Lightning

By Luke P. Burns, MS4

Elevated blood pressures are an important omen of brewing pre-eclampsia in pregnant women.

As vascular remodeling in the placenta goes haywire, microthrombi block up blood vessels and prevent adequate perfusion of vital organs. Blood pressure rises to dangerous levels, the patient suffers from an intractable headache and organ systems fail one-by-one.

An acute, persistent systolic blood pressure over 160 mmHg is worrisome enough for obstetricians to recommend immediate treatment with antihypertensives. Often the only recourse is delivery.

When Ms. R came in for her outpatient visit, her systolic blood pressure was well over 200 mmHg. She adamantly denied using drugs at any time during her pregnancy, but a urine toxicology screen was positive for methamphetamines.

I was several weeks into my sub-internship on the Maternal Fetal Medicine service when I met Ms. R. When we saw the elevated blood pressures, my resident begged her to go to hospital. The perinatologist attending joined him, describing the risks of preeclampsia, the stroke and fetal demise that accompanied numbers so high. I could see how frustrated they were. This woman’s reluctance to be admitted was killing her baby, but also killing herself. When Ms. R left the office with a prescription for more nifedipine and a vague promise to follow up, I could tell that both physicians felt like they had failed her.

The resident buried his head in his hands, slumping forward on the desk. “She’ll be dead within a year.”

The next day my resident and I were back on the inpatient service, halfway through rounds, when we received a page. It was Ms. R, and she had decided, reluctantly, to come to the hospital to be admitted.

As I checked in Ms. R and performed a physical exam, I praised her for making the right choice to come in to the hospital. She rolled her eyes and waved away my platitudes.

“I only came in because I wanted you all to quit bugging me,” she said. But as I struggled to find any amniotic fluid on the ultrasound, I noticed her peering nervously at the screen.

Whether it was the vasoconstrictive properties of the methamphetamine or true pre-eclampsia, something was preventing adequate perfusion of her placenta. The 27-week-old fetus it supplied was being choked of a blood supply.

The decision was made to proceed to immediate cesarean section. In the mad jumble of consultations and consent forms that precede every hastily-scheduled surgery, a voice rose above the crowd.

“Does anyone know if Ms. R wants a tubal?”

Tubal ligation, the most permanent form of contraception, is a simple procedure during a cesarean section, and is something we offer every patient, regardless of age.

No one was sure, and the team was about to move on to discuss the details of the surgery when I raised a hand.

I knew that Ms. R wanted the procedure. One of the first things she had told me when we met was how adamantly she wanted her ‘tubes tied’, how the Catholic hospital that delivered her last child had refused to perform this procedure on moral grounds, how this current pregnancy was unwanted, how she was homeless and barely able to support herself, let alone more children.

The attending turned his attention on me. So where was the consent form she was supposed to have signed, weeks ago, to this effect?

Due to the permanence of tubal ligations, mothers in California are required to sign consent long before the procedure takes place, allowing them enough time to think about such a serious decision. Without this prior permission, the tubal ligation could not happen even if the patient was now requesting the procedure. Now on the day of Ms. R’s surgery, she might once again be denied the tubal ligation.

But I had prepared for this. Earlier in the day, I had called up Ms. R’s outpatient clinic and requested the completed consent form be faxed over. I had thought nothing of it at the time. It was a standard medical student task and just one of a dozen other checkboxes on my to-do list that morning.

But the resident was ecstatic. “You probably just saved this patient’s life,” he told me. I was baffled. Why was he getting so worked up over a bunch of paperwork?

The cesarean section went beautifully. Holding retraction in the operating room, I caught a glimpse of the tiny infant as he emerged. In the hands of the pediatricians I could not help thinking he looked like a shriveled old man, eyes glaring up at us like he had been woken up too early from a deep sleep.

Ms. R recovered without issue, and her blood pressures went back to a normal level. She checked herself out of the hospital two days later, leaving her infant behind, still intubated and on a feeding tube.

I didn’t think about Ms. R for a long time after that. A few months later, I noticed her name on a patient list. But she wasn’t the patient.

It was her son, K. He had been assigned as my patient on the first day of my rotation in the neonatal intensive care unit, or NICU. He was still tiny and still on a feeding tube, but he was growing well. He was so premature that he had not even reached his scheduled birth date yet.

I felt so sorry for K. Born to a mother who clearly did not want him, nobody could be certain what kind of neurological issues he might have in the future, or even if he would survive his stay in the NICU. I knew that Ms. R had faced horrendous challenges herself, but I could not help quietly cursing her for abandoning him, for what she did to him, for what she exposed him to. How could someone do this to their own child?

And then one day, Ms. R was there.

Accompanied by her social worker, we met in a family conference room. I did not expect her to remember me, but her eyes grew wide when I walked in and she smiled with recognition. She looked wonderful. Her clothes were neat, her hair was combed, and her face was calm and peaceful. She told me her life had changed since K’s birth.

“I dumped his dad, quit the drugs and checked into a women’s center. I’m getting clean and they’re going to let me take K home when he’s ready.”

Suddenly, I remembered how my resident had reacted when I produced Ms. R consent form for the tubal ligation. Ms. R had not wanted to be pregnant. Her pregnancy had nearly killed her. I understood my resident’s triumph. Now, finally, an intervention had been performed that would allow her to break the cycle of poverty, pregnancy, dependence and abuse. This experience had changed her, had allowed her to reach a period of stability in her life. She was taking control, living for herself, and setting her own rules. She was the master of her own destiny again, and not beholden to a man who had refused to visit her in hospital, even as she nearly died carrying his child.

The task of filling out some paperwork had seemed so mundane, so quotidian at the time. As a medical student, sometimes these tasks are the only ones I am really qualified for. Surrounded by men and women with such advanced training, it can be hard to feel like I can have an impact.

But this little task had a gargantuan, life-altering impact. Faxing some paperwork had changed Ms. R life. Medical students do not need to wait until they graduate to start making a difference for their patients. A single kind word from a trainee, or an extra five minutes of listening may transform the entire experience of sickness and death for another human being.

So my advice for any students doubting their role on a medical team: know that you can change a life, no matter how insignificant you may feel.

And get good at sending faxes.

*All names in this post have been changed to respect the privacy

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The Burden of Knowledge

by Abdul S. Hassan, MS4

Before medical school, I was fascinated by the myriad diagnoses that seemed to live in the brains of doctors and how these doctors were so adept at keeping all of those different diseases in order. As I started medical school, I was invigorated by the notion that I could spend my time learning countless different maladies and become a cornucopia of medical knowledge.

Four years later, I can confidently say I know (some) diseases. Maybe even close to a hundred or so, but nothing that could compare to to the likes of Harrison’s Principles of Internal Medicine (the venerable tome of medicine). The reality is, the name of the game for medicine is pattern recognition. We are trained, and nowhere more rigorously than in our 3rd year and beyond, to recognize the specific ways different diseases present as well as the most common illness we will come across.

Take for example, the following vignettes:

1. 18 year old male with 2 days of umbilical pain that has radiated down and to the right; he endorses nausea, vomiting and no appetite

Appendicitis; confirm with ultrasound if stable or straight to OR if highly suspicious for perforation

2. 74 year old female with 3 months of dark black stools and 15 lbs of unintended weight loss; she endorses feeling weak and increased fatigue throughout the day

Colon cancer; confirm with colonoscopy and biopsy; CT scan for staging; potential surgery and chemotherapy or radiation

3. 29 year old female with intermittent history of eye pain as well as right hand and left thigh numbness; symptoms arise without warning and eventually return to normal

Multiple sclerosis; MRI to assess for plaques; initiation of DMARDS; possible physical and occupational therapy for residual deficits

Ask any medical student worth their weight in stethoscopes about the above scenarios, and they should be able to come up with the exact same diagnoses I have made.

At the time of writing, I am at the beginning of my 4th year of medical school, and I’ve come to see how this type of education has changed me. The pattern recognition algorithm doesn’t just turn on when I’m at the hospital or taking an exam, but it is now a base program that runs in the background constantly analyzing the outside world and all the people within it. This realization hit me in the middle of a much needed post-call run.

Running alongside some construction, I noticed a small patch of sidewalk that had not yet been demolished. And upon that small patch of concrete stood a gentleman with a bright orange hat, white dress shirt, some brown khakis and a cart with a random smattering of goods. I wouldn’t say he looked completely untoward, but he was a bit disheveled. He appeared to be talking to something or someone who was not there – his conversation was unheard against my running playlist. As I passed him by, I noted how his mouth and tongue seemed to writhe and undulate with preternatural conviction. And in that moment, my brain shot out:

Elderly male, disheveled appearance, questionable auditory/visual hallucinations, involuntary and repetitive movements of mouth and tongue

Schizophrenia and tardive dyskinesia likely secondary to antipsychotic medication.

Maybe I am wrong, but if you were to see this presentation on a medical school exam, then again, most medical students would think of the above answer.

A big part of me is taken back by how my brain has changed and how it will further change with more studying and more patients. But another part of me is saddened. Saddened because we in the field of medicine, know what the scariest and most life-threatening presentations of the most common diseases. At this point in my life, a headache, is not just a headache. A simple course of antibiotics for my patient is not just an afterthought. The nagging pain you have had in your back that seems to keep you up at night, has the same effect on me.

I know that there will be many people in my life, for which my inner conscious will be a harbinger of their ultimate end. I will have a close approximation of the diagnosis before they even finish their sentence. The people I love, my friends and family, are not safe from this constantly running program that seeks out disease. It is a gift, but it is also a burden. The burden of knowing too much is engrained in medicine.

And yet, I accept this knowledge with great humility. There is tremendous honor in being the voice that a patient listens too. The voice that has the power to completely alter someone’s life with only a handful of syllables. With that voice in mind, no matter how quickly my algorithm darts to the most malignant of diagnoses, I hope I can continue to call upon my heart and remain steady. May the burden of knowledge be not a weight that slowly drives us into the ground, but a shield we use to know when and how we can protect our patients; the people that have entrusted perhaps not just their lives, but the end of their lives to us.

What else do I have?

by Sandeep Prabhu, MS4

I often find myself getting irritated about the most mundane disruptions and problems. While the rational part of me realizes that my small frustrations are often unwarranted, I still struggle to control them. However, I recently met a patient, who I’ll call Mr. Sweet, who taught me the importance of appreciating what one takes for granted.

Mr. Sweet was immensely friendly and pleasant (even when I woke him up early in the morning before sunrise), which is all the more commendable given that he had liver failure and was admitted with an acute exacerbation. I found no known cause listed in his chart, so I dug a little further and asked him as well. I learned that he never used intravenous drugs, didn’t drink alcohol, was not obese and had no known genetic predisposition to liver disease. I finally came to the same conclusion that other providers before him had: his cirrhosis and liver failure was cryptogenic, with no known cause.

Furthermore, his kidneys had failed and he was getting regular dialysis. He was listed for a liver and kidney transplant and lived at home with his wife, making 3 weekly dialysis visits and periodic drainage of fluid that would build up in his belly. Given this tough scenario, I was surprised to see Mr. Sweet’s optimism.

Every morning when I pre-rounded on him, he was pleasant and optimistic, answering my questions patiently, complimenting me on my tie and reminding me what a great day it was . Over the course of the few days he was in the hospital, I visited him frequently and got to know him well. I asked him directly once how he managed to be so positive despite the seriousness of his condition. He chuckled, stating that his daughter had asked him the same thing, replied, “Well, of course I’m hopeful and optimistic about the transplant. Because if I don’t have optimism, what else do I have?” This profound statement really struck a chord in me.

Despite all the odds stacked against him, he didn’t give in. His will power was not only ironclad but he also exuded positivity despite having a condition that could very well limit his life to weeks. His attitude towards those few days I cared for him taught me two very important things. First, a person’s inner strength has no limits, despite being pushed to the brink. This is an important lesson for life as we all face what seem to be insurmountable odds. Being steadfast in trying to tackle them is only part of it, as he showed, but striving to be positive makes the challenging process a more positive one for us and those around us. Secondly, the importance of comfort in end-of-life care was illustrated well by his case. Those last few weeks or even days are priceless to patients like him and his loved ones. After he was stabilized in the hospital, he insisted on going back home where he could still maintain a good quality of life.

I left the service a few days after he went home. Unfortunately, he was readmitted a few weeks later. This time, however, his condition deteriorated further and he spent many weeks in the ICU. I later found out that despite all efforts, he passed in the hospital. He never got that liver and kidney. He didn’t even have a chance to be at home when he died. I never got to see him during that last admission, but I’m certain he was positive even when he knew the end was near.

Mr. Sweet may have passed on but he taught me to be constantly grateful for all the things I often take for granted and to reframe my momentary frustrations by looking at the bigger picture. He also showed that no matter what challenges one is facing, one can still radiate infectious positivity to those around them. And at the very end, that may be all that really matters.

 

Strength

I think a lot of times as medical students we feel inadequate. We feel overwhelmed. We feel not good enough. I think this is the case a lot of the time. Going to see your first patient in free clinic, or ACA, or even deep into 3rd and 4th year honestly.
So like everyone else in medical school, I feel the same feelings of guilt and embarrassment, with just a touch of pride that we all do when a patient mistakes me for a real doctor. And I mean the guilt and embarrassment, of course, comes from not knowing everything, or really anything at all sometimes. And that pride comes from knowing that someday we will know.
That we’ll walk into a room with full confidence we’re going to take care of our patients.
We will do everything to make them better.
That we’ll one day deserve that title.

But be humanistic? I thought I can do that. It almost sounds funny, because you come into 3rd year thinking of course we’re going be humanistic. We just had 2 years of POM. We can all do that. *wink*
But it doesn’t happen all the time. And I don’t mean to judge. It’s hard. It’s busy. Not every one is mentally there all the time. We’re worried about impressing this person and that person, and of course we are all guilty of it.
And I think what gets lost in all this, is that it makes a difference to just be there, not just for the patient, but for you. I was lucky enough to have a patient show that to me early on.

I was on my first day of my first rotation. And that sounds more dramatic than I’d like, but there it is. I had gyn-onc, which meant I was a bit sleepytime. For those of you that don’t know, it starts usually around 4am and ends around 6-7pm. I got assigned my patient on that day. Ms. B, let’s call her.
She had late stage cervical cancer and prognosis wasn’t great. She was in for a SBO – a small bowel obstruction. She was real young. I’m talking 30s. She had 2 amazing, awesome, and hilarious kids. Her mom took care of them. Grandma B aka Queen B. She seriously held it down.
So first day, I get in there and I introduce myself.

Ms. B says, “So, you’re a doctor?”
And I said, “No, no! I’m just a medical student.”
She replied, “Well you’re really young, that’s all.”
And I said, “Well, maybe I’ll grow on you.”

Which is not funny, but she laughed. Which is the best sound when you’re nervous as all hell, you know. And we talked a little bit, and I said I would be helping take care of her from now on.

So next day, I’m pre-rounding. I got my questions I wanna ask, I know what physical exam I gotta do.
And as I came in, she’s in pain. You can tell.
And she said “Boy, I know you are not in here to press on my stomach. One of you already came and did all that.”
I went over and I just asked her how her night went, eventually maneuvered into asking if she passed gas or *fingers crossed* had a bowel movement, meaning things got better. No luck.
I said, “So I have to do this physical exam.”
Daggers just started shooting out of her eyes.
I said, “Honestly, I just wanna help. If you don’t want me mashing on your stomach, I understand that. This is really for my learning more than anything, and that always comes second to how you feel.” So I said that, and I don’t if it was the right thing or not.
She agreed. And I lifted up her gown to expose her abdomen.
She said, “Not a pretty sight, huh?”
And suddenly I realized, it doesn’t matter if you’re 14, 40, or 90. It sucks the same when someone just looks at you, and you’re vulnerable, and you just don’t feel your best.
She had gotten a few surgeries already and she had areas of loose skin and a few scars along with an ostomy bag, which is a bag connected to your colon.
And so I looked at her and I said: “Are you kidding me? Ms. B, you are in the hospital, you’re feeling like trash probably, and you’re still killing it out here. I got dudes outside in line asking for your number, it’s shenanigans.”
She laughed a bit and said “Boy, you stupid” and sort of hit me with her hand playfully.
That was when I first noticed her tattoo. I didn’t get a good look, but I saw it. Her only one. Usually, not all the time, but when people get just 1 tattoo, that usually means something. I mean of course you can have a lot and have them all mean a lot. But this is just my experience, and it could be woefully ignorant.

So a few days later, she’s in bad pain again. Things aren’t going too well; we’re considering surgery now for the SBO.
I go in and she’s really upset. She’s in pain, but also something else. I don’t have to talk about it, she knows we’re all really busy she says. And told her that I wanted to hear, and I wanted to be here.
She told how she missed her kids and how she hated this. She hated feeling this way and being in bed. She hated the exams because she felt dirty all the time, and she didn’t want people to feel dirty after they touched her. She hardly even let her kids hug her when she was in here. We talked a little more, and I asked her what her kids might be doing. And she said that Grandma B was real soft and probably had them eating unhealthy stuff like burgers and fries. I said sometimes you just need that though. And we went on to talk about our favorite burger joints, and where she would go when she got out of here.
Then I asked if I could see her tattoo. She showed me.

It was an infinity. For those of you that don’t know, that holds a particular significance to a decent amount of us. And it hurt to see it.
There’s a great quote in a great book: “Few doctors will admit this, certainly not young ones, but subconsciously, in entering the profession, we must believe that ministering to others will heal our own woundedness. And it can. But it can also deepen the wound.”

It was an infinity with the word “Strength” in it.
I asked her why “strength?”
To which she replied, “Well it’s so I have the strength to deal with all this bullshit.” A woman of my own heart.
She said she, her mother, and sister got them at the same time. Her mother’s said “Faith,” and her sister’s said “Love.”

“When I look down at it, I get the strength to keep going and I feel loved even when I feel like everything else is crumbling around me.”

And then she told me a bunch of stories. Hearing those stories was the best feeling, during a time I felt incredibly low. But she was there for me. I told her a few stories back, and I got a few pity laughs and god I hope she felt even a little better.
Few days later, things still weren’t great and she wasn’t doing well in general and we decided we had to go to surgery to take out that section of bowel and reattach the pieces again. The intern was really overwhelmed and she let me talk to her, letting me be more autonomous than I deserved.

I talked to her in the next early morning and said we would likely go to surgery. She got really scared and asked if she was going to die soon. I told her I wished I was smart enough to answer that question, and that she should ask on rounds. And she said she understood what I was saying, and asked if I could stand next to her when the whole team came in.

So on rounds, I mentioned that she was going to ask this, and the team felt like that wasn’t an appropriate question, to say nothing of the fact that it was impossible to answer. We go in, and I stood next to her, and we talked about surgery in the near future and the senior resident said she couldn’t answer her question. It just didn’t feel good, you know. It wasn’t anyone’s fault. But sometimes you just feel interactions don’t go well. And things move so fast sometimes that you don’t really do anything about it. We were wrapping up when I got this idea. The team was leaving and she was upset, on the verge of tears. I lagged behind a little, and I pulled the marker off her little white board in the room and drew an infinity. I looked up at her. She graciously smiled at me, and said I better be in the surgery. I said I would be of no use at all.

“Boy, just be there.”

The surgery went well. Her bowel was in all the wrong places, and it looked angry, and there were adhesions everywhere, but the surgeon was amazing. The next day I told her just that. On my last day, I told her how much getting to know her meant to me and how much I learned from her. And this part I still remember as clearly as ever.
She said “Well?” then threw out her arms and said “Hugs!”
I gave her a hug.

I found out Ms. B had died 7 months later. As abrupt as you felt that now is as abrupt as it felt to me. My resident told me in passing.
She said, “It was weird, but she asked if you were around before she left on hospice. So I thought I’d tell you.”
I had never been more honored, I had never felt more grateful, than in that moment.

I went home later that day. I didn’t really share this story or anything, I actually have never told it. But I got home, and my roommate was there for me in a big way. I remember it clearly.
I walked in and I said, “Hey man.”
He looked up, his headphones on, and said “Hey I’m making spinach and eggs tonight, is that good for you?”
The man makes a mean spinach and eggs.
Sometimes that’s all it takes.

You know in these last years, I’ve seen my classmates and others organize days of fasting for solidarity, letter writing campaigns, courses for ESL at free clinic, tours for all kinds of organizations, create specialty groups from nothing, improve mentorship, take each other out when they think something is going on, make dinners and feed others, make kits for the homeless, it goes on forever.

Some things are devastating for no reason at all. Some things hurt more than they ever should. Most things are just not fair and make no sense. But we are made better by each other. And that’s what that patient taught me. That’s what I think humanism is. It’s not just being kind. It’s not just being compassionate. It’s reaching out. It’s letting people heal you while you heal them. It’s learning. It’s fighting. It’s taking a piece of you and giving it to someone else knowing they will give you a piece of them right back. Just being there can make all the difference. Just showing up. The strength of your presence, of your thereness, means more than you can understand, and it’s important to never forget that.

Dying the Natural Way

“What was the creatinine again?” the Critical care fellow asked, as I had rushed through the labs section of my presentation. In the time that I spent looking down at my notes to find the creatinine value, and reporting it, the fellow and I found ourselves alone at the patient’s door. We looked around to find that the remaining 6 members of our ICU team had ran over to the room next door. That room had become home to Mr. K for the past 2 weeks. His prognosis was dire. In fact, I remember my first introduction to Mr. K’s case being the following conversation:

“If he codes, we must keep it a very short code. We do not want him to suffer.”

There we were, at Mr. K’s door, looking up at a bradycardic rhythm. His heart was beating ever so slowly, at 30 beats per minute, irregularly, arrythmically. “Normally” we would call a code, fill his room up with nurses, physicians, staff, with a line of folks waiting to press on his chest and plea for his heart to beat rhythmically. But this was no normal occurrence. During Mr. K’s ICU admission, multiple attendings spoke with his wife about his wishes, as he was unable to make his own decisions. The complexity of a family member deciding if their loved one should undergo an attempted resuscitation, is in itself cause for another piece. For Mr. K, the conversations and understanding of his family’s position had evolved over the 2 weeks. At this point in time, while we stood in his room, the attending physician had been entrusted by Mr. K’s wife, to decide to not attempt to resuscitate him, if she deemed that the feeble body of Mr. K would not benefit from it.

“We are not running a code. Please give Fentanyl.” Our attending said, decisively, and to our relief. You see, seeing patients critically ill, with no realistic hope of return to a life with quality, we (as in, the collective healthcare profession) become partial to a certain acceptable way out of this world. Our human-ness comes out. We think, “Would I want that for me” and more appropriately yet “Should one want that for them”. The group of us standing in Mr. K’s room with him, watching him in his last minute of life, wanted this for him- the peaceful exit. We had seen the alternative on most days- the chaotic, loud, bloody, messy scene of a code. We cared about Mr. K, and were fortunate to have 2 weeks leading up to this moment to clarify what we should do in this moment. With most patients, we, and they, are not so fortunate. Most people do not like to think about their last moments.

Though we wanted Mr. K to have a peaceful exit, standing there, watching him die, was eerie. This was supposed to feel natural… yet it felt wrong. It seemed that the natural way to die, the default if you will, has been replaced in our minds as what happens most frequently in hospitals and on the media. The loud beep and the flat line, with the rush of white coats and scrubs who attempt, and many times, fail to bring the body back from the dead. That has become our default. My fellow medical student later reflected on this shared moment of Mr. K’s death that a reason she chose anesthesiology as her field is because while a patient is in the operating room, they are always “full code” meaning they will undergo attempted resuscitation. Standing by, not actively doing anything, while a person dies, was too difficult for my friend. Of course, I do not blame her.

Through it all, I gained the utmost respect for the ICU attendings who had the foresight to speak with Mr. K’s family, patiently, calmly, and slowly break down the misconception barriers of the role that attempted resuscitation did or did not have for Mr. K. I hope to emulate them, not allowing my career-born bias creep into my discussions with patients and families, but also tirelessly and patiently providing them the facts needed to make the decision of how their loved one may leave.

–Hedieh Matinrad, MS4

Untold Meaning

I handed her the humungous gardening shears and watched as she snapped through each rib providing access to the silent heart of our cadaver. Abruptly, the fire alarm rang out cutting short the most physically taxing day of our yearlong anatomy lab course. Once we had evacuated, firemen streamed into the building and I wondered if my lab-mates were also thinking about the horrific scene these men would encounter as they checked each room for stragglers. Garden tools rested on the half open chests of 24 lifeless bodies, globules of fat previously stripped away dripped into buckets below each lab table, and black plastic bags covered the faces of the anonymous men and women who had donated their bodies to medical education.

In elementary school I was deeply afraid of all things related to death and dying. At night I pulled my sheets up tight around my neck for fear that if there were any wrinkles left in it, it would look like a shroud and I would die in the night. I hated my bureau because it was big and rectangular and therefore looked exactly like a coffin. At Sunday school I could not drink from the water fountain because the water had certainly passed all the corpses in the graveyard on its way into the church. So, suddenly encountering dozens of pale, stiffened bodies, I thought to myself, “um, remind me again, why did I decide to go to medical school?”

As the fire trucks pulled away and we readjusted to the pervasive smell of formaldehyde, I thought about how quickly I had accustomed myself to slicing and combing through the unfamiliar territory of the human body. I was so fascinated by each new discovery that I forgot to worry about the proximity of death. Sometimes by the time I had changed into my scrubs and arrived at the dissection table my lab partners had already started and were ready to drill me on the day’s new terminology. “What’s this?” Mara asked, using her forceps to gently lift a white string running from deep within the neck down to the diaphragm. “The phrenic nerve?” I offered hopefully.

Relentless quizzing was a necessary evil because we had four exams to pass in order to move on to second year. The instructors tagged various body parts with numbers and we went from body to body writing the names of the tagged elements on our numbered exam sheets. It was highly unsettling to visit other lab tables. Each cadaver smelled foreign, this man’s cancerous liver made me wary, and his neighbor’s larger than life heart was unnerving. Shouldn’t someone formally introduce me to these people whose insides have been laid out before me? Without realizing it, I had developed a comfortable relationship with my own donor. I developed a relationship with a deceased woman who I knew nothing about beyond the elegance of her organs, the illnesses she endured during life, and the cause of her death.

My donor had passed by way of suicide. Throughout the year I tried not to make assumptions about the circumstances of her life and death but occasionally, as I walked out of the lab, my mind ran wild with questions. What had driven her to take her life after eight decades? Had she been lonely? In pain? Afraid? Or was it simply time to make that jump to the other side? We learned through the findings of our dissection that she had eaten within four hours of her death. What had she consumed? Did she make delicious molasses sugar cookies like my grandmother’s? We also discovered that she had fallen hard on her side upon passing and had lain for several hours before being found. Who had found her? Were they terrified beyond imagination at the sight or had they known this was coming? Did they grieve her still?

At the end of the year my class put together a memorial service for over 200 relatives of the donors. It was here, not leaning over a body with a scalpel, that I came face-to-face with the scariest aspect of death: the enduring empty space created when you die and the immense grief of those who remain behind. During the ceremony I stood in back with a woman whose mother was a donor. “I thought I had moved on, but clearly not,” she proclaimed, growing more distressed with each poem or piece of music my classmates had prepared to express appreciation to these loved ones. I listened and spoke what I hoped were consoling words. She told me I would make a great doctor and I remembered that I am in medical school to make the living more comfortable if only in small and temporary ways.

Afterward I spoke with two sisters who flew in from out of state just for the service. Their brother died while visiting San Diego and the family had been at a loss for what to do. For years, he had planned to donate his body to medicine but arrangements were only made to collect his body if he passed away in his hometown. They were grateful to the school for reacting compassionately and efficiently enough to grant him the honor of contributing to our education and the greater good of the world. “The donors are your first patients,” our anatomy instructors emphasized over and over again, “learn as much as possible from them while you have the chance.” Only then did I really grasp that our donors were patients who we could no longer save from death but to whose lives we had added untold meaning.

–Alicia DiGiammarino, medical student at the UCSD School of Medicine

Note: post originally appeared on Medium.com – https://medium.com/@aliciadigiammarino/untold-meaning-cf5eebfdbc73#.ahepvxhrt

“What could we have done differently?” | Thoughts on Institutional Forgetfulness

It is a question we often ask ourselves: “What could we have done differently?” Whether it’s when we’ve made a mistake, when an attending gives negative feedback, or when something unexpected happens, it helps us learn from our past. I find this to be an important question, and one that often guides me in medicine. Mistakes happen, and the process of a good medical education is full of trial and error. But how do we apply this learning to something bigger than a single person, like an institution or a school?

I visited a friend, also a medical student, in New York this past month. The day of my arrival, she informed me of some grave news: “A classmate of mine committed suicide this morning.” My heart ached for her school. I asked her if she wanted time and space to herself. She figured company would be good. Our lives paralleled one another– a year prior my school experienced a similar loss, and I tried to relate. But in those instances, it’s impossible to know exactly what a person is feeling.

As an outsider, I watched the tragedy of that morning unfold. My friend told me how their deans sent an email out to the school telling them someone had died but named no one. This caused a strange turmoil in her class given it could have been any member of their class that they lost. It was in whispers that many of her classmates found out who had passed and what had happened. The nameless email was just one of many things students felt the school had done wrong. Just hours later, school administrators held a student meeting. With just hours to process the day’s events people were already arguing, speculating the cause of this completed suicide, putting blame on the school and administration for unnecessary pressure the student likely faced. This meeting occurred while emotions were high; people were asking, “What could we have done differently?”

This event forced me to reflect on how my school handled its similar situation. I recall administration sending an email out, naming the passed student. Our school’s administration similarly held a meeting where we expressed our grievances with school stress, and need for mental health support. We were offered counseling, and made aware of the mental health resources available to us. Similar to my friend’s experience, students here were angry, upset with how the pressures we face can lead to things like this. But then months passed, and like lots of things in school, the passion that fueled concern for mental health and what had happened faded behind us.

I, too, asked, “what could we have done differently.” Though much can be said about suicide, and in particular physician suicide (here, here, here, and here), I wonder more about how we can institute change, and keep it relevant even after many of us have moved on. We shape our own personal knowledge by trial and error. But it’s difficult for us as transient four-year-students, to maintain an institutional memory of what we can do better. Administrators may persist, but those of us at the heart of wanting to create change are only temporary pillars trying to hold up this falling ceiling. We brainstorm ways to promote suicide prevention. We say, “this is how things should be.” But then we graduate, we move on, and leave future students who have not learned from our shortcomings.

In medicine, they say every patient is a teacher. In medicine you quickly realize people will die, you can’t save everyone. As healers we allow those we can’t save to become teachers, so that in the future maybe we can do something differently, and in the end save someone else. And in these two instances of losing our med-school colleagues, they have taught me the importance of mental health, that we need to address unnecessary stress, and we need to uncover and resolve systemic problems. But by evidence of persistent issues with higher rates of health-professional suicide, I’m not sure if institutions are remembering what they could have done differently. We need to figure out a way to remember what we have learned and not let time wear down these lessons.  And unless we fix this problem of institutional forgetfulness, we will keep asking ourselves, “What could we have done differently?” Unfortunately, this is a question of which I still have not found the solution.

 

With a heavy heart,
Bradford Nguyen


For those who wonder what we can do, suggestions from Jamie Riches, DO (http://blogs.jwatch.org/general-medicine/index.php/2016/07/what-is-resilience/):

“What can we do?

  1. Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
  2. End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
  3. Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
  4. Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
  5. Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
  6. Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
  7. Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.”