All posts by Stethoscopist

Said
8.27.16

you are afraid, the night said
you are too small on this earth
you are dust beneath the stars

but no
not so, I said

I have heard the ocean sing
you are alive, it said

I have heard the wind breathe
you are strong, it said

I have heard the leaves laugh
you are growing, they said

you are like us
here on this earth

I am not afraid, I told the shadows
and sang into the darkness
I may be small
but I am an ember
a spark
a firefly
and I will light
up this night

– Stethoscopist

First Code: Part 2

My resident says to call her after I finish my work. It’s early evening, and I’ve just returned from a teaching session, which was relatively uneventful except for a code blue announcement that made us pause our discussion on antibiotics. Two sets of closed doors had muted the words so I didn’t catch the exact location, but it hadn’t been in a place close enough for us to respond to.  We had finished talking about penicillins and moved on to fluoroquinolones.

I click the mouse to sign my note, adding it to the plethora of documentation in the electronic medical record.  As a medical student, my information bytes don’t count towards anything, but I go through the motions to help me prepare for when they will. I pick up my phone and I punch in the five-digit extension to my resident.

“Before you leave, stop by the computer room at the emergency department. I need to talk with you,” she says.

A brief flash of anxiety. Does that mean I messed up on something?

Take two flights of stairs down, make a quick turn, press my badge to the reader and wait for the beige emergency department doors to ponderously swing open.  Two turns down two more halls, right and right again. I slip into the computer room where we often type up our notes and slide onto a stool next to my resident, slightly breathless.

She swivels her chair to face me. “I have some bad news,” she says gently, her eyes meeting mine. “You know the code blue called this afternoon—”

Somehow, I know what she’s going to say, and everything instantly goes still inside me.

“It was for Ms. ——. She died.”

Silence inside me, the eye of a hurricane.

You died?

You were not supposed to die.

You were supposed to get better in the ICU and come back to our team and I was going to take care of you and you were going to get physical therapy and get stronger and go home and you

were

not

supposed

to

die

This wasn’t part of my plan.

You were alive yesterday.

“She might still be at her room… you could go see her if it would help you find closure,” my resident says.

I know I need that closure—I need to see you one more time. You were my patient for nine days. You were my responsibility. You still are my patient.

I’m biting my lip the whole way down the hall.

I’m not going to cry in the middle of the hospital.

I show up at the wrong ICU on the wrong floor and have to stop to look up your room number on the computer.  Backtracking down a floor, I try again.  This time I get it right.

As I approach your room, counting off the numbers on the walls, I see the curtain is drawn. The room looks deserted; no legs or shoes are visible beneath the fabric hem.

The early evening sunlight spills though the window and the curtain is a glowing sheet of sea-foam green. I peek around it before entering to see if you are still there. Your familiar gray hair spills onto the pillow as I catch sight of you.

I still clean my hands with the slippery foam sanitizer as I step into the quiet ICU room.  Habit, I suppose.

It is so still.

No beeping monitors, no waveform peaking and falling with the rhythm of your heart and the pace of your breaths. For the briefest moment, I entertain the thought that maybe you still are alive. Maybe they made a mistake, and you are just sleeping.

I’ve wakened you so many times over the past week, stirred you from sleep to check your heart and lungs and to see if you’re still having nausea. Maybe I can wake you again. You look so quiet, your eyes closed tight, lashes interlaced. You could be asleep.

But as I pause, I realize there is no breath in you.

That’s when I break down, standing alone beside your bed in the same white coat I’ve worn since I met you. I touch your forehead—your skin is smooth over your skull and not quite cold—and brush away your strands of hair.

I am still crying beside you when the nurses arrive to begin preparing your body, removing the stiff plastic tube protruding from between your lips, pulling off the array of cords and bandages we connected to you in our attempt to stave off the inevitability of death.

One of the nurses gives me a hug and hands me a couple of paper towels.

“She was my patient,” I say by way of explanation. “I’ve only been on wards for six weeks,” I add, trying to excuse myself.

I’m a novice still. I have not seen death like this before.

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Perhaps with time, I will stop crying so much when this happens, when time runs out and red bleeds to blue.  Perhaps I will grow to accept that the air we inhale at birth is only on loan and must one day be returned to the sky.

But you were my first.

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First Code

You were fine this morning.

No crackles in your lungs, no new murmurs in your heart, no grimace as I press into your abdomen, no redness around the catheter line protruding from beneath your clavicle. Nothing new to remark on as I pound away at the computer keys five minutes before I join my team for rounds. Alert and oriented times three, sleepy but able to be aroused.

I am in another room one floor down from yours, awkwardly swaddled in a contact precaution gown, when my resident’s phone beeps. She listens for a moment and then is tearing off her gown and heading for the door; she has to see you immediately. I rush after her, untangling myself from blue plastic sleeves and sweaty gloves.

I only realize I’m on the wrong floor when I see signs for the pediatric unit–not the one I’m looking for.  Turning, I scramble up the stairs.

The code blue is repeated overhead just as I round the corner, breaking into a half-run. People are already swarming around your room, spilling out of your open doorway and into the hall.  I squeeze past them, feeling like a minnow in the ocean.

You lie with your eyes closed, salt and pepper hair spilling over the pearlescent earrings you haven’t removed since you came here over a week ago. A doctor’s voice projects over the noise as he calls out his role as code leader. An anesthesiologist is already at the head of your bed, fitting you with a mask to feed you air.  The crash cart is already at bedside.

The names of medications are called out over the noise, approved, administered.

I squeeze your toes, pinching hard enough to feel your joints beneath my fingers, but you do not pull away like you should. Your skin is cool to my touch, and that chills me.

Move your legs. Move your legs, show me you can move. Squeeze my fingers. Can you hear me? Can you hear me?

Your heart rate is too slow.  We are pacing it, the muscles in your chest and abdomen jerking in rhythm as invisible tendrils of electricity seek out your heart, trying to capture its beat.

Open your eyes. Can you hear me?

Someone is asking for your pulse again, and I press my fingers into the crease where your leg joins your hip, seeking out the beat in your femoral artery.  No time to waste hunting for the smaller arteries I routinely check on pre-rounds.

Your heart is still pumping, tracing out peaks in fluorescent green on the monitor.  I can feel it and confirm it.

Another IV line. The needle slides beneath the skin over your wrist, the same wrist I took your pulse in this morning.  That all seems so long ago, that quiet time when I woke you up to ask you how you were feeling and to press my stethoscope to your skin.

I am in free-fall with no time to contemplate if I can fly.

The ICU will take over from here.  Everyone is unplugging monitors and switching cords and unlocking the bed’s brakes so they can roll you out of the doorway, oxygen tank and IV line in tow.  You are surrounded by a halo of monitors as the beeping bustling fades down the hall away from me.

My team and I regroup for rounds; we still have several patients to see.  The next one is mine, and I need to discuss the mass in his gastrointestinal tract.

I am fine, I tell myself.

I am fine.

 

I am not fine.

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Intention: Humanity

I’ve heard that at the beginning of a yoga session, people may set an intention to guide that period of time and help it translate into life as a whole.  While I haven’t formally done yoga before, I really like the idea of setting intentions.

In past years, I’ve picked a word or phrase to help guide the year in lieu of writing out a list of January resolutions (which I never seem to look at again anyways).  This year, I set an intention to be curious about life and each new experience it brings.  I was in the tentative first few weeks of a new relationship as 2016 rolled in, and my goal of embracing curiosity helped me to keep my heart open to the day-by-day unfolding of what has now become a beautiful part of my life.

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I’m finding that sometimes life can knock the wind out of you, and other times it can give you wings to fly.  The relationship that started with curiosity has been an incredibly wonderful instance of the latter.

Time has been moving quickly, and now I’m exactly 30 days away from starting my first clinical rotation.  The idea of setting an intention is coming up again, this time because I’ve spent a portion of the past two days thinking about what it means to be a compassionate medical caregiver.  I’ve also been spending a good deal of time pondering how on earth I’m going to manage being a clinical student.  I’m 26 now, and I can see that I’ve grown a lot (especially in the past year), but I’m still trying to figure out who I am.  So perhaps part of this is a cry from my soul to reaffirm who I am, to reconnect with the reasons I am in medicine.

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I’ve decided I want to set an official intention for my clinical years.  I already have one (hopefully) realistic goal for clinics: walk into my rotation on Day 1 with my head up, get along well with my team, learn from the mistakes I make, connect with the patients I’m assigned to follow, and walk out the door at the end of the day with my head still up.

As the lyrics go, chin up buttercup.

I also want to have a broader intention for my full 16 months of clerkships.  I think I’m starting to sort that out as I try to chart the courses of the rivers draining into the cognitive and emotional depths of who I am.  What are the reasons at the core of why I want to be a physician?  Why am I doing this?  What is going to get me out of bed every day for the next several decades?

It reminds me of when I was in the throes of applying to medical school several years ago, asking the same question–why medicine?–as I agonized over my AMCAS application form and the ensuing secondary essay questions. I actually went back to some of those essays today, blowing dust from the computer files.  It was like opening a time capsule and reliving the tense anticipation of applying to medical school: waiting for a secondary application invitation…waiting for an interview…waiting on pins-and-needles for an acceptance.

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Are my reasons still the same as they were when I was a 22-year old student fresh out of undergrad?  I believe they are, at their core, although they’ve evolved and grown with the passage of time.

Sitting down with my journal, I parsed out four reasons why I am in medicine:

  1. When I’m able to bring a moment of compassionate connection into a hospital room or patient interaction, I feel like my soul has been nourished (and hope the feeling is mutual with the person I’ve connected with).
  2. I enjoy being able to share information; it’s gratifying and gives me the sense that I’m contributing something to other’s lives.
  3. Medicine is full of stories if I stop to pay attention and listen to them.  I want to learn people’s stories and give them the space to share them, if they want to.  This ties in to reason #1.
  4. Learning engages my mind and makes me feel incredibly happy and alive.  The medical field is one of lifelong learning.  This leads to reason #2.

Ultimately, I found that everything can be reduced to the following: (1) I find compassionate connection with other humans to be deeply satisfying and meaningful and (2) I enjoy the personal growth and sense of contribution to society that comes from learning new information, thinking critically, and teaching others.

So these are the bare-bones reasons of why I am in medicine.  Medicine is an environment where compassion and information-sharing can be practiced on a daily basis, and it positions me at a time point in peoples’ lives where this is especially needed.  I personally found, when undergoing a minor (but painful) medical procedure recently, the only two things I cared about were whether I trusted my provider (i.e. whether I felt he cared about and respected me as a person) and whether he was competent (i.e. could do everything efficiency and effectively).  I know everyone has unique priorities when interacting with the medical team, but I feel that trust and competency would likely show up as common themes.  And those are words I’d like to be able to be applied to me.

I actually feel a bit vulnerable sharing all this on my blog, because it gets down to why I’m doing what I’m doing.  And of course, there’s always the question, is it enough?  Are my reasons good enough?  And am I?  I have to believe that I am, and that I can do this.  I may not become the absolute best at what I do, but I will try my absolute best.

So my intention for the next year and a half?  To be compassionate, to pay attention to people’s stories, to accept that I’ll make mistakes, and to do what I can to learn from them.

In a word?

Humanity.

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Faces

I’ve been thinking about wrinkles, and it’s making me kind of happy. I know that sounds funny, but I’ve decided that I want to live and love so much that when I am older, I will see crinkles like starbursts around my eyes and find laugh lines jump-roping across my cheeks. I want them so that when I look in the mirror someday, I will see all the memories and all the people I have loved etched indelibly in my skin.

I want to see them in the corners of my eyes and around my mouth and along my nose because I want to know, at the end of everything, that I lived life as fully as I could and loved as much my heart could hold.  And maybe then some.

I don’t want to see my face when I look in the mirror.

I want to see a lot more than that.

Alive

Pulse arcing against my fingers
words and silence cast aside
stars and shadows burst within me
I am here
I am alive

This is my reality
the endless spinning of my dreams
echoes, shadows, valleys, meadows
look around
and hear me sing

With this music in my mind
I have the wings to take me high
aloft, alone above the clouds
I soar among the stars and sky

– Stethoscopist | drafted 5.20.15

Looking back

 

It’ve been two years since I wrote the poem below.  I remember being in my immunology class during the second quarter of medical school, listening as our instructor talked about anaphylaxis.  The emotions it evoked later found their way into written words.  I’ve shared this poem a few times in different ways–first in my creative writing class, later in our medical student journal–but I haven’t revisited it in at least a year.

A lot has changed in the course of that time, even if I didn’t see it happening.  Perhaps I haven’t paused and looked back often enough, to see how far I’ve come since the beginning of my journey into medicine.  I’m almost done with my third year now, and sometimes I forget just how much I’ve learned since I began.  I think it is that way for many of us, actually.  We live with ourselves 24/7, and it makes it difficult to see ourselves grow because it happens so gradually.  But grow we do.

This poem looks back to a time when I was seven years old, and my brother (who was a toddler at the time) went into anaphylactic shock after tasting peanut butter.

He just turned 19 years old this January, and I turned 26.

To this day, I’m thankful for the medicine that saved him.

____

Dim lecture hall and early morning and I am sitting in the seat I always take, watching the words flashing against the wall. Pruritus. Urticaria. Angioedema. 

Immunoglobulins, the E isotype, not the A isotype…so many letters to keep straight. 

I am a child again, tracing out the alphabet, learning to spell like when you were born and I had to remember to write your name with an “a” two letters from the end, not an “e.” A child again learning my ABCs: airway, breathing, cardiac. Treatment includes epinephrine. 

And suddenly, we are children again. 

Flashes of images in my mind, a moment remembered, transected from the whole. 

The stroller with its small wheels, and you in it, and Mom bending over to give you a bite of our sandwich because you are hungry on that sunny walk in the park, and we are carefree. 

So ordinary, the child and the peanut butter and jelly sandwich and the young family paused in time on the sidewalk. 

And then the next image, more sound than sight: your sneeze, and the worry in Mom’s voice. 

And then you buckled in the car seat and Grandpa getting into the car beside you and Mom rushing because you have to go to the emergency room. An impression of puffiness, of you and your elfin ears and fine brown hair and a body suddenly too full of that which should have been life. 

An empty driveway, lonesome gray against the sky. 

Me waiting. 

You came back—you came back to us before your lungs could squeeze out the last thin tendrils of your breath and the surging current of medicine drew your tiny boat back from a shore we could not reach. 

And I am the medical student in the lecture hall caring about the mechanism of epinephrine, and I am the sister caring about nothing other than that you came back.

Just One Step

Attempting a new endeavor sometimes leaves me feeling like I’m standing in my hiking boots at the base of a slope, debating whether there are enough handholds to scramble up without falling and breaking my leg.  Or my neck.  Whether it’s writing papers, doing research, or starting a new phase of medical school, it’s often daunting to summon the internal energy needed to begin.

I’m beginning to realize, however, that my ability to gauge the energy required to take a particular action is not always so accurate.  I enjoy meeting goals, and I have some long-term ones in place as guiding stars for my life journey.  It’s like picking a distant mountain peak and saying, I am going to trek from here to there.  Doing so may keep me from getting completely off-course, but if I think that I need to have enough energy to make the 100-mile hike in a single shot, I’m not likely to ever get out the door.

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In reality, I would only need to have enough energy to make it to my first campsite.  I wouldn’t presume to have enough stamina to make it to the end without pausing, and if I felt beaten at the thought of doing so I wouldn’t blame myself.  But I certainly do that with less tangible journeys.  If need to start something and feel overwhelmed at the thought of carrying it to completion, I can respond to myself in any number of ways and they usually aren’t positive.  It’s something I’m trying to become more aware of, and perhaps this post is, in its own way, a part of sorting this out.

Being more realistic certainly would help.  If I realize that I only need enough internal power to get started–to create the ignition spark–it will help keep me keep the big picture in mind without feeling daunted by its implications.  One strategy I’ve used is committing to a first step that is so small, it would be ridiculous not to do it.  Need to write an email I’ve been putting off because it feels like too much to do?  Just log into my computer and open my inbox, and that is all.  No expectations beyond than that–if I get into my inbox, I’ve accomplished my goal.

By beginning with something small like that, I’m able to overcome the inertia of starting because I narrow my focus to what I need for the step right in front of me.  I’m no longer trying to bully myself into walking for miles; I’m just lifting one foot off the ground. I’m surprised each time I do this by how well it works–usually I end up getting far more accomplished than I had planned.

So far, I’ve applied this strategy mostly for writing-related things like papers or emails.  We all face more in life than emails, however.  I have a few landmark peaks in the distance, and the highest one would be realizing my dream to become a physician-writer.  That’s what I’m aiming for: to be someone who cares for the body without forgetting that it contains the human spirit.  It will be a lifelong journey, one that will hopefully include matching into residency, graduating from medical school, finishing my post-graduate training and finding my place in the world as an attending physician.  Right now, I’m just trying to figure out how I’m going to make it through clinics.  It feels overwhelming to think about right now, but I’m going to try taking the one–step approach to starting my rotations this April.

Review how to take a medical history.  One step.

Find one video to practice the eye movements in the neurological exam.  One step.

Watch the video.  One step.

Sign up to volunteer again at one of Stanford’s free clinics.  One step.

They’re little steps, and they don’t seem like much, but they’ll keep me from postponing everything until I feel ready.  Because, honestly, I’ll never feel completely ready.

And one day near the end of April, I’ll take a deep breath and remember to keep my head up.  And I’ll take one step that will carry my over the threshold into my clinical years.

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Lights

I think I’ve found a new favorite refuge, sitting here on a cold cement balustrade in the damp January twilight.  It is the only thing left from Meyer Library, which Stanford demolished last year in a project that morphed the seismically unsound structure into a verdant circle of greenery and flagstones.  Normally I walk right past the out-of-place block of concrete, but tonight I paused for a while as dusk faded to deep blue. Settling down in the driest area I could find, I watched as illuminated windows turned to gold and became the spines of books lined neatly on shelves, bursting with a thousand imagined worlds.

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Above me, branches fringed with silver-green needles held back the ghosts of dissipating clouds. Lamps along the path floated like spheres, their posts fading into the dusk until the lights seemed suspended from the sky — the lures of stars fishing for dreams.  I watched the ebb and flow of people around me: a lady in high heels and a glittering dress, a toddler trailing behind his family, countless bicycles and their riders.  It was like being a drop of water, watching the ocean.

My brain has been a hundred whirring gears, ready to overheat with too many questions about life and not enough answers.  I had decided to go outside partly because I needed to mail a letter, and partly because the paced rhythm of walking has a calming effect on me.  Now, settled beneath the trees, I found it remarkably soothing to simply sit and focus on the illuminated geometry of rectangles and spheres before me.  A line from one of Coldplay’s songs echoed over the clamoring of my mind:

Lights will guide you home

I let my scattered fragments of attention converge on the rails leading down to the paved circle where Meyer Library once stood.  They were lit from below, and the gleaming lines looked like spiderwebs beaded with dew.  Lights guiding the way.

It felt amazing to just sit and notice the metaphors and similes around me.  It was like I used to do all the time as a kid, before college and adult life carried me away from my imaginary worlds.  Stopping to notice things with an open mind is so simple and yet so difficult — like trying to catch sunlight.  Conceptually, catching a sunbeam should be easy: to grasp something, you simply put your hand where it is and close your fingers snugly around it.  The execution is nearly impossible: no matter how many times I clench my fist in the light, I cannot hold it.

It is only when I place my hand into the light with an open palm, that finally, it rests there.