raise money to bury a dead family member. The whole family sets up in a parking lot and depends on the money they raise to pay for the funeral. I can't imagine this grief; that you would be mourning your loved one while soaping a stranger's tires to earn money for a burial. Families of dying patients don't come to the hospital because they are picking fruit and will not make wages without a full day's work. Sometimes they die before their family gets there. Moms with babies, broken down on the side of the road. Parents that don't bring their kids to the doctor for fear of deportation. A man with six black widow bites on his back, from a day of grape picking (they fall out of the vineyards down the workers' shirts) who didn't come in for treatment until his shift was over. Families that share one apartment, one car, one social security number. This poverty is heartbreaking and deeply compels me to do the one thing I am able to do: provide compassionate and quality medicine.

And then there are the people that I tend to think of as selectively poor. A man who cannot "afford" his $4 prescription from Walmart, yet has a four pack per day smoking habit. People that demand that the doctor sign a disability form so they don't have to go back to work. Parents who use food stamps in front of me in line and then put their groceries in the back of their Cadillac Escalade with 26" spinner rims. A 17 year old with four kids whose frame of reference and way of life is to live on a government check. The woman at the clinic who is on MediCal, pays nothing for the $500 IUD I just put in her, and walks out chatting on her iPhone with a Coach bag slung over her shoulder.

I had expected my work here, even though I was in school, to be rewarding. And sometimes it is. But more often than not, I am confused by a population that drives a nicer car than I do to the swap meet on thursday morning, while I go to work. Some of my patients are appreciative of the care they have received, and motivated to make changes in their own health. Most of the time, however, the patients treat me like it is my duty and honor to serve them, and demand a lot in return for nothing. What I'm left with is a genuine desire to help those in need, with a disillusionment of needy people. I feel like my work here matters, but only to a few. I am tired of trying to make changes in people's health who only want Vicodin and a disability form signed by the doctor. I enjoyed working in practices where bills were paid by private insurance; where the patients asked thoughtful questions, were polite to me, and seemed committed to maintaining a healthy lifestyle.

I don't like myself for wanting to work with those above the poverty line. It seems like a failure, like I wasn't good enough of a person to reach out to those in need. But what I've experienced is that you give and give to people who are not invested in their own health and it is an unfulfilling experience for all involved. The truth is, public clinics have a hard time retaining doctors; they come for a few years (possibly for loan repayment) and then move on to a better life. I want to be a doctor who is excited about what I'm doing, who feels like my work has a purpose. I thought the greatest purpose of all would be in serving those who would otherwise not receive quality healthcare, but instead I'm left wondering what might be a better fit for me. In the end, all people need healthcare, everyone gets sick. It's just that some have better access to care than others. I am not content settling only in a comfortable practice with patients that pay their bills on time, but maybe there is a balance between this and the community health center. I'd love to have a practice that is a good fit for me and volunteer for Doctors Without Borders. Is this enough? I don't know. A comfortable, wrapped up ending to this post? There isn't one. Somewhere between my sense of morality, guilt, and desire for an enjoyable practice I'll have to figure out how and where I should practice medicine.

What Do I Want To Be When I Grow Up?

One of the great things about medical school is it allows you to put off the question "what do I want to be when I grow up?" Sure, you decide to become a doctor and go to medical school. But the real decision- what kind of doctor you're going to be- is put off for another four years post college graduation. While your peers are stuck in a working world trying to find their niche, you are protected in the safety catchall of "I'm in medical school."

I'm supposed to decide on a specialty soon. There is this TV show, Scrubs, that I love because it portrays the experiences of a couple young physicians. It's goofy, but really taps in to some experiences that must be essentially universal for all young doctors. One episode (that I saw while in my first year of medical school) shows the student sitting on his stuffed unicorn, asking it what his specialty should be. At the time I thought, well that's stupid. They must have put that in there just to make the audience laugh. Now that the time is near for me to choose a specialty, that actually seems like a reasonable solution. I have no better ideas for how to make the decision.

So much of the perceptions of the clinical rotations is subjective based on the experiences that the student had during that time. Do I dislike family medicine because the patient population that I worked with was noncompliant, the clinic was four degrees too warm and smelled like a bologna sandwich, and the attending didn't let me talk or touch? Or is it because I really don't like being only the sounding board for problems; for having to redirect anything too serious into the direction of a specialist? Do I love ob because I had an attending that let me do deliveries, assist in surgery, and do patient exams on my own? Will I still love deliveries when they are in the middle of the night and I've been doing this for thirty years? Is it just the novelty and excitement of the experience that I love, or is it really that I love the experience?

Someone told me once to pick the specialty that you actually want to read the journals that they send you. I think that advice actually has a lot of merit. Once I got into medical school, I seem to have automatically ended up on the mailing list of every professional organization out there. I now get more junk mail from professional medical groups than I do from the grocery store, drugstore and LL Bean combined. From the mail that lands on my coffee table, the journals for cardiology, surgery, neurology, and pediatrics get tossed in the recycle bin immediately. I'll peruse the journals of osteopathic research, oncology, and family practice, and then recycle those. The journal of obstetrics and gynecology gets read and kept for another look.

Despite these inclinations to a particular practice, its still hard to choose. It's unsettling to commit to a lifestyle of being on call. Specialties like dermatology, ophthalmology, and anesthesia offer a comfortable, rested lifestyle (which is very appealing in itself) but possess less inherent interest for me than obstetrics.

So, I'm kind of left where I started. Do I choose a practice that I declare the hours and workload, and am left with medicine that I like but don't care deeply about? Or do I match with a residency that trains me for a lifestyle of long hours but rewarding work? I'm not sure. But I'll have to figure it out pretty soon.

Now where's that damn unicorn?

The Great Physician

Today I accompanied my parents to the church I grew up in. Reading through the prayer requests, I was struck by how the great majority of them focused on a physical ailment. Loved ones who suddenly died of heart attacks. So-and-so with Parkinson's. A newly diagnosed breast cancer. A kid with brain tumors refractory to chemo and unhealed despite gamma knife surgery.

The church prays for God's healing hand on these people. My heart has a different prayer: "Help me become a good doctor." I believe sometimes God does miracles, and can heal people. More often, I believe that he provides medicine to do that for him.

As I thought about this, I reflected on the idea of Christ as The Great Physician. Luke recorded this phrase, probably in reverence (and some jealousy?) as he himself was a physician. Jesus was a doctor with many specialties. Some that come to mind are:

• Dermatologist: he heals men of leprosy (Luke 5)
• Orthopedic Specialist: crippled men are healed (Mark 2, Luke 7)
• Otolaryngologist: he heals a deaf person (Mark 7)
• Opthalmologist: the cure of a blind man (John 9)
• Pediatric Intensivist: the healing of a dying child (John 4, Luke 8)
• Hematologist: curing a woman who had been bleeding for 12 years (Luke 8)
• Neurologist: the healing of an epileptic (Mark 9, Luke 9)
• Pyschiatrist: healing of mental illnesses (Matthew 4)

The quality of all these encounters was caring, listening, clear directions, and effective treatment...all the aspects of a patient visit that a good physician wants to create. As I consider my career in medicine, with Medicare cuts, health care reform (?), and uncertainty in the profession, I pray that my life in medicine is modeled after the Great Physician.

The Cost of Medical School

At our white coat ceremony, the speaker warned us of the sacrifices we would have to make to become doctors. I was so happy to be there, I wondered what he was talking about? My whole life I wanted to be a doctor, and now I finally was going to be. It would have been more of a sacrifice not to get in than to do the work to get out. I looked down at my clean white coat, embroidered with "Anne Kennard, Student Doctor" and thought, whatever it takes, its worth it.

What does medical school really cost? Four years, eight if you count residency, but you knew that going in. $45,000 a year, plus living expenses? Somewhere along the way you realize that it costs more than that three hundred thousand dollars accruing at 6.8%. What it really takes is the focus of your life. You have kids, but hey, you've got to study. You work a long day, and come home to answer practice questions at night. It's hard on your self-esteem, because nobody likes a medical student. The attending is riding you, the nurse is resentful because she has to take orders from a student that knows less than she does, you're in the office staff's way, and you are competing with the other students to look like the star. You rotate in a different place every four weeks, packing your suitcase and stethescope and leaving your spouse.

Sometimes I wonder if someone knew, if they really really knew, what it takes to become a doctor, would anyone do it? Some days it feels like no, but the answer I came to for myself was ultimately yes. It takes more sacrifice than I ever imagined, but I'd still do it because I love medicine and feel like nothing else would be quite right for me except doctoring. You're lucky if those around you support you, because it is quite possibly more of a sacrifice for them than for you. I have classmates whose wives have put their careers on hold to focus on kids while their husbands are in school. I myself have a thoughtful husband who does the dishes while I study and who packs my suitcase when I'm leaving him to go on a rotation.

Someday, it'll be worth it. I'll be a doctor, make money, and have more time at home (or so I'm told). I'll chip away at that interest, working my way down the principle. I'll start doing the dishes. Maybe someday I'll be on a medical faculty somewhere, informing another little doctor of the costs, both monetary and otherwise, and they won't know what I'm talking about. And that's probably for the best.

My suitcase, packed for another rotation

For Your Entertainment

Today I saw a 90 year old man with prostate cancer. He was getting some chemo, but doing well. I asked him what he likes to do for fun, and he said that he goes to the gym for an hour four times a week. Impressed, I asked him which machines he likes to use at the gym? He said, "Oh, any old machine...I just sit on it anyway and watch the ladies."

LOL.

Picture Books

Being a medical student is a lot like being a toddler. A small child is exposed to so many new things each day, her world grows exponentially in a short amount of time. Likewise, each day I see new things and am exposed to new situations, forming a frame of reference for the rest of my career. We show babies picture books in the hopes that once they see an picture, they will be able to apply that knowledge next time they encounter that image. What else is medical school? I see something once or twice, learning the character of that disease, in the hope that next time I see it, I'll correctly diagnose that patient. Of course, I had a lot of books during my didactic years in school. But the picture books are formed during the clinical years.

Some pictures in my book:

The joy on a father's face when I hold up his baby for the first time

My first written prescription

A tiny 15 week old fetus with perfect fingers and toes, laying in my hands

The subtle differences between polyps, ulcers, cancers, and rashes

The waxy covering on a baby I just delivered

A young patient dying from incorrect treatment of neutropenia

Riding along for a home visit of a bedridden patient

A chest wall covered not with skin but with the surface of an extensive breast tumor, beginning to be gangrenous, and my hand holding her hand

A tiny heart beating on ultrasound

I suppose the nature of these snapshots is that they are something new; something different, shocking, heartbreaking or joyful. You remember them clearly to try to create a healthy experience, to fix something earlier than when you saw it before. There's a weight of these images; a responsibility to know them and learn from them. After all, these picture books form the foundation of a physician.

The Family Doctor

Every physician is a family doctor. I don't mean to say that they all specialize in family practice. On the contrast, the majority of physicians now enter subspecialties. My point is that every physician, no matter their specialty, ends up being "the doctor" in their family. Sometimes this is okay. There's not a holiday that goes by the someone doesn't want a mole looked at, a consult on pain or bleeding or GI trouble...whatever ails them. Usually I don't mind taking a look and giving an opinion, although sometimes it is tiresome. What I'm struggling with is where and how to draw the line between family and patient. I think the real issue is that there is no line to draw within myself. I am not a doctor from 9-5 (or 7-11, more realistically), and a daughter, a granddaughter, a niece, a wife on all the other hours. I've said it before, you are never "off call" as a doctor. It is a casualty of the training. You think and observe medically, every moment, without thinking about it.

This duality is something I haven't learned to balance yet. It can be hard both ways: for a doctor-daughter to be a family member while entrusting her parents' care to other people, and for a daughter-doctor experiencing human grief whilst being expected to care for and relay medical information to the rest of the family.

My dear friend lost her young fiance last weekend, after he collapsed during a half marathon. She said he had a massive brain hemorrhage. My friend heart breaks for her, while my doctor-friend mind wonders if he had an arteriovenous malformation, if the increased heart rate and blood pressure probably triggered the rupture of the aneurysm. There is no separation between these two thought processes for me.

So, I am learning to manage this new addition to myself. It is easier to go to the hospital and just flip through the chart, rather than pestering a relative for information that they don't have. On the other hand, if I find something abnormal, I feel compelled to do something about it, and maybe miss out on the richness of caring for someone simply as their granddaughter, their friend. It's hard as a doctor to trust the care of someone you love to another doctor. But you have to, otherwise you'll be exhausted of patients before you even step foot in your own office.

iRx: An Oncologist's Prescription for Treatment

Oncology allows room for the humanistic side of medicine. A lady presented today for a follow up on her metastatic uterine carcinosarcoma. She had been feeling very weak from her chemotherapy, and needed another treatment and a CT scan. She wanted to go to Monterey for two weeks over the as holiday to visit her son, but it interfered with her treatment schedule and she would have to come home early. The oncologist told her not to worry, and to come in when she got back for her treatment.

This recommendation was not on the treatment schedule published by the American Cancer Society, but it was on Mary's* treatment schedule. Why? She is 85 years old, with metastic cancer. A visit with her son may be the best medicine for her. Will her cancer progress faster given the treatment delay? Maybe. Will this be her last Christmas, either way? Probably. The oncologist knew this and governed her treatment accordingly.

This is what I love about oncology. You see a patient for a prolonged period of time, in a manner that no other practitioner experiences. You get to know what matters to them and their family. It is one of the few practices that you can stray from published guidelines and still remain in practice. You can make treatment decisions based on the person, not the disease.

Amid a practice of dying patients, success lies not in the prolongation of years, but in the improvement to your patients' health. And even though you know how it ends, there is great satisfaction in contributing to the well-being, both physical and mental, of these patients in their time of sickness.

*name has been changed