jobmd
JOBLOG
A pondering emergency medicine physician
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To the Leaves
I’m sorry we didn’t appreciate you,
When you were green,
Everything that you did before you fell,
The shade you provided,
The abode to many,
Before we whisked you into bags,
Into trucks, black smoke pluming,
Now you are gone and it is silent,
And yet you will give us another chance,
A lesson in forgiveness
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Sick vs Not Sick
When you’re not sick, it's hard to realize how disconsolate it is… A casual swallow feels like shrapnel from a viral explosion; air barely squeezes past nasal turbinate rubble. The symptoms are never crucio levels, but they are just enough to bother. They keep your mind on alert… “We are under siege, so don’t go overdoing yourself. Drink water, eat some soup… and hopefully, it will all be over soon. Tomorrow will be better.”
I was good for a while, until I wasn't. Even then, my innate immune system handled offenses thrown its way. How does an entire household can come down with COVID except one member? There’s so much we don’t know about our bodies, especially how systems interact… now my happiness is dependent on my gut microbiome? But eventually it did happen, I got sick, and now my whole body reminds me constantly. It hurts, it’s annoying, and generally I don’t know how to feel about it. I think it will pass with time, like most things do, but what if it doesn’t? What if I’ve mistaken a common cold for something more pernicious and more pertinacious. I’m trying to focus on getting better, getting back to my life before sickness. I promise to appreciate that feeling of not sick. But what if I succumb to the disease?
The sting of the IV focuses a scattered mind. The cold fluid flushes over me - a cool, salty refreshment - and already I am feeling better. Placed by a skilled hand, patient and provider are now bonded in blood. As the fluids drip, the connection grows, and I feel like a new man… oh what a bag of saline can do. As much as I like to think I am strong, I need medicine. We all get sick. I am a statistic, based on genetic, epigenetic, and environmental influences. My thing is, I don’t really want to be a statistic. I want to be me, healthy and true. Not sick, I notice how good my breath feels. Not sick, my nose is clear, my throat is smooth.
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Me, The Gardener
I used to think, in the winter the plants died,
Had I never heard of a perennial?
I understand the seasons, but sometimes not this season,
Is it always so hot?
I sometimes plant at the wrong time,
Don’t some seeds want something new?
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Loss
When I was a kid I used to lose things all the time. It would infuriate me… and I would ask God, “Why do I have to spend all this wasted time looking for something… Can’t you just reveal it?” Although I lose things less often now, that question still creeps up in the back of my mind. It’s hard for me to realize the benefits of searching… or of losing altogether, although deep down I know they exist.
Faced with prodigious loss in my life, I still struggle to find the good. Here I am, searching, digging deep, examining my psyche for sparks when all I find is void. It’s a dark nothing out there sometimes.
To be human is to search. In college I studied anthropology, specifically ape behavior. I was struck by their intelligence and social structure… a lot of which I (we) don’t fully understand. What makes us uniquely human, is so clearly not our intelligence, but our unquenchable desire for knowledge.
I guess where this leads me, is that it is ok to not understand. The desire, but lack of understanding is what makes us us, and I am comforted in the unity. All of us humans experience loss, and we bond through confronting it. I recently read that when we are sad, we want to be helped, heard, or hugged. In reality, I think we just want to be hugged. As a non-hugger, I mean this metaphorically of course.
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All Me
I thought I didn’t like this guy at work. Dislike…It’s a primitive, shallow, immature excuse for an emotion. It makes it easier to avoid, like swiping on my social media feed, off into the digital abyss. Of course, obviously, duh… I didn’t understand him, his past, the situation, or myself. I never want to judge, and I realize that we all do, and I’m ok with that. Usually I can take a step back and realize that everyone has struggles, everyone has different experiences that shape them, but this went beyond. What I didn’t realize is that other people do like him. He wasn’t even being a jerk, it was actually all me. All me for real. My insecurity, my struggle to express, my fear of failure and vulnerability. Other people appreciate his personality, his humor, and his general presence… and he is needed for them. His presence is based on others’ perception and feedback.
He, a person, just like a cell in an organ, doesn’t exist alone. A cell's personality is defined by its milieu, dynamically changing based on others’ perception and feedback. A red blood cell doesn’t choose to be red, but it binds oxygen just the same, delivering it to tissues in need. We all have our roles, our duties, and despite my best efforts, mine is not to judge, or even to understand. We do what we think is needed in the moment. My goal is to recognize that moment, so I can enjoy it. Genes beget DNA, beget RNA, beget protein, signals are sent, and communication defines life.
I know I don’t have to like everyone and everything. As I get older, the more I appreciate brutal honesty in others and in myself. Let’s not waste time on this ride. But like and dislike are the first step to understanding deeper. When I dislike, I want to look inward and express my feelings further. And when I like, I want to appreciate the connection, like a red blood cell scooping up a perfect fitting O2 molecule.
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Organic
In the summer, I planted seeds of grass in the yard,
I quickly learned they needed to by soaked, respect to the sun,
Oxygen gave some life, but the seed majority nestled into stasis,
What becomes of the un-grown, under layers of footprint foliage?
Do they dig deeper, try harder, or harp patience, stay strong?
When do the bonds that hold them grow weak?
I imagine nirvana; the soil breaks down their DNA,
The hands of the double-helix unfold, embracing the surrounding mycelia,
Atoms collide, nitrogen transfers, and the seeds grow after all.
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Water
Water, water, a servant of the dry earth,
Forever reparations for the crimes we commit,
A tithe… a toll, tax or compact,
Although only time and compassion can gift,
The cardinals stay loyal, the other birds drift,
The wave travels, the soil flora shift,
But where do we sit in the entangled vine,
On this rock, our place in line,
Mind your step, they say across the pond,
A constant lesson for those with eyes to the sky,
With lungs to the trees and a heart always radiant,
To breathe is to thank and and to think is to pray.
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hERe, thERe, EvERywhERe
The sanctuary lamp in a catholic church always burns; a vibrating unity amongst places of worship. To me it represents solemn peace, as I feel myself kneeling before something grand. In the ER, we have sacred turkey sandwiches, holy Haldol and soft restraints that strap us all together. In my career, I have gotten to know roughly 10 different ERs… all with unique features and flow, yet hold common truths. The omnipresent, ever-open ER, an idea of unknown, unexpected and all-accepting, now feels like home to me.
The last few years I have grappled with adulthood, realizing time accelerates as you grow. This period has been defined by my time in the ER, as a pre-med, student, resident, and attending. The metamorphosis was a blur, and life thereafter has not slowed despite my best efforts to keep on the brakes.
The ER itself is grand-prix; and it’s easy to get caught up in the chicane. Everyday I see life-altering moments, unfair diagnoses, also compassion, sacrifice. I see gun shots, bed bugs, pompous, poor, red and blue. Sometimes I feel big, yet most of the time I feel so incredibly small, and it puts my life into perspective.
I round the corner and pause outside the room. My vantage is familiar, off-white, clean. Inside is warmth, color, humanity. As I am about to report good, or bad news, I ritualistically open my hands for communion. I take it, step to the side, and breathe. The rhythm brings me home, slows things down and reminds me of my place in the grand universe. The sanctuary light is warm, when I remember to be vulnerable and greet the now around me.
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I Am Gladiator
Omricon hit, hospitals filled, and the ER felt like a tension pneumo needing decompression. I was suffocating, recognizing symptoms from an experience in my final year of residency. At that time I was moonlighting, interviewing, balancing a long-distance relationship, and taking care of an elderly, weight-challenged pug (and his instagram fame)!
I thought I was fine… in-spite-of multiple attendings, friends and family telling me I was burnt. Finally, post-shift, a mentor asked if I was ok and it hit that I was not.
It took meditation to bring me back to the motivation that got me into and through med school. I remembered my family, my education, my passion, and I sublimated stronger on the other side. I chose the ER for a reason; not for the life-saving moments, but for a marginalized population falling through the cracks.
Nonetheless, on the 3rd wave of the pandemic and I felt short of breath again. There were good moments, but I was overwhelmed by the nihilism that the healthcare system imbued, particularly with patients who were held in the ER, in waiting rooms, being denied the care they deserved. Healthcare workers cried out, but were left on read by admin, gov’t and local {physician} leadership. Heading to work I felt like Maximus, stabbed in the back, rising from the dungeons of The Colosseum to fight Emperor Commodus.
I didn’t want to continue my current path, and contemplated leaving medicine altogether. I sat, eyes closed, and looked back… I thought about my mentors, the ones who helped me through the stress of residency. I thought about my dad (ID doc) and mom (pharmacist) discussing Vanc, Dapto, at the dinner table…. About my first bio class, my wonderment of the miracles of the human body. I always wanted to be a doctor, and during each step of that path the fire of my passion rose. I let the flames of reflection consume me until the temple of my body collapsed into inferno (cue, Donda).
I like being a doctor; it gives me purpose (and endless party stories). I cling to it as an identity, and as I dive deeper, I realize this is my ego, my insecurity revealed. At this point, I wish I could say I took a macro-dose of psilocybin, DMT or licked some chilean toad and my ego died. In reality, I had to hold my gaze in the mirror while taking away each aspect of my identity. Instead of seeing my past, and my future, I just saw me right now. I didn’t worry, plan, or reflect. I am not my”self”, not JOB, not a doctor… I am my action. I am my DNA in motion, forever a thermodynamic representation of family, humanity, biology. I will transform, but my actions will carry on.
In the end, when a maimed Maximus overcomes Commodus, the empire is his. Without hesitation he surrenders it to the senate. There is no thought, no desire for recognition, only action.
They say no two golf shots are the same. For me, no two decisions are the same. Right now, I choose medicine, but it’s different than when I chose it as an adolescent. I know the ugly, the mountains beyond mountains (RIP Paul Farmer), and the unforeseen valleys. Without hesitation I choose the people: the patients and the individuals who care for them. I choose to listen, to overcome, to battle for others. I choose patience over worry. I am right now. I am gladiator.
“Whatever comes out of these gates, we've got a better chance of survival if we work together. Do you understand? If we stay together we survive.” - Maximus Decimus Meridius
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Masked Man
We’ve all gotten more familiar with masks as of late. There exist different shapes, designs, but the small, blue variety has won out. An uncomfortable paper-like garb that represents this enduring pandemic. We mask to protect us from COVID, yet masks expose society’s flaws instead. With masks hiding our expression, Zooms hiding our reality, and social media hiding our presence, we live in a post-community era. We have witnessed a strain on schools, hospitals, and everyday human interaction. We sink deeper into the confines of the zucker-verse, and it becomes easy to lose our filter and respect for others’ afflictions. Although the effects are not all negative (WFH, Telehealth development, more time in comfy clothes), it does seem that as individuals we have become more self-serving and perhaps more egotistic.
On the topic of egotism, we look to its patron saint, Kanye West (or just Ye). With his latest album release and ostensible divorce, he has nagged the public eye like a floater. Never shy to flaunt a new wardrobe, recently Kanye has been seen in some brash fits. His boots are oversized, croc-type material and that might help if you were in a storm on the moon. His jeans, leather jacket and hat are black, boxy and faded. If I had to label, it would be ‘apocalyptic dad bod.’ Nevertheless, it is Kanye's masks that have defined him. Leaving no ornament left unhung, Kanye’s embracement of masks has been well-documented, predominately with the bedazzled Margiela full dome coverings in the Yeezus era. Nowadays he has diversified; from an all black ski mask, to Jesus painting hoods with just breathing holes, to even a few halloween inspired monster masks.
Although the precise meaning of each may never materialize, for Kanye, the mask continues to protect him from illness and from the public eye alike. He managed to make a medical device fashionable, albeit a bit scary. It is our human nature to adapt and evolve, and we have demonstrated strokes of genius in the face of the spike protein. We have developed a vaccine, novel treatments and technology, and remote strategies for continued productivity. The successes during the pandemic have been from dedication to science and achieving goals, not finger-pointing about masks, vaccines, mandates, or Kanye’s recent antics. When we take off the mask we are the same people as before, with the same problems. If we aim to solve these problems, looking inward is a start. COVID is not over, and us on the frontlines must continue to be an example of perseverance and not political divide.
I get frustrated often, often at work. When pushed to the brim, as everyone in healthcare has been pushed, I’ve judged, lashed out, and spoken poorly of others. I’ve learned this only makes me feel worse, and deliver worse care to my patients. I chose to be in the ER, not for the variety of medicine, nor the shift-work. I chose it to remain calm in times of stress, to navigate a tortuous system for people in need. We may never go maskless again inside the hospital confines, but alas, let us not forget what is beneath.
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Nirvana
Sometimes we loose. The world closes in, and we have nowhere to go. Where do we go from there? How can we take good from a truly awful situation? I had to tell the husband, parents, that we could not bring her back. I left them with the unimaginable. I left lost and empty, trying to pick up the pieces.
I pick up the dog toys, try to get them organized. Last year we bought a house. As we upgrade furniture, kitchenware, rugs and lighting, I realize the greater challenge than upgrading is down-cluttering. After years of building, it seems an impetuous and unceremonious transition to breaking down.
I break down thinking of the unimaginable. I think of my own family, our losses, the passing of my dad last July. Often we try to focus on the good times, neglecting the undeniable sorrow and its significance. Sadness and joy both exist, related and unrelated, a concept of non-duality that I strive to understand. I breathe in… I breathe out.
In buddhism, Nirvana is described as a release… Literally, to breathe out, exhale. It is less-so an achievement, more-so an emancipation. Monks spend lifetimes meditating in search of Nirvana. Buddha sat under the Bodhi tree, and gained enlightenment only with his renunciation of all things.
All things I ever wanted was to go to medical school, then to get into an emergency medicine residency, then to find a job. Here I am, jobful but not full. Just like my house, I begin to declutter. I renounce, realizing I am not my job, not my salary, not my failures nor my successes. I appreciate the broken chains, the weightless feeling without The Earth’s gravity. I am happy, and sad.
The next day at work I got a call from a patient I had seen a few weeks prior. “You saved my life.” She said. I try to understand; I breathe in… I breathe out.
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It’s Quiet Uptown
Have you ever gotten sick after pushing through something? You have 3 finals in 2 days, might have pulled an all-nighter, head buzzing off Rockstar, driving home to see your parents and you notice your throat is sore and your head is light. Next thing you know you watched 2 straight seasons of Entourage because you couldn’t lift yourself off the couch. I doubt the physiology is well understood but it’s as if your body is getting back at you for sacrificing it in the name of a report card.
This is my brain post residency. Looking back, it’s hard to re-face the tribulation. The misses, the near misses, the I wishes, the we did everything we could, the this was their time, the young, the old. Telling a parent we couldn’t get their son back, then going to see another patient. Such suppressed sorrow.
I loved it, I hated it, I learned, I failed. I found myself and lost myself in the same breath. I was so focused on being a good doctor that I forgot what got me there in the first place. I got sad leaving the ER, and felt anhedonic on off days. With time and reflection, I am able to refocus. I realize that the best me is the best doctor, and a rising tide lifts all boats. Now, when I get frustrated, I remember my desire to help others, my determination to become a doctor, and my family and friends who sacrificed to help get me here.
A wise cashier at the hospital cafeteria told me it’s a blessing everyday you walk out of a hospital on your own volition and your on your own 2 feet. I don’t know how to tell a parent their son is gone. I can’t imagine being in their shoes. I couldn’t process this then and I still can’t now.
One particular day I walk out of the ER and shove an AirPod in; the Hamilton soundtrack comes on and a song called It’s Quiet Uptown plays. For those who haven’t seen or heard Hamilton in its full, please do so immediately. The song showcases a broken Alexander after he loses his son and is now, “working through the unimaginable.” The piano arpeggio sets the stage as Hamilton learns to live with loss, guilt, while struggling to maintain his sense of purpose. Medicine for me is, often times, unimaginable. I can’t possibly explain the infinite sadness I have not only witnessed but played a role in.
There are moments that the words don’t reach
There is suffering too terrible to name
You hold your child as tight as you can
And push away the unimaginable...
Hamilton finds no resolution, nor does he search for it. He simply and humbly asks for forgiveness… and so will I. As a resident, I felt bombarded by checks…. At times I felt as though I couldn’t take a step without someone questioning it. As a fresh attending, I feel naked without the safety net. I pray that I am enough and ask for forgiveness when I am not.
This past summer I lost my dad, and it is my deepest lament that our medical careers did not overlap. He was a reserved, yet happy being. This aura resonates with me now more than ever. Words cannot quite capture the experiences inside the walls of a hospital. I wonder if his demeanor was formed by years of working through the “unimaginable” at work: not able to fully process what we do but thankful to be a part of it.
There are moments that the words don’t reach
There is a grace too powerful to name
As we learn to live with the unimaginable...
-It’s Quiet Uptown, Hamilton
On my last shift, and on my next shift sorrows are met by miracles of similar clout and my hope continues. When I sit and listen, really listen, I have been floored by patients’ grace and gratitude through suffering. It is with this admiration that strive to do my absolute best for everyone that I have the pleasure of meeting in the ER. And when the unimaginable hits, I know my dad is by my side.
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Choreographed Chaos
I don’t know if it’s the mask or the mask debate… but sometime in mid-2020 a breath of fresh air became my new religion.
Just like that I find myself outside, using the plum colored sky as my reflecting pond.
I drag my diaphragm down and pop open every last alveoli, realizing that I only get 21% oxygen. I breathe deeper, thinking I need more, and I look up. I see Saturn and Jupiter beaming at one another in choreographed chaos. The Moon illuminates my wander.
I look down, Chico is reviling in the layered aromas. Does he adore the stars? How infinitely more magical they would be, if I didn’t know their composition. In The Moon I see my dad and I feel him pat me on the back, sturdy. He is lithic; the salt of the cosmos.
Clouds sulk past. In the hospital I live a life of reality, not of imagination. Statistics meet diagnoses. In school they don’t teach us that numbers have family. You never learn that probabilities are, at best, probable.
Exhaling CO2, I watch its apparition spiral away into the pond. I ponder the life of my breath… the carbon atoms…. Were they once a part of my dad? Perhaps they spent centuries on the gray beaches of The Moon. Wherever they were and wherever they go, I am now along for their cosmic ride. I am carbon. I am The Moon, Saturn, and I realize that 21% oxygen is quite alright.
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Nauseous and Proud
In residency, the carnival began. I payed the entrance fee; enamored by the flashing lights, nuanced smells, and endless supply of strange. Everyday I hop on a ride, spin around in a saucer, and hold on until my turn ends. I step off holding my paper bag. I’m sick, but I’m happy I did it.
Reality. I get home, take the dog out as my lungs thank me for providing non-hospital air. Just a few hours earlier an older woman remained aware and appreciative as her heart’s electricity literally twisted around a point. While working to reboot her heart I was pulled next-door to a man who demanded narcotics for chronic pain. I sat with him, my knee tapping anxiously. He wanted to know why I could not (would not?) give him the medication he desired. The first patient got a pacemaker… The second? A heart-to-heart and a referral to pain management. I can’t decide to feel nauseous or proud so I pick both, a feeling to which I’ve grown accustomed.
A lot has changed in 3 years. Textbooks came to life as I struggled to remain me in situations I never imagined I - or anyone - would ever be in. What do you say when a patient demands to be admitted without a medical problem? What about when nurses refuse to care for a verbally abusive patient who requires medical attention? A consultant who refuses to consult?
I look down; I see me, and I see me struggle through the complex human interaction. I know who I want to be and we are fraternal at best. I wish I had spontaneous creativity and compassion. I want to be able to stick to my values, to what got me here. I write and I reflect, and I hope to get better. For me, this is residency: an imperfect doctor working in an imperfect world.
Another day. I twist around the tilt-a-whirl and the ride slows to a halt. The carnival is ending and I only was able to try a few of the rides. I still have so much to see and learn, but in a lot of senses, I grew up. I got engaged, adopted a dog (luh u Cheeks), bought a house, and fulfilled my dream of being a doctor. I am so incredibly thankful for everyone and everything that got me to this point, including all the patients I had the opportunity to care for. Now, my goals shift from achievement to appreciation. I think of what’s ahead… perhaps a theme park?
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The Beast (Part II)
The administration was tired of losing money on the sepsis campaign. Ding this, ding that. Go ding yourself, they said. Their leader, Claire Difton, had a solution: combine all antibiotics into a bazooka super-drug. “Even the ER doctors can’t mess this up,” the suits muttered after slide 52 of her powerpoint.
In went the penicillins, then the aminoglycosides, followed by the cephalosporins, so on and so forth. Alas, they almost forgot the secret ingredient, hand sanitizer. The pipette of Purrell dripped its last drop and the concoction boiled over. Overjoyed by the creation of their new Fevrmycin, they didn’t see the smoke billowing from the leakage into the drainage system.
The Fevermycin dripped into the depths of the hospital biohazard waste onto fresh pathology specimens. Acid became deoxyribonucleic and a terrible teratoma twitched to life. The Beast was spawned... humble roots indeed. Over the next few weeks, the beast inhaled used syringes like water in a forgotten-about NPO mouth. The beast grew: rows of scalpels as teeth, petri dishes as eyes, latex glove fur. The beast grew…
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Who am I?
A wave of electricity crashes and my heart opens. It must be high tide… a full moon, perhaps. Chemicals vibrate, shimmering like stars in the sky, sending signals to those who accept. Blood meet brain, brain meet blood. Thoughts fibrillate… is there more? Who am I, really, and do I exist outside of this amalgamation of acids?
To answer, it would behoove me to first look where I inherited 49% of my genetic makeup. As a kid my father was difficult to get to know, and only now do I appreciate the lessons he taught. His reticence of judgment accentuated his subtle personality, exemplifying patience and gratitude. Although quiet he was the opposite of absent: he taught me how to drive, guided my college decision and attended all of my DIII college football games. In his most present times he remained reserved, providing space for growth in depths of mistake.
In 2012, I called my dad, told him that I had gotten into medical school. He told me that was the best thing that ever happened to him.
Now, with my father’s dementia advanced, I see his presence more clearly than ever. He doesn’t walk well, not able to say much, but when he does he is thankful. When I am with him I am calm, open. He is proof in spirituality, that our souls exist through connection with others. Who is he? He is my mom, he is my brother and my sister. He is his parents, his friends, the patients he cared for; he is me.
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What’s Best For Him
My dad has gotten lost more than several times; requiring police search and escort. He can’t bathe on his own. He can use the restroom on his own only sometimes.
He has Alzheimer’s and is declining. His course has been slow and steady, but rocky. Each step-off has been more abrupt, more difficult to swallow. My mom has viciously kept her sanity, caring for him 100% of her time.
I have accepted the situation; even felt thankful that our family is now closer. Changed forever, but closer. My mom proposed putting him in a facility, of which I am a strong proponent. My brother and sister are less enthused. My mom, irresolute.
She has gone back and forth: she wants him to be safe but doesn’t want him to be disoriented. She wants him to be engaged but doesn’t want to push him too hard. She wants him to have the best care but doesn’t want him to miss time with family. She wants what’s best for him.
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