Go Here, bookmark it, sign up for the new email alerts. . and yeah (it's purty)
http://companionpeace.wordpress.com/
If you want the explanation . .see below
Well folks. . (is there anyone even out there anymore).
I know, I've been quiet so long it's like I've been dead. Sleeping, really. . slumbering.
So as most of you know, tomorrow is a big day. . . a big, big day.
It's a change - a big change. So to mark it, I'm revealing my new blog at wordpress.
I've moved all of my blogs over there, so you can change all of your links.
That's what I'll be updating, now that I'm back in the game (oh yeah, so back).
Wednesday, March 16, 2011
Sunday, February 20, 2011
Vulnerability
This is good. . a testament to something I am struggling with daily. . and something that consistently changes my life for the better when I allow it to seep in. . .
Thanks Brené Brown. . .
Find the TED Talks video here
The highlights (the best is at the end) from the speech (haphazardly typed down). .
"And shame is really easily understood as the fear of disconnection - is there something about me that if other people know it or see it, that I won't be worthy of connection. The things I can tell you about it is: it's universal, we all have it. The only people who don't experience shame have no capacity for human empathy or connection."
.there was only one variable that separated the people who had a strong sense of love and belonging and really struggle for it and that was that people who have a strong sense of love and belonging believe they're worthy of love and belonging. That's it. They believe they're worthy.
And so to me, the hard part of the one thing that keeps us out of connection is our fear that we're not worthy of connection.
What the wholehearted people had in common was a sense of courage. And I want to separate courage and bravery. Courage, when it first came into the English Language - it's from the Latin word - cour, meaning, heart). And the original definition was to tell the story of who you are with your whole heart.
And so these folks, very simply, had the courage to be imperfect. They had the compassion to be kind to themselves first. And then others, because as it turns out, we can't practice compassion with other people if we can't treat ourselves kindly.
And the last was they had connection - and this was the hard part - as the result of authenticity. They were willing to let go of who they thought they should be in order to be who they were, which you absolutely have to do for connection. The other thing that they had in common was this - they fully embraced vulnerability. They believed that what made them vulnerable made them beautiful. They didn't talk about vulnerability being comfortable nor did they talk about it being excruciating, They just talked about it being necessary. They talked about the willingness to say, "I love you" first. The willingness to do something where there are no guarantees. . . .the willingness to invest in a relationship that may or may not work out. They thought this was fundamental."
And now my mission to control and predict had turned up the answer that the way to live is with vulnerability and to stop controlling and predicting.
And I now know that vulnerability is the core of shame and fear and our struggle for worthiness, but that it's also the birth place of joy, creativity, belonging, love.
We live in a vulnerable world and one of the ways we deal with it is we numb vulnerability. And I think there's evidence. We are the most in debt, obese, addicted, and medicated adult cohort in US history.
Why? The problem is, and I learned this from the research. is that you cannot selectively numb emotion. You cannot say , "here's all the bad stuff - vulnerability, here's grief, shame, fear, disappointment. I don't want to feel these. You can't numb those hard feelings without numbing the other feelings - joy, gratitutde, happiness. And then we are miserable and we're looking for purpose and meaning.
The other thing we do is make everything uncertain, certain. Religion has gone from a belief in faith and mystery to certainty. "I'm right, you're wrong. Shut up." That's it. The more afraid we are, the more vulnerable we are, the more afraid we are."
Our job is to look at our children and say, "You're imperfect and hard-wired for struggle, but you are worthy of love and belonging." That's our job. Show me a generation of kids that grows up like that and we'll end the problems that we see today.
And this is what I've found. To let ourselves be seen, deeply seen, vulnerably seen. To love with our whole hearts even though there's no guarantee. To practice gratitude and joy. In those moments of terror when we're wondering, "Can I love you this much? Can I believe in this this passionately. Can I be this fierce about this? Just to be able to stop and instead of catastrophizing about this say - "I'm just so grateful because to feel this vulnerable means I'm alive." And the last, which I believe is most important, is to believe that we're enough. Because when we work from a place that says, "I'm enough" then we stop screaming and we start listening. We're kinder to the people around us and we're kinder and gentler to ourselves.
Thanks Brené Brown. . .
Find the TED Talks video here
The highlights (the best is at the end) from the speech (haphazardly typed down). .
"And shame is really easily understood as the fear of disconnection - is there something about me that if other people know it or see it, that I won't be worthy of connection. The things I can tell you about it is: it's universal, we all have it. The only people who don't experience shame have no capacity for human empathy or connection."
.there was only one variable that separated the people who had a strong sense of love and belonging and really struggle for it and that was that people who have a strong sense of love and belonging believe they're worthy of love and belonging. That's it. They believe they're worthy.
And so to me, the hard part of the one thing that keeps us out of connection is our fear that we're not worthy of connection.
What the wholehearted people had in common was a sense of courage. And I want to separate courage and bravery. Courage, when it first came into the English Language - it's from the Latin word - cour, meaning, heart). And the original definition was to tell the story of who you are with your whole heart.
And so these folks, very simply, had the courage to be imperfect. They had the compassion to be kind to themselves first. And then others, because as it turns out, we can't practice compassion with other people if we can't treat ourselves kindly.
And the last was they had connection - and this was the hard part - as the result of authenticity. They were willing to let go of who they thought they should be in order to be who they were, which you absolutely have to do for connection. The other thing that they had in common was this - they fully embraced vulnerability. They believed that what made them vulnerable made them beautiful. They didn't talk about vulnerability being comfortable nor did they talk about it being excruciating, They just talked about it being necessary. They talked about the willingness to say, "I love you" first. The willingness to do something where there are no guarantees. . . .the willingness to invest in a relationship that may or may not work out. They thought this was fundamental."
And now my mission to control and predict had turned up the answer that the way to live is with vulnerability and to stop controlling and predicting.
And I now know that vulnerability is the core of shame and fear and our struggle for worthiness, but that it's also the birth place of joy, creativity, belonging, love.
We live in a vulnerable world and one of the ways we deal with it is we numb vulnerability. And I think there's evidence. We are the most in debt, obese, addicted, and medicated adult cohort in US history.
Why? The problem is, and I learned this from the research. is that you cannot selectively numb emotion. You cannot say , "here's all the bad stuff - vulnerability, here's grief, shame, fear, disappointment. I don't want to feel these. You can't numb those hard feelings without numbing the other feelings - joy, gratitutde, happiness. And then we are miserable and we're looking for purpose and meaning.
The other thing we do is make everything uncertain, certain. Religion has gone from a belief in faith and mystery to certainty. "I'm right, you're wrong. Shut up." That's it. The more afraid we are, the more vulnerable we are, the more afraid we are."
Our job is to look at our children and say, "You're imperfect and hard-wired for struggle, but you are worthy of love and belonging." That's our job. Show me a generation of kids that grows up like that and we'll end the problems that we see today.
And this is what I've found. To let ourselves be seen, deeply seen, vulnerably seen. To love with our whole hearts even though there's no guarantee. To practice gratitude and joy. In those moments of terror when we're wondering, "Can I love you this much? Can I believe in this this passionately. Can I be this fierce about this? Just to be able to stop and instead of catastrophizing about this say - "I'm just so grateful because to feel this vulnerable means I'm alive." And the last, which I believe is most important, is to believe that we're enough. Because when we work from a place that says, "I'm enough" then we stop screaming and we start listening. We're kinder to the people around us and we're kinder and gentler to ourselves.
Tuesday, March 9, 2010
Iron and Irony
"I've been practicing CPR since I was was 12 and yet I have never done it on a real person." This was me this morning as I explained to an attending how all I really wanted to do on my ER rotation was CPR and how I was somewhat disappointed, and more than a little surprised, that I had yet to get the opportunity. I joked, "Maybe I'm a good omen, maybe as long as I'm in the hospital, no one is going to die."
Well, dreams do come true, or irony kicked in, because a bit more than one hour later I was wearing a trauma gown hunched over a patient sweating bullets as I pumped hard on his chest.
CPR is not easy. It is surprisingly difficult, exhausting really. You lean over someone (inevitably at the wrong height such that your back starts aching or you have to be on your tippy toes), you lock your elbows, and then you push down as hard as you can. And then you do that again, over and over and over again. Your arms scream out and when you don't stop, they scream out louder. You realize 2 minutes is an awfully long time. And every time your arms start to lighten up, you remember that you are the only thing keeping the patient alive. It is your hands on his chest, your arms pushing down, your body weight compressing his rib cage and simulating the heart beating and the blood flowing such that your colleagues can feel the pulse in his groin or neck. Your arms, your effort are differentiating life from death. And all the while, all you can think of in your head is, "Harder, push harder, push HARDER," and you sync your hands to the tune running through your head: "Ah, ah,ah, ah Staying Alive, Staying Alive." Or "Dom, dom dom, Another one bites the dust," which is equally effective in tempo, but perhaps a bit more macabre in message. (I tried to sing the former, but ended up with the latter stuck in my head.)"
At 37, this man was not your typical massive coronary artery occlusion leading to cardiac arrest patient. He did not make it. I'll break that news right now. When exactly it became clear that he was not going to make is hard to say. Was it when he collapsed? Was it after the hour they spent in the field trying to resuscitate him, performing CPR the entire time? Was it when he arrived to our ED, chest compressions in progress? Was it when he regained a pulse (albeit slow and irregular) and a pressure (low and nerve-wracking) and was being readied for the cath lab but the attendings for the cath lab could not be contacted - was it that delay? Was it when, after that moment of pulse and organized electrical activity, he slipped back into pulseless chaos? Or was it when, at 8:12, after an hour of CPR and resuscitation efforts and with the parents by the bedside, the code was called?
Codes are interesting things. They are rather gruesome events, but also incredibly well orchestrated, calm, and surprisingly easy to participate in. There are usually somewhere between 10 and 15, maybe 20 people involved in a code. Everyone has a job, and every job is focused and compartmentalized. The exception to this is the person running the code and, perhaps, the attending leaning over their shoulder like a good angel, whispering guiding words of wisdom throughout the code. It is the compartmentalization that makes the whole experience manageable. I knew that the only thing I needed to do throughout the code was step up to the patient, perform 2 minutes of good CPR, and then step away from the patient and get back in the CPR line (a steady, pre-selected rotation of 3-5 medical students and medical assistants). Occasionally I would do something like get a syringe or set up the patient for an ECG, but these were just part of my role in the whole effort - a doer, someone who did stuff.
And during the code there was almost this jovial atmosphere. This sense of, "Hey, yes, we are doing a good job. Things are working, it's all going to be ok because everyone is doing what they are supposed to and everyone is doing a good job of it." And the atmosphere is calm and aloof. We are airy in our approach. We are urgent, but only in the race to do our jobs well and defeat death. Not in the race to save the life of the patient. The patient. I don't think anyone knew his name until 30 minutes into the effort. Even after that realization, he remained exposed, face covered by the bag and mask and hands twitching at his sides (when the patient first came in he was making movements with his hands and fists, despite having no pulse). It was the ultimate dehumanizing experience.
And then, it wasn't. His mom and dad entered the room and suddenly all of the humanity that had been stripped away from the patient came flooding back to engulf him like a shroud. Suddenly E. had a name. The mom asked to hold E's hand and E became a young man with a partner and 2 children at home. The father shouted, "E, don't leave, you are needed HERE E, we need you right here," and E became a 37 year old with a troubled past who had spent the last year successfully picking up the pieces of his life. With each sob that was cried, E became a banker, a student, a runner, a food service worker, an alcoholic, a brother, a lawyer, a vagrant, an abused child, a husband, a father, a son. Each tear shed was a story; each plea to stay was a relationship. And with E's sudden humanity, the train that was our resuscitation effort derailed. We increased our efforts, put on a better show, but our hearts were heavy with the reality that when we stopped CPR, which we knew we would, it would be to pronounce this human, this person, dead.
And a heartwrenching moment, a reminder to watch your mouth:
The code leader says, "Well, we will continue CPR until the priest arrives."
The father said: "What you meant to say was until our son wakes up."
Well, dreams do come true, or irony kicked in, because a bit more than one hour later I was wearing a trauma gown hunched over a patient sweating bullets as I pumped hard on his chest.
CPR is not easy. It is surprisingly difficult, exhausting really. You lean over someone (inevitably at the wrong height such that your back starts aching or you have to be on your tippy toes), you lock your elbows, and then you push down as hard as you can. And then you do that again, over and over and over again. Your arms scream out and when you don't stop, they scream out louder. You realize 2 minutes is an awfully long time. And every time your arms start to lighten up, you remember that you are the only thing keeping the patient alive. It is your hands on his chest, your arms pushing down, your body weight compressing his rib cage and simulating the heart beating and the blood flowing such that your colleagues can feel the pulse in his groin or neck. Your arms, your effort are differentiating life from death. And all the while, all you can think of in your head is, "Harder, push harder, push HARDER," and you sync your hands to the tune running through your head: "Ah, ah,ah, ah Staying Alive, Staying Alive." Or "Dom, dom dom, Another one bites the dust," which is equally effective in tempo, but perhaps a bit more macabre in message. (I tried to sing the former, but ended up with the latter stuck in my head.)"
At 37, this man was not your typical massive coronary artery occlusion leading to cardiac arrest patient. He did not make it. I'll break that news right now. When exactly it became clear that he was not going to make is hard to say. Was it when he collapsed? Was it after the hour they spent in the field trying to resuscitate him, performing CPR the entire time? Was it when he arrived to our ED, chest compressions in progress? Was it when he regained a pulse (albeit slow and irregular) and a pressure (low and nerve-wracking) and was being readied for the cath lab but the attendings for the cath lab could not be contacted - was it that delay? Was it when, after that moment of pulse and organized electrical activity, he slipped back into pulseless chaos? Or was it when, at 8:12, after an hour of CPR and resuscitation efforts and with the parents by the bedside, the code was called?
Codes are interesting things. They are rather gruesome events, but also incredibly well orchestrated, calm, and surprisingly easy to participate in. There are usually somewhere between 10 and 15, maybe 20 people involved in a code. Everyone has a job, and every job is focused and compartmentalized. The exception to this is the person running the code and, perhaps, the attending leaning over their shoulder like a good angel, whispering guiding words of wisdom throughout the code. It is the compartmentalization that makes the whole experience manageable. I knew that the only thing I needed to do throughout the code was step up to the patient, perform 2 minutes of good CPR, and then step away from the patient and get back in the CPR line (a steady, pre-selected rotation of 3-5 medical students and medical assistants). Occasionally I would do something like get a syringe or set up the patient for an ECG, but these were just part of my role in the whole effort - a doer, someone who did stuff.
And during the code there was almost this jovial atmosphere. This sense of, "Hey, yes, we are doing a good job. Things are working, it's all going to be ok because everyone is doing what they are supposed to and everyone is doing a good job of it." And the atmosphere is calm and aloof. We are airy in our approach. We are urgent, but only in the race to do our jobs well and defeat death. Not in the race to save the life of the patient. The patient. I don't think anyone knew his name until 30 minutes into the effort. Even after that realization, he remained exposed, face covered by the bag and mask and hands twitching at his sides (when the patient first came in he was making movements with his hands and fists, despite having no pulse). It was the ultimate dehumanizing experience.
And then, it wasn't. His mom and dad entered the room and suddenly all of the humanity that had been stripped away from the patient came flooding back to engulf him like a shroud. Suddenly E. had a name. The mom asked to hold E's hand and E became a young man with a partner and 2 children at home. The father shouted, "E, don't leave, you are needed HERE E, we need you right here," and E became a 37 year old with a troubled past who had spent the last year successfully picking up the pieces of his life. With each sob that was cried, E became a banker, a student, a runner, a food service worker, an alcoholic, a brother, a lawyer, a vagrant, an abused child, a husband, a father, a son. Each tear shed was a story; each plea to stay was a relationship. And with E's sudden humanity, the train that was our resuscitation effort derailed. We increased our efforts, put on a better show, but our hearts were heavy with the reality that when we stopped CPR, which we knew we would, it would be to pronounce this human, this person, dead.
And a heartwrenching moment, a reminder to watch your mouth:
The code leader says, "Well, we will continue CPR until the priest arrives."
The father said: "What you meant to say was until our son wakes up."
Monday, March 8, 2010
Death Bear
I really like this story.
I think this is similar to one of the duties those of us in healthcare professions are lucky enough to have. We are semi-anonymous professionals in front of whom individuals bare all. We are rarely members of the same community as our patients and, as such, we are, essentially, blank. I've talked about this before - this blank slate concept - but this is a new and beautiful incarnation of the idea. In truth, almost anyone who has ever been in the service industry has, at some point, been a Death Bear to someone else. By listening to, absorbing, or even just witnessing a stranger's pain without judging it or engaging with it they are able to help that person start the healing process.
I think this is similar to one of the duties those of us in healthcare professions are lucky enough to have. We are semi-anonymous professionals in front of whom individuals bare all. We are rarely members of the same community as our patients and, as such, we are, essentially, blank. I've talked about this before - this blank slate concept - but this is a new and beautiful incarnation of the idea. In truth, almost anyone who has ever been in the service industry has, at some point, been a Death Bear to someone else. By listening to, absorbing, or even just witnessing a stranger's pain without judging it or engaging with it they are able to help that person start the healing process.
Tuesday, March 2, 2010
Minimize
The ER is unlike any other place in the hospital. Tragedy, disaster, shock, pain, agony, fear linger unchecked around each patient bed. There is little room for comfort, reassurance, paced improvement, or doctor-patient relationships. Those can be found on the upper floors. The ER is not a place for healing, but rather for the stabilization and "packaging" of patients before they go to other places in the hospital. As such, the arc of illness is rarely completed in the ED. For sure, more people are discharged from the ED than admitted, but those people were rarely very sick to begin with. And, without a doubt, lives are saved every day in the ED, but saving a life is very different from healing one.
Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.
This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.
That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.
Because of this, and because emergent situations are best dealt with using algorithms, it is easy to dehumanize patients in the ER. Not only is it easy, it is expected and, to some extent, necessary. If you know that no matter what a patient looks like, where they come from, or what their name is you are, first and foremost, going to evaluate their ABC's (airway, breathing, circulation), the larger picture of who they are becomes less important. For certain you want to hear the story of their main complaint - their signs and symptoms - and a few important details about their social situation - where do they live, do they drink alcohol or use IV drugs, do they have anyone to take care of them when they leave here. This information, however, is not used to build relationships, but rather to determine the diagnosis of the patient and expedite the discharge. Doctors are often criticized for minimizing the patient and maximizing the disease, but in the ER, this actually makes sense. Here we are taught to sort sick from not sick. Names make less sense, so you remember patients by their diseases.
This dehumanizing runs counter to most of what I am drawn to in medicine. But I also find something very appealing, and almost comforting about it. The ER is, to some extent, the most socialist, egalitarian place in our country. Without a doubt, the people who see the ED as a place for primary care and urgent care needs come from a certain underinsured, underserved demographic, but they aren't the only people who come to the HX ED. Trauma knows now boundaries and as the major trauma center for the state and several surrounding states as well as a world-reknowned orthopedic and burn center, people from all extremes of society pass through HX ED. And everyone gets care. As they pass through the ED doors, they (more or less) become their condition, and they receive whatever care their condition asks for. In determining what a condition calls for, no one asks, "what is the patient's insurance," and that is a beautiful thing.
That said, the flip side of not asking "what is their insurance," is that no one is asking, "is this test really necessary." Actually, that's not entirely true. Everyone asks that question, but everyone follows it up with, "It's very low yield, but we might as well do it to rule X out," or "It's not necessary, but it is standard of care, so. . ." Clinical judgement is a dying art and we, as medical professionals, need to revive it if health care reform is going to stick.
Sunday, February 28, 2010
Diet Coke
First night shift tonight. The switch to night shift? Brutal. . This is probably not helped by the fact that last night was Purim and, despite my attempts to not drink too much, I drank too much. I wouldn't call it a full blown hangover that I woke up with this morning, but the drinks were certainly saying, "hello, remember me?" My plan was this. . go out, stay up as late as I could, sleep today. Parts 1 and 2 went well. Part three hasn't gone so well. Turns out despite being tired, sleeping during the day is hard. Also turns out "waking up" at 5:30 pm to get ready for work is even harder.
You know what this calls for? It calls for diet coke - first one in months. Sigh, ER, you may beat me down yet.
I do have some stories for y'all, but didn't get to writing them tonight. Hopefully soon.
You know what this calls for? It calls for diet coke - first one in months. Sigh, ER, you may beat me down yet.
I do have some stories for y'all, but didn't get to writing them tonight. Hopefully soon.
Tuesday, February 23, 2010
Coming to America
The 67 year-old Ethiopian man did not speak a word of English. Well, that's not entirely true. At various times in the conversation, he would interject with, "And what is your name?" (I had already told him about 5 times).
He also knew thank you. And although he used it appropriately, it was a bit uncomfortable when he said, "Thank you," after I finished doing a rectal exam. In my fluster of not knowing what to say, I said "thank you" back, which compounded the awkwardness (for me, not for him). I slowly exited stage left.
With the interpreter on hand, things got a bit easier, but not as much as one would expect. When I asked him if there was anything else that was bothering him, he grabbed his belly with his hands. "This," he said (through the interpreter), shaking his belly furiously. "This is wrong. This was not here 3 months ago. This came on since I moved here. Now I do nothing and my belly has gotten big. The doctors tell me to lose weight, but I don't even eat that much. Like today, I have eaten nothing." The interpreter giggled a little, "I want this to go away; can you make this go away?"
Sigh. . welcome to America, I suppose.
He also knew thank you. And although he used it appropriately, it was a bit uncomfortable when he said, "Thank you," after I finished doing a rectal exam. In my fluster of not knowing what to say, I said "thank you" back, which compounded the awkwardness (for me, not for him). I slowly exited stage left.
With the interpreter on hand, things got a bit easier, but not as much as one would expect. When I asked him if there was anything else that was bothering him, he grabbed his belly with his hands. "This," he said (through the interpreter), shaking his belly furiously. "This is wrong. This was not here 3 months ago. This came on since I moved here. Now I do nothing and my belly has gotten big. The doctors tell me to lose weight, but I don't even eat that much. Like today, I have eaten nothing." The interpreter giggled a little, "I want this to go away; can you make this go away?"
Sigh. . welcome to America, I suppose.
Tuesday, February 16, 2010
A few days ago I was speaking with someone I had just met who asked me what I do. The conversation went something like this:
Her: And what do you do?
Me: I am in school.
Her: What kind of school?
Me: Graduate school.
Her: What are you studying?
Me: Medicine.
Her: Oh. . nursing school?
Me: No, medical school - I am studying to become a doctor.
This is a common conversation. I have it frequently and it made me think that, in a bit over a year, the conversation will be different:
Her: And what do you do?
Me: I am a resident. I am a doctor.
That's a big difference. . "becoming" versus "am."
This is going to happen to me very soon. In one day, I will walk up to the podium and receive a diploma and suddenly "I am becoming a doctor" will change into "I am a doctor." And yet it won't. Because getting the MD after my name won't make me any more skilled, competent, secure in my knowledge, or successful at healing patients. It's experience that does that (or so I am told). And skilled, competent, secure, and successful aren't points that you reach like mountain peaks. Instead they are paths that you travel on. Through experience you become more skilled, competent, secure, and successful.
Becoming. It may seem like a silly, or even obvious point to harp on, but I think it's an important one. Except in a few fields (the trades being some of them), in our modern-day society, we seem to have a binary approach to professions and careers. What I mean by this is that you aren't something, then you go to school to learn about becoming something, and then you get a degree and you are something. In many areas, we have lost the idea of apprenticeship. Without a doubt, school (especially the long road to the Ph.d. or the shorter road to becoming a teacher or therapist) serves as a sort of apprenticeship, but it seems like we have lost a structure for learning on the job. Everyone says that the most important learning occurs when you actually do something, so why don't we have any formalized structure for that?
Once you get your teaching degree and land a job, you are a teacher who is given as much responsibility and evaluated with the same criteria as a teacher who has been teaching for 30 years. No one expects you to be as successful as the teacher with more experience, but there is no allowance for that built into the system (except perhaps through pay). We suffer from the absence of mentorship. Pretty much everyone would benefit from a mentor, especially one who can evaluate your skills and say, yeah. . I think you are ready to try this.
One of the things that is often criticized in medicine is it's hierarchical nature. I am not 100% convinced that it is a bad thing. Doctors with more experience have seniority and are treated as such. Younger doctors should be able to speak up (and they are with more volume with the changing times), but in a field like medicine, experience should carry significant weight. It's a field where hierarchy appropriately refuses to die. It's a field that that seems to acknowledge that one is eternally becoming a doctor.
Her: And what do you do?
Me: I am in school.
Her: What kind of school?
Me: Graduate school.
Her: What are you studying?
Me: Medicine.
Her: Oh. . nursing school?
Me: No, medical school - I am studying to become a doctor.
This is a common conversation. I have it frequently and it made me think that, in a bit over a year, the conversation will be different:
Her: And what do you do?
Me: I am a resident. I am a doctor.
That's a big difference. . "becoming" versus "am."
This is going to happen to me very soon. In one day, I will walk up to the podium and receive a diploma and suddenly "I am becoming a doctor" will change into "I am a doctor." And yet it won't. Because getting the MD after my name won't make me any more skilled, competent, secure in my knowledge, or successful at healing patients. It's experience that does that (or so I am told). And skilled, competent, secure, and successful aren't points that you reach like mountain peaks. Instead they are paths that you travel on. Through experience you become more skilled, competent, secure, and successful.
Becoming. It may seem like a silly, or even obvious point to harp on, but I think it's an important one. Except in a few fields (the trades being some of them), in our modern-day society, we seem to have a binary approach to professions and careers. What I mean by this is that you aren't something, then you go to school to learn about becoming something, and then you get a degree and you are something. In many areas, we have lost the idea of apprenticeship. Without a doubt, school (especially the long road to the Ph.d. or the shorter road to becoming a teacher or therapist) serves as a sort of apprenticeship, but it seems like we have lost a structure for learning on the job. Everyone says that the most important learning occurs when you actually do something, so why don't we have any formalized structure for that?
Once you get your teaching degree and land a job, you are a teacher who is given as much responsibility and evaluated with the same criteria as a teacher who has been teaching for 30 years. No one expects you to be as successful as the teacher with more experience, but there is no allowance for that built into the system (except perhaps through pay). We suffer from the absence of mentorship. Pretty much everyone would benefit from a mentor, especially one who can evaluate your skills and say, yeah. . I think you are ready to try this.
One of the things that is often criticized in medicine is it's hierarchical nature. I am not 100% convinced that it is a bad thing. Doctors with more experience have seniority and are treated as such. Younger doctors should be able to speak up (and they are with more volume with the changing times), but in a field like medicine, experience should carry significant weight. It's a field where hierarchy appropriately refuses to die. It's a field that that seems to acknowledge that one is eternally becoming a doctor.
Monday, February 15, 2010
Day One
So here I am. the ER. The ER and I. It's been six weeks since I've talked to a patient, 10 weeks since I've been invested in a patient's care (and that was a psych rotation), 5 months since I've really touched a patient, and over a year since I've been expected to manage a patient. In other words, it's been a damn long time since I've felt like a doctor, or even a student doctor.
I've been told that rotation through the Hospital X (HX) ER* will cure even the most reluctant medical student. There is no shallow end there, it's all deep. It is a "kick you out of the nest, watch you hit the ground, then roll you to a cliff and push you off again" sort of rotation. Fly dammit, now.
The anticipation - horrible. I've been fretting about this rotation since I signed up for it. And the fretting became physical about a week ago. . culminating with my last 2 days of "freedom" being spent mourning the fast encroching loss of my freedom and worrying about how may days into the rotation I will be kicked out of medical school for my lack of knowledge, skill, and all-round un-doctorlyness. Needless to say, I was spinning a wee bit the night before. For example, at 10:00 at night I decided it would be a great idea to make not some not-so-important cheat sheets I've been meaning to make for a year. It shouldn't be a surprise to anyone that I did not sleep so hot that night.
The introductory lecture of the rotation only added to my anxiety. I thought the rotation director would be gentle and smiley and welcome us to HX with big hugs and words of reassurance. Instead she was more than a little manic (tip to SR) and spoke so fast that I'm still not really sure of about half of what she said. I left the room even more wide-eyed and petrified. I ran through the list of probable alternative jobs in my head: teacher, sign language interpreter, singer, farmer, lab rat, dog trainer, whale tank cleaner, balloon animal maker .. . really, anything. ANYTHING would have been less stressful than this, I thought. What the F was I thinking? If I could go back to that 23 year old and talk to her, I would shake her. . . a lot. . and say you stupid, naive girl. Stress. . .it sucks, I promise you that by 29, you will realize it's not even close to what it's cut out to be. That's what I was thinking as I speed walked across the street to the ED, trying desperately to keep up with the clerkship director who apparently also walks manically.
So day 1 started, and day 1 continued, and then day 1 ended and I didn't die OR cry once. (Of course with 17 days left, there is plenty of time left for that).
The ED Green (where the less acute patients are seen - think urgent care) has a fast pace and you tick away your time there by patients rather than hours. We work "12 hour" shifts, but they end up being more than that since you have to tack time on for the patients that are essentially ready to go, but not out the door, when your shift ends. The responsible doctor and med student doesn't just hand those patients off to his/her replacement. . nope, he/she finishes what he/she started. You discharge those patients, and that's a lot of paperwork and a bit of time. Plus you have to finish any and all charts that you might not have had time to complete during the day. This took me 2 extra hours my first day. . .I'm hoping I can trim that time down a bit.
Somehow, in an ED that sees few to no pelvic exams, I ended up doing 2 today. This morning during our tour, we walked by the pelvic exam room and the clerkship director pointed at the room and said. . "There's the pelvic exam room, but you probably won't ever see it. We really don't do pelvics here." (On a side note, I found this statement rather odd. . really, any woman coming into the ED with abdominal pain and/or vaginal bleeding should probably get a pelvic exam). But despite that statement, it was like the Gods of irony and the Gods of Gentle Introductions to Scary Rotations were holding hands and blessing me today. Female problems and pelvic exams are a homecoming from me. I'm not saying I was perfect, but at least I can understand the gynecological language.
The high point of the day was the young female (from jail) who presented with abdominal pain and thought she was 3 months pregnant. Her uterus was just too big for her reported gestational age so I thought, she has to be further along. Turns out we were both right. A quick bedside ultrasound showed us a head, an arm, a leg, a heart. . then we moved the ultra sound probe and saw the heart again. . but then we also saw a different heart. . and then the first heart. . and then the 2 hearts side -by-side. Twins, with a gestational age of about 4 months! An exciting moment for the ED.
And the look of surprise, fear, and joy on the girl's face was, well, heart warming and heart wrenching. She flashed the first smile I'd seen on her face all day.
*In order to keep these posts somewhat confidential, I will be changing identifying characteristics of patients, including the name of the hospital, which I have changed to Hospital X, or HX for short.
I've been told that rotation through the Hospital X (HX) ER* will cure even the most reluctant medical student. There is no shallow end there, it's all deep. It is a "kick you out of the nest, watch you hit the ground, then roll you to a cliff and push you off again" sort of rotation. Fly dammit, now.
The anticipation - horrible. I've been fretting about this rotation since I signed up for it. And the fretting became physical about a week ago. . culminating with my last 2 days of "freedom" being spent mourning the fast encroching loss of my freedom and worrying about how may days into the rotation I will be kicked out of medical school for my lack of knowledge, skill, and all-round un-doctorlyness. Needless to say, I was spinning a wee bit the night before. For example, at 10:00 at night I decided it would be a great idea to make not some not-so-important cheat sheets I've been meaning to make for a year. It shouldn't be a surprise to anyone that I did not sleep so hot that night.
The introductory lecture of the rotation only added to my anxiety. I thought the rotation director would be gentle and smiley and welcome us to HX with big hugs and words of reassurance. Instead she was more than a little manic (tip to SR) and spoke so fast that I'm still not really sure of about half of what she said. I left the room even more wide-eyed and petrified. I ran through the list of probable alternative jobs in my head: teacher, sign language interpreter, singer, farmer, lab rat, dog trainer, whale tank cleaner, balloon animal maker .. . really, anything. ANYTHING would have been less stressful than this, I thought. What the F was I thinking? If I could go back to that 23 year old and talk to her, I would shake her. . . a lot. . and say you stupid, naive girl. Stress. . .it sucks, I promise you that by 29, you will realize it's not even close to what it's cut out to be. That's what I was thinking as I speed walked across the street to the ED, trying desperately to keep up with the clerkship director who apparently also walks manically.
So day 1 started, and day 1 continued, and then day 1 ended and I didn't die OR cry once. (Of course with 17 days left, there is plenty of time left for that).
The ED Green (where the less acute patients are seen - think urgent care) has a fast pace and you tick away your time there by patients rather than hours. We work "12 hour" shifts, but they end up being more than that since you have to tack time on for the patients that are essentially ready to go, but not out the door, when your shift ends. The responsible doctor and med student doesn't just hand those patients off to his/her replacement. . nope, he/she finishes what he/she started. You discharge those patients, and that's a lot of paperwork and a bit of time. Plus you have to finish any and all charts that you might not have had time to complete during the day. This took me 2 extra hours my first day. . .I'm hoping I can trim that time down a bit.
Somehow, in an ED that sees few to no pelvic exams, I ended up doing 2 today. This morning during our tour, we walked by the pelvic exam room and the clerkship director pointed at the room and said. . "There's the pelvic exam room, but you probably won't ever see it. We really don't do pelvics here." (On a side note, I found this statement rather odd. . really, any woman coming into the ED with abdominal pain and/or vaginal bleeding should probably get a pelvic exam). But despite that statement, it was like the Gods of irony and the Gods of Gentle Introductions to Scary Rotations were holding hands and blessing me today. Female problems and pelvic exams are a homecoming from me. I'm not saying I was perfect, but at least I can understand the gynecological language.
The high point of the day was the young female (from jail) who presented with abdominal pain and thought she was 3 months pregnant. Her uterus was just too big for her reported gestational age so I thought, she has to be further along. Turns out we were both right. A quick bedside ultrasound showed us a head, an arm, a leg, a heart. . then we moved the ultra sound probe and saw the heart again. . but then we also saw a different heart. . and then the first heart. . and then the 2 hearts side -by-side. Twins, with a gestational age of about 4 months! An exciting moment for the ED.
And the look of surprise, fear, and joy on the girl's face was, well, heart warming and heart wrenching. She flashed the first smile I'd seen on her face all day.
*In order to keep these posts somewhat confidential, I will be changing identifying characteristics of patients, including the name of the hospital, which I have changed to Hospital X, or HX for short.
Monday, December 14, 2009
The Give
It often seems like each rotation has something essential about it, and that essence often echoes the themes of my life (or vice versa - this is a chicken or egg situation, of course). For example, while I was on orthopedics, every day I saw desperate patients begging for (and often promised) a solution to their pain. In my life, I seemed to be making all sorts of rather desperate hail mary gestures (there is an entry in here somewhere, I promise). Now that I am on neurology, I am watching people deal with breathtaking loss of physical functions; my life this last month has been filled with a wide range of witnessed and experienced loss of people, ideas, expectations, and places.
What amazes me is that no matter the source of the loss, the outcomes all seem to converge. It appears that loss in any form distills the world down to something very small. Like someone who has suffered a stroke, an emotional or external loss leaves one childlike. Someone coping with loss moves from moment to moment (for how can you think beyond that?) and, similar to the recovering stroke patient, even the most fundamental activities become a challenge. Eating, drinking, moving, speaking, sleeping can be so difficult that they essentially have to be relearned. Sometimes it takes all the effort and concentration one has just to breathe - and there is nothing more basic than that. And those who lose are completely dependent on those around them to hold them, feed them, remind them to breathe until those activities are relearned. Loss, then, is so transformative that it serves as a sort of rebirth (although it's a rebirth partially mocks our fantasy of wiping the slate clean).
But it's only a partial mockery of the clean slate fantasy, since the loss of something familiar (and it has to be familiar, for we cannot lose something we did not know) results in at least the hope of pursuing the aspirations and dreams that were blocked from fulfilling before. "I will do this because I was never able to do this with them around/that plan in place." It's a partial mockery because the slate is not clean - it is not simply a free space, but an actual vacuum created by the loss. In other words, what was once there defines the "clean" slate. The decisions that follow in response to loss are wholly created and shaped by the loss itself. And in stroke patients, the parameters for how they relearn walking, talking, reading, eating are set by the nature of the functions they lost.
What amazes me is that no matter the source of the loss, the outcomes all seem to converge. It appears that loss in any form distills the world down to something very small. Like someone who has suffered a stroke, an emotional or external loss leaves one childlike. Someone coping with loss moves from moment to moment (for how can you think beyond that?) and, similar to the recovering stroke patient, even the most fundamental activities become a challenge. Eating, drinking, moving, speaking, sleeping can be so difficult that they essentially have to be relearned. Sometimes it takes all the effort and concentration one has just to breathe - and there is nothing more basic than that. And those who lose are completely dependent on those around them to hold them, feed them, remind them to breathe until those activities are relearned. Loss, then, is so transformative that it serves as a sort of rebirth (although it's a rebirth partially mocks our fantasy of wiping the slate clean).
But it's only a partial mockery of the clean slate fantasy, since the loss of something familiar (and it has to be familiar, for we cannot lose something we did not know) results in at least the hope of pursuing the aspirations and dreams that were blocked from fulfilling before. "I will do this because I was never able to do this with them around/that plan in place." It's a partial mockery because the slate is not clean - it is not simply a free space, but an actual vacuum created by the loss. In other words, what was once there defines the "clean" slate. The decisions that follow in response to loss are wholly created and shaped by the loss itself. And in stroke patients, the parameters for how they relearn walking, talking, reading, eating are set by the nature of the functions they lost.
Friday, December 4, 2009
The Take
Strokes are not subtle events. They happen with a vengence. The onset comes with little warning. The symptoms may begin quietly, but they quickly crescendo until they reach an intensity impossible to ignore. Strokes rip away functions so fundamental that they only becomes visible in their absence. They are wholly changing events. The climatological equivalent of a stroke would be a tornado - they develop unexpectedly and cause focused destruction - leaving one thing intact while destroying something else. One day your house was there - strong, sturdy, filled with many years of improvements and memories. You knew how to skip each creaking step and where to leave the faucet handle so that the water temperature was perfect. The next day, your house is gone. Strokes are similar. One day you could walk, shake hands with a stranger, smile at a child, tell your partner you love them. The next day, you can't. And just like in a tornado, where your house is destroyed and your neighbor's is fine, a stroke doesn't take away everything. Instead, it picks and choses - so your right leg may be fine, but your right arm is unusable. You may talk, but you might not understand anything. You may understand everything, but not be able to speak intelligibly. Walking might be easy, but seeing difficult.
The recovery from a stroke thrusts adult patients into the role of a child. Like a young baby, they are forced to rely on those more capable for help with daily living. And like an infant, they must (re)learn how to do things. They have to take a first step, form their first words, eat their first solid foods, read their first book. It perverts the desire to be childlike in one's approach to life - for these patients are not childlike in mind, but rather are forced to depend like a child and learn the tasks of a child with the understanding of an adult.
The recovery from a stroke thrusts adult patients into the role of a child. Like a young baby, they are forced to rely on those more capable for help with daily living. And like an infant, they must (re)learn how to do things. They have to take a first step, form their first words, eat their first solid foods, read their first book. It perverts the desire to be childlike in one's approach to life - for these patients are not childlike in mind, but rather are forced to depend like a child and learn the tasks of a child with the understanding of an adult.
May you Live in Interesting Times
I'm fairly certain Neurlogy is not for me. It is, as my attending declares, a field of nerds. And while I indulge myself with the label of nerd, he is referring to a very specific brand of nerds who are meticulous in their pursuit of the diagnosis. It is not just the highly specific diagnosis that they enjoy, they also love the pattern used to acquire that diagnosis. The art of physical pursuit is exemplified in neurology. The science of futility is also exemplified by neurology. While the diagnoses are specific and intricate, it is rare that something can be done to treat the condition (prevention of progression they can do, treatments of symptoms they can sort of do, but curing the disorder - rarely achievable). Neurologists define the label "academic," (as in he practices a very academic form of medicine).
The patient interview usually involves the doctor asking some questions and the patient answering them. The doctor nods his head, the patient looks concerned. The doctor then turns to me, says about 20 words, only 15 of which I understand (only 5 of them are comprehensible to the patient, and those are: the, it, but, because, and patient). He then proceeds to nod a bit more, perhaps ask me an unanswerable question, tell an unrelated story about Chamberlain and the Battle of Gettysburg, and then say:
"Isn't this an interesting case. You know, the Chinese have a curse. . 'may you live in interesting times.' The medical equivalent of this is 'may you be an interesting patient.' Man, you never want to be interesting to medical students. Nope."
He then turns back to the patient (who is looking confused, concerned, and petrified) and says, "there's just not that much we can do for you," maybe writes a prescription for some medicine that may or may not relieve symptoms, and wishes the patient a good day.
OR, my other favorite patient interaction is by the bedside:
Imagine a patient, recovering from a very severe stroke, who can barely move the right side of her body, is confused about where she is, and can't get her words out very well.
Dr: "Wow. .you are doing much better than your MRI would lead us to believe."
P: Mmdfnek kitten throws?
Dr: Hmm. . well, really, believe you me, you are doing great. . Just great. I mean, you can move your arm on the right side. . that's just amazing. Yes, I would expect you to have some difficulty talking, but really, you are just doing awesome.
P: Mdhadfk group trial of words?
Dr: Ok, well. . we'll be back to check on you tomorrow. Have a great day. . I'm really quite impressed.
And that's about it.
In fairness to the doctors. . these are certainly exaggerated stories. There are many wonderful things that Neurologists do (seizure control, headache management, peripheral neuropathy management, MS treatment, etc - the list is endless). Their physical exam is a beautiful thing. And they do a good job of delivering (continually) bad news - they do it day in and day out, and they are better at it than most doctors.
So that's a bit of neuro. May you never have to see a neurologist.
The patient interview usually involves the doctor asking some questions and the patient answering them. The doctor nods his head, the patient looks concerned. The doctor then turns to me, says about 20 words, only 15 of which I understand (only 5 of them are comprehensible to the patient, and those are: the, it, but, because, and patient). He then proceeds to nod a bit more, perhaps ask me an unanswerable question, tell an unrelated story about Chamberlain and the Battle of Gettysburg, and then say:
"Isn't this an interesting case. You know, the Chinese have a curse. . 'may you live in interesting times.' The medical equivalent of this is 'may you be an interesting patient.' Man, you never want to be interesting to medical students. Nope."
He then turns back to the patient (who is looking confused, concerned, and petrified) and says, "there's just not that much we can do for you," maybe writes a prescription for some medicine that may or may not relieve symptoms, and wishes the patient a good day.
OR, my other favorite patient interaction is by the bedside:
Imagine a patient, recovering from a very severe stroke, who can barely move the right side of her body, is confused about where she is, and can't get her words out very well.
Dr: "Wow. .you are doing much better than your MRI would lead us to believe."
P: Mmdfnek kitten throws?
Dr: Hmm. . well, really, believe you me, you are doing great. . Just great. I mean, you can move your arm on the right side. . that's just amazing. Yes, I would expect you to have some difficulty talking, but really, you are just doing awesome.
P: Mdhadfk group trial of words?
Dr: Ok, well. . we'll be back to check on you tomorrow. Have a great day. . I'm really quite impressed.
And that's about it.
In fairness to the doctors. . these are certainly exaggerated stories. There are many wonderful things that Neurologists do (seizure control, headache management, peripheral neuropathy management, MS treatment, etc - the list is endless). Their physical exam is a beautiful thing. And they do a good job of delivering (continually) bad news - they do it day in and day out, and they are better at it than most doctors.
So that's a bit of neuro. May you never have to see a neurologist.
Monday, August 10, 2009
Gone Fishin' (with photos!)
I went fishing on Saturday and although i discovered that my sea legs are not quite as strong as i'd like, I had a great time. The sea was calm, but consistently rolling and in the fog that made everything surreal and eerie, the horizon was nowhere to be seen. Apparently this was not a good combination for me, as I got queasy. But I held my stomach and learned that my personal solution to sea sickness is to sit down outside while holding a metal thermos - go figure. The fish were biting and we immediately caught a triple (every line had a fish), although I lost mine and we sent one lucky guy back to the sea. I caught some fish, I lost some fish, and I learned that when a pole wobbles with a fish, everyone gets very excited. I'm not sure I'd really call fishing the most relaxing thing I've done: each fish would go something like this:
Fish! There's a fish! Set it! Set it! Shit. . .Set it! Reel, reel, reel, reel. . harder, reel harder, STOP!!!!! Don't reel anymore, move back step back, steady, steady. . damnit. . bring it closer to the net, closer. . There! Got it in the net. . . . . . . .Thwock, Thwock Thwock (sound of fish getting hit on head with club). . silence, flop, flop, flop. . WOAH!. . Thwock, thwock, thwock.
Yes, I the animal lover did hit a fish or two on the head, but mostly it was because I would look in the cooler and see the fish still flopping and that would make me sad because I thought that they might be suffering, so I would hit them again. Sometimes it worked. I will admit that it was satisfying to get a good clobber in, but ONLY because I knew I was putting the fish out of its misery, I swear.
As the fish stopped biting and our cooler filled - silvers and pinks and bass, oh my - our captain turned the boat towards the sunshine and we headed to Long Island, which is just off of Kodiak. Kodiak Island was a major staging area for North Pacific operations during WWII. During WWII, Long Island housed Fort Tidball, bunkers, and gun emplacements. Per one of my guides, due to leaked PBCs, Long Island has the distinction of being the first superfund site in America. Apparently it's not safe to drink the water or eat the deer or feral cows that roam the island. Yes, feral cows. We boated past a puffin rookery and hiked up to a bunker site and lollygagged (love that word) in the sun for a bit.
Here's a map.
Here are some links with info about Long Island:
Military History (scroll down to the Long Island section)
Deer Point info
The boating adventure finished with a trip down cannery row (in the water) to a cannery that cleans and packs the fishies for winter eatin'. . and then over to the sea lions where we cleaned the fish. But don't tell anyone we did that, it's illegal. But goodness illegal things are sometimes awfully cool - it was pretty dang neat to be so close to such silly, big, slow moving creatures.
The day ended with a delicious feast on two of our fishies (a bass, a pink salmon, and a king salmon that Mark had caught a few days ago). I went to the house of the two docs who own the clinic and it was, without a doubt, my dream house - absolutely gorgeous with a great big open kitchen and living room. Right on the water with a gorgeous deck. They built it themselves (at least half of it). . and lived in a tent while doing so. "We never fed our children store bought meat and we never eat frozen fish." Sigh. . .I'm a bit in love with their life.
Click the photo below to see even more photos (look at me, I'm doing pictures - wow).
Fish! There's a fish! Set it! Set it! Shit. . .Set it! Reel, reel, reel, reel. . harder, reel harder, STOP!!!!! Don't reel anymore, move back step back, steady, steady. . damnit. . bring it closer to the net, closer. . There! Got it in the net. . . . . . . .Thwock, Thwock Thwock (sound of fish getting hit on head with club). . silence, flop, flop, flop. . WOAH!. . Thwock, thwock, thwock.
Yes, I the animal lover did hit a fish or two on the head, but mostly it was because I would look in the cooler and see the fish still flopping and that would make me sad because I thought that they might be suffering, so I would hit them again. Sometimes it worked. I will admit that it was satisfying to get a good clobber in, but ONLY because I knew I was putting the fish out of its misery, I swear.
As the fish stopped biting and our cooler filled - silvers and pinks and bass, oh my - our captain turned the boat towards the sunshine and we headed to Long Island, which is just off of Kodiak. Kodiak Island was a major staging area for North Pacific operations during WWII. During WWII, Long Island housed Fort Tidball, bunkers, and gun emplacements. Per one of my guides, due to leaked PBCs, Long Island has the distinction of being the first superfund site in America. Apparently it's not safe to drink the water or eat the deer or feral cows that roam the island. Yes, feral cows. We boated past a puffin rookery and hiked up to a bunker site and lollygagged (love that word) in the sun for a bit.
Here's a map.
Here are some links with info about Long Island:
Military History (scroll down to the Long Island section)
Deer Point info
The boating adventure finished with a trip down cannery row (in the water) to a cannery that cleans and packs the fishies for winter eatin'. . and then over to the sea lions where we cleaned the fish. But don't tell anyone we did that, it's illegal. But goodness illegal things are sometimes awfully cool - it was pretty dang neat to be so close to such silly, big, slow moving creatures.
The day ended with a delicious feast on two of our fishies (a bass, a pink salmon, and a king salmon that Mark had caught a few days ago). I went to the house of the two docs who own the clinic and it was, without a doubt, my dream house - absolutely gorgeous with a great big open kitchen and living room. Right on the water with a gorgeous deck. They built it themselves (at least half of it). . and lived in a tent while doing so. "We never fed our children store bought meat and we never eat frozen fish." Sigh. . .I'm a bit in love with their life.
Click the photo below to see even more photos (look at me, I'm doing pictures - wow).
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| Gone Fishin' |
Sunday, August 9, 2009
Kodiak Island
Kodiak Island is BEAUTIFUL. I have been to many a pretty place in my life, and this may be the prettiest place I've ever been. It's a mixture of the dramatic mountains of the Pyrenees, the lush green of Guatemala, the coastline of the San Juan Islands, plus the wildflowers of Idaho. It's pretty in comparison to Alaska, which is saying a lot, since Alaska is, well, gorgeous.
I've just begun to explore Kodiak, but already I can tell that it runs on "island time." In other words, it's mellow. But more than that, it's got the energy of a community whose rhythms, at least to some extent, are determined by mother nature's. Things like the tides, the weather, migration patterns of fish all impact the days, weeks, months, and years of the people who live here. I like living somewhere where the local radio station includes the tide with the weather and both are significant beyond mere interest. The population of Kodiak wanes and waxes as the fishing boats and the Coast Guard patrols depart and return. Turnover is high - the hardship of fishing and the maximum of a 4 year station make for impermanence.
One week done and I really do love it here. Family Practice is back on the very short list. Folks here are so incredibly nice. The docs here love to teach and care for their patients in this calm, relaxed way that puts the patients at ease. 15 minute appointments are rare, so nothing is ever rushed. Being an FP doctor here would mean practicing primary care the way it should be practiced - more than a mere gateway, you are the center of your patient's care. You handle the things you are qualified to handle (and maybe a few that you aren't, out of necessity) and refer the very complicated things. In the lower 48, it seems like most FPs refer everyone and everything they are expected to and they can. Malpractice is on everyone's mind and no one general is given agency to make decisions they at one point were qualified to make. The primary care profession is leeched of confidence (and thus competence)
Up here on Kodiak, you build relationships with specialists in the big city (Anchorage) and call on them when you need help or advice - and they eagerly (and non-possessively) give it because they understand that in Alaska, referring to a specialist is not always possible. You deliver babies (maybe do c-sections if you are trained), work in the ER, and see patients in clinic. You tailor your practice both in the patients you see and the hours you work. And at KIMA, your fellow health care providers are amazing, inspirational people. This is one of those seductive practices (like Alaska Women's Health Services) that lures you into the field (family medicine in this case) by fooling you into believing that all practices are like this.
The separation of practice versus profession. How much of what I like about being an FP is dependent on location? What about with pediatrics?
I'm quite thankful I don't have to make my decision tomorrow (yes more loans, I knew there was a reason I signed on to you).
I've just begun to explore Kodiak, but already I can tell that it runs on "island time." In other words, it's mellow. But more than that, it's got the energy of a community whose rhythms, at least to some extent, are determined by mother nature's. Things like the tides, the weather, migration patterns of fish all impact the days, weeks, months, and years of the people who live here. I like living somewhere where the local radio station includes the tide with the weather and both are significant beyond mere interest. The population of Kodiak wanes and waxes as the fishing boats and the Coast Guard patrols depart and return. Turnover is high - the hardship of fishing and the maximum of a 4 year station make for impermanence.
One week done and I really do love it here. Family Practice is back on the very short list. Folks here are so incredibly nice. The docs here love to teach and care for their patients in this calm, relaxed way that puts the patients at ease. 15 minute appointments are rare, so nothing is ever rushed. Being an FP doctor here would mean practicing primary care the way it should be practiced - more than a mere gateway, you are the center of your patient's care. You handle the things you are qualified to handle (and maybe a few that you aren't, out of necessity) and refer the very complicated things. In the lower 48, it seems like most FPs refer everyone and everything they are expected to and they can. Malpractice is on everyone's mind and no one general is given agency to make decisions they at one point were qualified to make. The primary care profession is leeched of confidence (and thus competence)
Up here on Kodiak, you build relationships with specialists in the big city (Anchorage) and call on them when you need help or advice - and they eagerly (and non-possessively) give it because they understand that in Alaska, referring to a specialist is not always possible. You deliver babies (maybe do c-sections if you are trained), work in the ER, and see patients in clinic. You tailor your practice both in the patients you see and the hours you work. And at KIMA, your fellow health care providers are amazing, inspirational people. This is one of those seductive practices (like Alaska Women's Health Services) that lures you into the field (family medicine in this case) by fooling you into believing that all practices are like this.
The separation of practice versus profession. How much of what I like about being an FP is dependent on location? What about with pediatrics?
I'm quite thankful I don't have to make my decision tomorrow (yes more loans, I knew there was a reason I signed on to you).
Sunday, May 31, 2009
Steinbeck
Sitting in College Coffee in Fairbanks, AK. In a bit of a funk these days - a Fairbanks funk. Apparently it's de rigor for the rotation up here. And not surprising, really. The town is a bit strip mally for most folks (think Twin Falls meets Pocatello or Idaho Falls) and it's lonely. And for many of us, spending significant amounts of time with doctorly folks intently focused on the money in medicine can be disheartening.
But all that is beside the point. . .a funk is a funk is a funk. And it's dissatisfaction defined. It's unsettled and aching. It's a pity party, but a confused one.
And so I'm sitting in the coffee shop and I walk up to the board and see this written:
"Where does discontent start? You are warm enough, but you shiver. You are fed, yet hunger gnaws you. You have been loved, but your yearning wanders in new fields. And to prod all these there's time, the Bastard Time."
-John Steinbeck, Sweet Thursday
Ahh Steinbeck, your words are wise. Message received, funk in check, thank you.
But all that is beside the point. . .a funk is a funk is a funk. And it's dissatisfaction defined. It's unsettled and aching. It's a pity party, but a confused one.
And so I'm sitting in the coffee shop and I walk up to the board and see this written:
"Where does discontent start? You are warm enough, but you shiver. You are fed, yet hunger gnaws you. You have been loved, but your yearning wanders in new fields. And to prod all these there's time, the Bastard Time."
-John Steinbeck, Sweet Thursday
Ahh Steinbeck, your words are wise. Message received, funk in check, thank you.
Tuesday, May 26, 2009
Touch-up
In the last 3 years, I've noticed myself momentarily hesitating before I touch someone. Rest assured, this isn't the result of me becoming a born-again germaphobe, although medical school has afforded me a new found respect for protective barriers. Certainly I now ask myself, "are your hands washed," before I touch I touch anything (a patient, a door handle, my book, my food, a friend), but there is something else contained in my hesitation. It's more a pause to clarify the reason behind my touch, what I want to gain or communicate. Of course touch is significant - this is why we find comfort in it, why it makes us cry, why we are so stingy with it, and why we recall moments of touch (especially the first ones) with visceral clarity. It used to be that my reasons for touching were buried somewhere beneath my awareness - not repressed, but not considered either - like food, touch was simply a thing to receive or give, want (even need) or reject.
In the last few years, the significance of touch has risen into my consciousness. Now I am almost hyperaware of it's existence and completely dependent on it's power. Practically speaking, in the doctorly profession, it is through touch that we learn about the decay of the skin or the disease of the heart. A patient's response to our hands on their abdomen allows tells us to move appendicitis higher or lower on our differential (the running list in our head of reasons for symptoms). Pressing behind the ankle and on top of the foot, we learn about circulation problems. A toe dulled to sensation makes us concerned for diabetic neuropathy. We ask, "Does it hurt here? Can you feel this?" We say, "Your knee feels swollen. Your abdomen tight. The two sides of your lungs sound different to percussion (essentially tapping on the body)." Before we order the (very important and useful) blood draws and the CT scans and and the stress tests, we gather information by touching.
And then there is the other side of touch. Its less practical, but more human (and almost more useful) significance. It is through touch that we are concerned and passionate. Standing side by side, a hand on the back emphasizes that we, the patient and the doctor, are allies in the process of health. Running a hand up and down an arm a few times conveys sympathy. Two hands on the shoulder, looking a patient in the eye tells them we are heartfelt, serious, and speaking the truth. A long hug tells a patient it's O.K. to cry.
For the record, I am not celebrating the days when touch was our primary diagnostic tool. I do not believe that we can heal through touch alone, but I do think that without touch we cannot heal.
Touch is different for me now. I am aware of its significance, and so I try and choose with consciousness. And this new-found awareness does not stop with patients. Now before I shake hands with a patient or hug my dad, before I lay my head on my mom or test a patient's reflexes, before I feel a patient's heart or hold hands with a friend, I delay momentarily. And in that delay my mind runs through these questions: Who is this person? What is my relationship to them? What does this touch mean? And, of course: Do I need to wash my hands before this or after this?
In the last few years, the significance of touch has risen into my consciousness. Now I am almost hyperaware of it's existence and completely dependent on it's power. Practically speaking, in the doctorly profession, it is through touch that we learn about the decay of the skin or the disease of the heart. A patient's response to our hands on their abdomen allows tells us to move appendicitis higher or lower on our differential (the running list in our head of reasons for symptoms). Pressing behind the ankle and on top of the foot, we learn about circulation problems. A toe dulled to sensation makes us concerned for diabetic neuropathy. We ask, "Does it hurt here? Can you feel this?" We say, "Your knee feels swollen. Your abdomen tight. The two sides of your lungs sound different to percussion (essentially tapping on the body)." Before we order the (very important and useful) blood draws and the CT scans and and the stress tests, we gather information by touching.
And then there is the other side of touch. Its less practical, but more human (and almost more useful) significance. It is through touch that we are concerned and passionate. Standing side by side, a hand on the back emphasizes that we, the patient and the doctor, are allies in the process of health. Running a hand up and down an arm a few times conveys sympathy. Two hands on the shoulder, looking a patient in the eye tells them we are heartfelt, serious, and speaking the truth. A long hug tells a patient it's O.K. to cry.
For the record, I am not celebrating the days when touch was our primary diagnostic tool. I do not believe that we can heal through touch alone, but I do think that without touch we cannot heal.
Touch is different for me now. I am aware of its significance, and so I try and choose with consciousness. And this new-found awareness does not stop with patients. Now before I shake hands with a patient or hug my dad, before I lay my head on my mom or test a patient's reflexes, before I feel a patient's heart or hold hands with a friend, I delay momentarily. And in that delay my mind runs through these questions: Who is this person? What is my relationship to them? What does this touch mean? And, of course: Do I need to wash my hands before this or after this?
Wednesday, May 13, 2009
Adventuring in Fairbanks
I just finished my first week of surgery rotation in Fairbanks, AK. I'm starting this rotation after 12 weeks of doing nothing related to medicine. Well, not exactly nothing - I had 6 weeks of psychiatry (the neglected underbelly of the medical world, not because it isn't important, but because it operates blind, with unpredictable pathology refractory to what few "treatments" are available) and then 6 weeks of nothing related to medical school (blissful, beautiful stress-free nothing). And despite my best efforts, time passes, so now I'm back in the med school game again.
A decision: I decided to expand my last year - meaning I will take 2 years to do my fourth year. This is great because it enables me to do some last minute adventuring before I graduate, postpone decisions I'm not quite "ready" to make, and basically revel in studentdom for that much longer. This is terrible because it means I am a student for that much longer.
A few first week tidbits to share.
1) I have heard arguments on both sides and I've officially decided that Fairbanks is not the best of what Alaska has to offer. That's really all I have to say about that.
2) Dr. Montano is an old cowboy who has been operating in Fairbanks probably before the hospital was even built. He's done surgeries that people spend 8 years in residency learning how to do. He's cowboy defined, and it's unsafe for patients, but he's grandfathered in because he has been doing it for so long. The other surgeons had to band together to convince him to stop doing craniotomies (hole in the head). He's thin and spindly, crotchety and irreverent. Reminds me of Harry Dean Stanton. He's the definition of a libertarian. And he's got a great sense of humor.
I told him Ross had told me to tell the docs that they shouldn't be mean to me. He said, "I couldn't be hard on you - it'd be like being mean to a puppy."
He found out I was from Idaho (I emphasized Idaho over California - it seemed like a wise decision) and his second question was, "Are you Morman?" He's not subtle.
His daughter is a pediatrician in Anchorage and he told me I shouldn't be a pediatrician cause I won't make any money.
He also has 5 houses, I think.
That's it for now. More stories to come.
A decision: I decided to expand my last year - meaning I will take 2 years to do my fourth year. This is great because it enables me to do some last minute adventuring before I graduate, postpone decisions I'm not quite "ready" to make, and basically revel in studentdom for that much longer. This is terrible because it means I am a student for that much longer.
A few first week tidbits to share.
1) I have heard arguments on both sides and I've officially decided that Fairbanks is not the best of what Alaska has to offer. That's really all I have to say about that.
2) Dr. Montano is an old cowboy who has been operating in Fairbanks probably before the hospital was even built. He's done surgeries that people spend 8 years in residency learning how to do. He's cowboy defined, and it's unsafe for patients, but he's grandfathered in because he has been doing it for so long. The other surgeons had to band together to convince him to stop doing craniotomies (hole in the head). He's thin and spindly, crotchety and irreverent. Reminds me of Harry Dean Stanton. He's the definition of a libertarian. And he's got a great sense of humor.
I told him Ross had told me to tell the docs that they shouldn't be mean to me. He said, "I couldn't be hard on you - it'd be like being mean to a puppy."
He found out I was from Idaho (I emphasized Idaho over California - it seemed like a wise decision) and his second question was, "Are you Morman?" He's not subtle.
His daughter is a pediatrician in Anchorage and he told me I shouldn't be a pediatrician cause I won't make any money.
He also has 5 houses, I think.
That's it for now. More stories to come.
Friday, March 20, 2009
Nighty?
So I'm driving into work today (yes driving, working on that) and in front of me is a much-too-large SUV with a license plate that says "Nighty." And I say to myself, "Nighty," what does that mean, or, more importantly, what does the owner intend that to mean? I'm thinking . . maybe they like night gowns, maybe they are trying to say good night, maybe they associate with the night and intend "Nighty" to mean "night-like." In that vein, it's possible that they are middle-age enthusiasts and couldn't fit the K on the plate. It also crossed my mind that maybe they wanted to say "Naughty," but that was already taken. In any case, the message was lost in translation. This is the problem with free vanity plates.
Monday, March 16, 2009
Butterflies
Well, so much for promises n' resolutions n' stuff. One week, one month. . . what can I say.
In my defense, I did write something between my last entry and this one. Unfortunately, it was in desperate need of a fine tooth comb-through. . . and, well, that never happened.
So yes, I am on psych. And yes, this is one of those rotations that affords me with quite a bit of free time. It's also one of those rotations that is rich with stories. These are ridiculous, unbelievable stories. They are incredible, fascinating stories. They are heartbreaking stories and they are not my stories. These stories belong to other people. Without a doubt, the stories that I have told during other rotations are other people's stories too, but there is something more intimate about the stories of the mind.
For one thing, the majority of the patients that I am working with do not have the capacity to understand their own stories, at least not in the way that the rest of us understand them.
For another thing, these are difficult stories. The insane trace paths that are frighteningly close to the sane. In the beginning, the stories sound and feel the same; their potential is limitless. But somewhere they split. More than just diverging away from each other, they come to exist in a completely different reality. Indeed, I'm beginning to find that the sane and the insane seem to live parallel lives in entirely different universes. And sometimes it is so easy to see how they jumped into their reality. This scares me because it makes sanity seem so fragile. It makes me wonder what will set me off. Other times it is impossible to dissect a patient's movement into psychosis. Their stories are indecipherable, completely obscured. These patients underscore the tragedy of a psychotic break because it is impossible to tease out the person inside their illness.
For a third thing, these stories are funny. Devastatingly funny. It's hard not to laugh, but I feel guilty for laughing. I don't know how else to cope, because I am depressed by what we, "the healers," are forced to force the patients to do. So I laugh. I'm not sure if that's fair to the patients. I am laughing at them, for they do not have the ability to laugh with me. And so I tell the stories to those who are capable of laughing with me - and we laugh together. I am fairly certain, however, that we do not laugh out of humor. The laughter seems to come from a place of uncertainty, discomfort. I think we laugh out of disbelief.
And so I tell these stories out loud and the little conscience butterflies I keep in my stomach flutter self-consciously. Which is why I have yet to be able to write them down. But I'm working on it.
In my defense, I did write something between my last entry and this one. Unfortunately, it was in desperate need of a fine tooth comb-through. . . and, well, that never happened.
So yes, I am on psych. And yes, this is one of those rotations that affords me with quite a bit of free time. It's also one of those rotations that is rich with stories. These are ridiculous, unbelievable stories. They are incredible, fascinating stories. They are heartbreaking stories and they are not my stories. These stories belong to other people. Without a doubt, the stories that I have told during other rotations are other people's stories too, but there is something more intimate about the stories of the mind.
For one thing, the majority of the patients that I am working with do not have the capacity to understand their own stories, at least not in the way that the rest of us understand them.
For another thing, these are difficult stories. The insane trace paths that are frighteningly close to the sane. In the beginning, the stories sound and feel the same; their potential is limitless. But somewhere they split. More than just diverging away from each other, they come to exist in a completely different reality. Indeed, I'm beginning to find that the sane and the insane seem to live parallel lives in entirely different universes. And sometimes it is so easy to see how they jumped into their reality. This scares me because it makes sanity seem so fragile. It makes me wonder what will set me off. Other times it is impossible to dissect a patient's movement into psychosis. Their stories are indecipherable, completely obscured. These patients underscore the tragedy of a psychotic break because it is impossible to tease out the person inside their illness.
For a third thing, these stories are funny. Devastatingly funny. It's hard not to laugh, but I feel guilty for laughing. I don't know how else to cope, because I am depressed by what we, "the healers," are forced to force the patients to do. So I laugh. I'm not sure if that's fair to the patients. I am laughing at them, for they do not have the ability to laugh with me. And so I tell the stories to those who are capable of laughing with me - and we laugh together. I am fairly certain, however, that we do not laugh out of humor. The laughter seems to come from a place of uncertainty, discomfort. I think we laugh out of disbelief.
And so I tell these stories out loud and the little conscience butterflies I keep in my stomach flutter self-consciously. Which is why I have yet to be able to write them down. But I'm working on it.
Friday, February 27, 2009
That Entry
Hello world.
I'm back.
This is the requisite, "I'm back" entry. The entry where I apologize for being so MIA and thank my readers profusely for sticking with me. The time in a blog where I explain that I was busy and then busier, and then just exhausted and taking a break from everything that involved anything, and then I got caught up in some stupid, stupid, stupid, poorly written books about stupid teenage vampires. And then when I finally had time to write/realized how stupid the vampire books were (and continue to be), I was a little unsure about how exactly to get back on the proverbial horse. But then it dawned on me: Just write an entry about how you are going to start writing, about how you are sorry that you have been gone, but that you are back again.
And so that's what I'm doing.
Also required in this sort of come back is a brief update of what I have been doing for the last several months. . . it should be a sentence, no more.
Since November, I finished medicine, went to California, came back to Alaska, started and completed my pediatric rotation (right now, I am about 95% pediatrician, 5% family medicine doc - more on that dilemma later), went backcountry skiing, got new skis and bindings, went backcountry skiing again on my AMAZING new skis and bindings (thanks Luc and Tarby), broke some pipes in my apartment, saw Josh Ritter (love the boy), went out dancing a few times, have generally been enjoying myself despite the fact that I continue to have agonizing dilemmas about what I am doing with my next year/life, and am welcoming back the sun. Speaking of the sun - damn, it's nice to have it back. Speaking of the weather - it's been all over the place. No global warming up here, Sarah Palin says so.
And last requirement of this entry (self-imposed) is a tantalizing teaser of things to come:
I'm on psych now, working at the state lock-down psych facility, need I say more? My goal (if you put goals up in public, you are more likely to hold yourself to them) is to write at least weekly.
So to recap:
I'm sorry I've been gone for so long, I did some shit, fat skis rock, there are some crazy folks in the world, most importantly, thank you for your patience, encouragement, and continued attention, and I'm back.
I'm back.
This is the requisite, "I'm back" entry. The entry where I apologize for being so MIA and thank my readers profusely for sticking with me. The time in a blog where I explain that I was busy and then busier, and then just exhausted and taking a break from everything that involved anything, and then I got caught up in some stupid, stupid, stupid, poorly written books about stupid teenage vampires. And then when I finally had time to write/realized how stupid the vampire books were (and continue to be), I was a little unsure about how exactly to get back on the proverbial horse. But then it dawned on me: Just write an entry about how you are going to start writing, about how you are sorry that you have been gone, but that you are back again.
And so that's what I'm doing.
Also required in this sort of come back is a brief update of what I have been doing for the last several months. . . it should be a sentence, no more.
Since November, I finished medicine, went to California, came back to Alaska, started and completed my pediatric rotation (right now, I am about 95% pediatrician, 5% family medicine doc - more on that dilemma later), went backcountry skiing, got new skis and bindings, went backcountry skiing again on my AMAZING new skis and bindings (thanks Luc and Tarby), broke some pipes in my apartment, saw Josh Ritter (love the boy), went out dancing a few times, have generally been enjoying myself despite the fact that I continue to have agonizing dilemmas about what I am doing with my next year/life, and am welcoming back the sun. Speaking of the sun - damn, it's nice to have it back. Speaking of the weather - it's been all over the place. No global warming up here, Sarah Palin says so.
And last requirement of this entry (self-imposed) is a tantalizing teaser of things to come:
I'm on psych now, working at the state lock-down psych facility, need I say more? My goal (if you put goals up in public, you are more likely to hold yourself to them) is to write at least weekly.
So to recap:
I'm sorry I've been gone for so long, I did some shit, fat skis rock, there are some crazy folks in the world, most importantly, thank you for your patience, encouragement, and continued attention, and I'm back.
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