A thriving infant swiftly, within just over a years time, transitions from being comfortably cradled in his mothers arms, to exploring the wonders of the floor world, to finally ambulating independently on two feet. With each transition, there is often a period of time in which the infant familiarizes himself with new muscles. He inevitably outstretches his arms and legs and learns new ways to move them. He builds strength, as he unknowingly exercises them with every movement. And he grows with the nurturing milk of his mother. I've recently witnessed my favorite little man, Noley Posole (as I call him) complete this process. He currently waddles from room to room, across vasts patches of grass, between the legs of his cooking mother, and even climbs down from the couch with ease.
My first two years of medical school were much like the stage of being cradled. We were only accountable for ourselves, we were given lectures and tests in which we reproduced the information, and we were guided through physical exam maneuvers with hired patients, who were virtually healthy. We basically had no real responsibility (surely at the time it didn't feel this way, but looking back it wasn't all that bad.)
Following this we 'graduated' from the classroom after taking one of the most important tests of our lives: USMLE (United States Medical Licensing Exam) Step 1 exam, or as it is informally called 'the boards' or 'the step.' This exam is a measurement of our knowledge in all the fundamentals of science, behavioral sciences, and so much more. The score has the ability to determine your future, as it gives residency programs a baseline score to compare you to other students across the nation. You have no other option, but to pass it if you want to continue your medical education and become a doctor. In an attempt to prepare for this oh-so-important test, I locked myself in a beautiful 3 bedroom cabin in the middle of the Pecos wilderness, surrounded by a peacefully flowing river, towering pine trees, and on many days blankets of white snow and sheets of ice. It was for six weeks my little piece of heaven, which I shared with my little sister's dog Oreo. While I didn't take too much advantage of the breath-taking outdoors, I did use the never ending peace and quiet to focus on studying. I stuck to a ridiculously stringent routine of awakening by 7 to make coffee, having breakfast, and listening to a recorded lecture by the all-knowing Dr. Goljian and by 8am I was already hitting the flash cards and books. I studied nonstop from essentially 8am until at least 8pm, if not 10pm on days where my energy reserves permitted. Of course, I allotted time to lunch and dinner and even an hour for exercise (which changed to an hour of napping, when times got rough). I studied six days a week, with the exception of one 4 day weekend to San Diego to see little sis get hitched. It was absolutely the longest studying binge I had ever had and by far the most self-discipline I have ever had to endure. There were times when I thought I was losing my mind and times when my mind would completely shutdown and I'd have to read sentences repeatedly before absorbing the information... yet, I persevered. In complete devotion, I even gave up my social networking addiction and my cell phone was completely disabled... determined to get an excellent score or completely insane? I have yet to decide. This preparation was much like the in-between period before learning to walk. It was a time to explore the world completely stabilized by four limbs instead of two... a time to test your true understanding of concepts and a time to reinforce concepts that were weak.It was a time to test your endurance and will to succeed, and finally a time to test yourself. We were learning to crawl and explore the "floor world" of medicine as an infant does before it dares to walk on two feet. It was a time that won't even be a blur in our future.
Following that dreadful six weeks of frustration; fatigue; endless sample questions; reading my prep book three times from cover to cover; and another book through and through once; and listening to lectures on my computer while exercising, cooking, cleaning, and even getting ready at times; I took that nearly 8 hour exam....
and PASSED with a pleasingly high score!
Following this six weeks of seclusion and brain-saturating days, I left the country for a much needed break and returned for a four week transition course that would prepare (or rather attempt to prepare) us for the year to come: Clerkships, a time to rotate through various specialties of medicine and a time to see what being a doctor is all about. This four week course was also a time to recuperate and get as much socializing and sleep in as possible, although this proved to be tough with endless research deadlines (which I might add is proving to be a nice breakthrough in the public health arena), planning the annual School of Medicine Ball with only two other ladies, helping organize the Hippo Awards (which is essentially an event to honor our favorite professors and perform skits that remind us of our first two years of med school), and so much more! I guess you could say we never really rest as med students.
And then literally one weekend of freedom later, we were thrown (kicking and screaming) into hospitals and clinics across town. We we're now entering the stage of infancy where we would learn to walk, whether or not we were ready. We would be lifted from our bodies that had only recently mastered crawling and we would be launched forward into the next stage of development. The class I had spent hours with day after day for the last two years was separated abruptly never to be reunited... Little did I realize that our only interactions would be passing each other in the hallways as we swiftly march to patient rooms only to ask quickly "what rotation are you on" and after receiving an often anticipated answer, you march back off to the task only slightly remembering the words of your peer.There's always too much on the mind to fully hear anything... to much on the mind to think, yet were in positions where thinking is absolutely vital, absolutely required.
The wards are a different world. The language is different and I am slowly learning it. We speak in acronyms most of the time and we type in code. For example, the first line of one of my notes might look something like this:
"Mr. J. is a 55 yo male with pmh of HTN, CHF and CKD who p/w SOB X2 days and denies chest pain, n/v/d/c, f/c."
Translation??
Mr. J is a 55 year old male with a past medical history of hypertension, chronic heart failure, chronic kidney disease who presents with shortness of breathe for two days and denies chest pain, nausea, vomiting, diarrhea, constipation, fever and chills."
It's a language that no one really teaches you, but expects you to know. Sometimes when I'm in the midst of conversation with a group of docs regarding a patient, I wonder what an outsider looking in would think... They'd probably think we were making crap up, babbling like idiots! Sometimes, actually many times, I have to scribble down acronyms to remind myself to look them up later. Let's just say this learning curve is rather steep... in fact it wouldn't be far from the truth to describe it as a learning cliff.
The hospital is a place like none I've ever known. I am surrounded by sorrow and sickness. And on the mornings when I arrive before the sun is only preparing to light my walk from the parking lot to the hospital, I walk through halls that are easily described as eerie. Faces turn to look at you more slowly and shuffling feet in the hallway penetrate the quietude. The nurses move like molasses at the end of their long night shifts and the overnight docs blankly sit in front of their computers typing as if doing so automatically. The cough of a common cold sounds more like a TB patient hacking up a lung and the moans and groans of the lady in room 306 sound just like the llorona lady your grandmother always scared you about. And while it's not a pleasant place, I often found peace and comfort in knowing that my ill and often dying patients were sleeping and resting their weary and worried minds. I found peace in knowing that they had survived the night. I found peace, a very unusual peace, in the stillness and the slowness of those early mornings.
There is hierarchy in the hospital, a very very prominent hierarchy that you would be foolish to lose track of. Every team of doctors.... and me.... is named after a color. At the U (the shortened and more used version of UNM), I was on the gray team- a rather boring color, which did not accurately portray the not-so-boring experience I had; and at the VA I was on the yellow team. You spend your entire day with the team, you meet up in the morning and triage, you round on each patient, you sit and write notes together, you go to meetings together, and you even sit in the physician work room exhausted as can be, but cheerfully jamming out to Tom Petty and eating junk food that the intern bought with his stipend money. You spend nearly every waking hour with your team. More or less, each team is comprised of an attending (the jefe of jefes), then the resident (a young doc who is about 2-3 years post medical school), then the intern (fresh outta med school), the sub-intern (a fourth year medical student, with exponentially more responsibilities than the measly med student) and finally there's me- the bottom of the totem pole... literally as low as you can go. My team changes on a regular basis as docs switch between teams, or from one service to another, or they graduate and move on. My last team was incredible- my attending was a middle-aged German woman who had stories from abroad as she doctored around the world and she's known for buying a dying patient some barbecue sauce to douse their last meals with; my resident was a devoted Latina woman who is invested in the care of each and every patient and who advocates for their care in an admirable way; my interns (I have two) are incredibly rambunctious and helpful young adults who take the time to teach me a thing or two every spare moment we have (which isn't too often unfortunately). In a matter of 5 weeks, I've worked with so many doctors- an intern who literally took an hour out of his busy schedule to read through my plans and provide feedback; a sub-I who I felt so comfortable with I could as the dumbest of questions; and my very first resident who waddled around pregnant as could be, but working until the very day she delivered. All in all, I was delving into a world of doctors of all shapes and sizes, with bedside manner and without, with foreign accents and with country twang, with absurd talents and dull as can be, with a never-ending passion for their job and a regret for not having gone to pharmacy school instead, with old-school training and straight off the printing press. It was a world I would slowly progress through and each year become closer and closer to achieving the title "Attending." I am in the midst of medicine, an imperfect and continuously evolving science that sooner or later I would be expected to have command over.I am in the midst of growth.
While I couldn't do anything without an incredible team, it was the patients that kept me driving forward... It was the patients who brought the purest of smiles to my face and the most sorrowful of tears to my eyes. They're the ones with the incredible stories... the ones that hang around in my thoughts from sun up to sun down.
She was a young woman, not much younger than me, but she thought she was invincible... she thought the world couldn't hand her a problem she hadn't already seen. She was indestructible, but completely destructed and she didn't take the time to accept it. Each time I met with her I lost a little hope no matter how tightly I attempted to grasp it. She was on my mind nearly every minute of every day... Our stories first intersected one day while I was on call and was sent to the Emergency Department to interview a patient who had overdosed. That was the only description I got for what I later would learn was an absolute train wreck.
He was an old cowboy from the mountains of Eagles Nest, an outdoorsey kinda guy who was tall and strongly built. A man with uncontrollable blood pressures and a diseased aorta, but a man I grew fondly of instantly. He was merely a consult patient, which means he's under the care of a whole different group of doctors, but we just make a quick visit to make sure a specific problem is being managed appropriately. It was the first and last time I would ever see him, yet his stories still weave their strings through my memory bank. He told me about knowing all the police officers in town and never getting a speeding tickets, he told me about the time his aorta burst and he was on the brink of death when a young stranger saved his life, he told me about his children and the strong relationship he had with each of them, he told me about his life as an entrepreneur and the family business that continues to prosper and finally he told me about a very special Christmas dinner with his grandkids. It was the first dinner he would host at his house after the death of his long time wife and the mother of his children. He told me about prior Christmases when his wife would wrap multiple gifts for each grandchild and how eager they were to visit for the holidays. But on that particular Christmas, the first since his wife's death, he chose not to purchase any gifts. At this point in the story, tears streamed down his face and the box of kleenex was securely tucked under his arm as he said he thought that if he didn't buy gifts, his grandchildren would remember to miss his wife. He was engulfed in worry that they would grow up and forget her. It terrified him, so he purposefully deprived them of a tradition that they had likely always taken advantage of in hope that their grandmother's memory would live on. I thought about my very own grandparents... and a bitter flow of sadness rushed through my entire body, made my eyes water and my stomach upset.
Upon entering the room in the Emergency Department of my overdosed patient, I was surprised by a slightly overweight dark skinned girl with what looked like large boils from being burned on the side of her face and down the side of her body. She was unresponsive to my questions and upon rubbing her sternum vigourously she was only mildly irritated by the painful stimuli. She moaned and groaned like a big bear, but could not articulate words. Her story for showing up here at the emergency department was a fragmented one from her worried mother and grandmother. But it was the test that the ER docs ran that provided a slightly different story- the tox screen from her urine showed more than 7 different types of drugs, her physical exam revealed track marks up and down her arms where she undoubtedly introduced her poison of choice, and her vital signs showed that her most likely diagnosis was overdose. Unable to get a complete story and unsure of what to do I returned to the on call room where I reunited with my team. Their only suggestion was to wait. So I did just that.
She was the first and last female patient I would have at the VA medical center, and I was the last student that she would interact with during her hospital stay. She was an elderly woman with a fairly advanced stage of dementia who was admitted after suffering a devastating heart attack that the staff at her nursing home thought was merely a bad urinary tract infection. Despite her poor medical condition, she often smiled and exhibited her very aloof and forgetful state of mind. She would lie peacefully in bed and each day she would decline in health a little bit more. She awaited the arrival of her well accomplished doctor son and his wife from the east coast. One day, early in the week, I entered her room the same as every other morning. I asked the same questions to assess her mental status as I did every other day... but today her mood was energetic and her answers were lengthy and with each word spoken she shared a memory from what appeared to be a pleasant past and a happy life. As I was invited to enter her past, I felt a glimmer of hope that she was going to pull through this devastating hospital stay. She told me about her young adult life in Vermont and how much she missed the maple trees. She told me about a trip she had taken to Munich and how she loved it there. She painted pictures with her words about her adventures learning to ski and how it would become one of her favorite hobbies. And when her body was tired from telling her stories, she quietly slumped back into bed into her usual demented state and my attending and I meandered out of the room, down the hall, into the elevator and out the door on the first floor... only to recieve a phone call upon exiting the elevator that this lovely woman from Vermont who had traveled abroad had died a rapid and peaceful death. We retraced our steps to the room that we had been in just minutes ago and there she layed, already cold and already exuding the dull gray color that flushes over a dead body. We listened to her heart only to hear the post-mortem changes of blips and blops as blood dribbled among the non-pumping chambers of her heart. We listened to the lungs that would never again move air. She was dead only two hours before the arrival of her son's flight, and I'm glad that she didn't spend those last moments alone. I'm thankful that I could hear the last stream of consciousness that sprinkled through her mind. I was thankful for short period of time she had spent in my life.
"So did you intentionally overdose in an attempt to commit suicide," I asked her calmly as if it was a normal question of everyday conversation. In an angry tone she told me about how she had used a new heroin dealer and he must have given her something laced. And that was about all the story I muscled out of her for at least the first three days of her hospital stay. She couldn't tell me why she was found at the bottom of two flights of stairs in a mangled position practically cooking on the hot cement sidewalk. She couldn't tell me what had happened in the moments leading up to her overdose. So I continued to learn about her from the lab results I received- the positive hepatitis C she had likely acquired from sharing needles, the positive chlamydia test, the history of skin infections from injecting into her once untainted arms that I read about in her chart. Since she had fallen down two flights of stairs and had been found lying in the scorching heat for an unknown amount of time, her muscles had succumbed to a terrible disease process called rhabdomyolysis. Slowly but surely the strings of muscle fibers that made up her body were degrading and breaking down, and slowly but surely her kidneys were essentially becoming clogged. She was headed into renal failure and she could care less.
Another patient of mine, was a middle-aged immigrant from Europe. He presented with his teary-eyed and broken hearted wife, as she told his story because he refused to speak. She told us how a tumor had invaded his brain and was relentlessly entangling itself in his mind figuratively and literally. His thoughts had been jumbled and his personality, something we humans like to think belongs to us forever, something we can securely say we have control over, had been re-circuited and he succumbed to anger not only because of his circumstance but because of the precise location of the tumor. He avoided ye contact with his wife, who not only appeared fatigued and sorrowful, but terrified. His entire body had a tremor and he had no control over his strength, and could not perform simple tasks like touching his finger to his nose. He was a slave to his tumor, a tumor that would sooner or later take his life. I talked to him for a long while and attained his whole story. I had learned that the cancer docs had given up hope and how he had stubbornly refused to stop walking and kept falling. I had learned that he had immigrated to the US when his now adult children were young and that he had been healthy his whole life. And when I, like the cancer doctors, had nothing else to offer I asked him what food he most wanted to eat, I asked him if there was anything I could offer him to make him feel more comfortable. I wanted to offer him the world, but all I could offer was a special request to the cooks in the kitchen, I was even prepared to go out and buy a steak and lobster dinner for him.... but in a shaky voice he firmly provided a response that will always clearly remain in my thoughts, he said, "Make me a strong man again." My tool bag was empty and all the knowledge I had acquired until now had failed me, so I stood there completely helpless and on the verge of heartbreak.
My patient who had overdosed on heroin was still in my care after a week. We'll call her Faith for confidentiality purposes. Her mother was always at her bedside and her grandparents visited sporadically and often at the most opportune times- like once when my patient adamantly refused to go to dialysis, her big Mexican grandpa talked some sense into her with a stern and concerned voice. Yup, my young-prime-of-her-life patient was on dialysis because her muscle breakdown has debilitated her kidneys to the point where they no longer functioned to make urine or clean the toxins from her system. When I told her about the severity of her illness, she looked me in the eye and with any sign of hesitance said, "I don't care, I've been through worse. You and your perfect life, you don't know me." I've never been one to have a temper, but I literally had to turn around and leave the room instantly. I wanted to shake some sense into her... better yet I just wanted to shake her. Every day before I left the hospital, I researched her problem, I looked for treatments. I developed detailed plans to treat her. I showed up extra early in the morning to review her labs and make any needed adjustments. I was working so hard, only to be repaid with worsening lab values and an immature attitudes towards my efforts. I was breaking little by little. The chipper med student I had set out to be was being torn apart from the inside out.
Cancer was an unwelcomed guest that crept into the doors of many of my patient's lives, and one of these victims clearly stands out in my memory. He was an old hippie with a long white beard and stringy white hair that he messily tied high on his head. He wore glasses and talked about how he had hitched a ride from the west coast after struggling with a bad bout of constipation. He already knew he had colon cancer, but denied treatment about two years ago. Instead he returned to his nomadic life in the southwest. He hitch-hiked from state to state, lived on the street (because homeless shelters are full of "stinky people" as he noted) and ignored the symptoms that worsened each month. When he finally presented to us, he had admitted to not having a bowel movement in ages, feeling terribly bloated and having bad gas... symptoms that wouldn't be uncommon with a big bowl of beans, but given his history we knew we had to get a CT scan.... and what we found was astonishing. The cancer had taken up residence in his entire abdomen. It was even starting to creep into the muscles in his buttocks and posterior thigh. When the resident physician broke the news to him, she asked what we could do to make things comfortable for him. All he wanted was a warm glass of milk. He said while living on the streets, milk had always brought him comfort, maybe because he knew it had enough calories to last him a day in case food was scarce or maybe because milk is the drink of childhood. When we asked if we could call anyone, this grown and adventurous man, a man who had survived a life of living on streets surrounded by danger, cried. He cried and cried. He told us how he had never stayed in one place long enough to make friends. He said he didn't have a single soul who would care to hear of his news. The next day he had left in the middle of the night, after asking the hospital social worker for a bus ticket to Colorado- the place where he said he wanted to die, and a place free of Albuquerque bums and druggies (as he put it). I still wonder if he's alive roaming the cool mountains of Colorado enjoying the scenery, or if her died completely alone underneath a bridge somewhere. I wonder if he even made it to Colorado.
One week had passed and we were already nearing the end of the second week of Faith's stay. He kidneys still did not respond to dialysis and the nephrologists had even thrown around the diagnosis of End-Stage-Kidney-Disease... a diagnosis that would immediately qualify her for long term dialysis and a spot on the kidney transplant list. By this time her impudent spirit began to break. She had broken me and now she was on the verge of breaking herself. I entered her room early one morning and asked how she had done overnight, a question I asked every day and a question that usually got the response, "I'm trying to sleep!" But today she was already bright eyed and her mother wasn't at her bedside. She started to cry before a word even left her mouth. Her tears rolled down and I just sat there holding her hand and I let her cry. I didn't dare to break the streaming tears, the tears that were hopefully allowing reality to soak through. And when she stopped, I examined her and told her she could talk to me about anything. She nodded and I left the room. So while she didn't speak a single word, I felt peace in the interaction we had just shared and I didn't need any verbalization of the situation, I didn't need confirmation that she understood her prognosis, I didn't need promises that she would change her life. I just needed tears.
Many of my stories from the internal medicine rotation were sad- from grown men writhing in pain because of alcohol withdrawals so intense they cried like infants and brains that had been re-wired from years of alcoholism so that the individual told lies without hesitance. But in between there were also stories filled with joy, love and laughter. They were not few and far between. I had an incredible elderly couple, in which the wife didn't speak English and the husband didn't speak Spanish and when I asked about it they just giggled like school-aged children. I had a 90 year old patient who was spunky and healthy as can be. I had patients who bounced right back after treatment was started like a middle-aged quadriplegic who came in completely septic unable to vocalize his symptoms and within 24 hours was teasing the nurses and eating Chinese food his friend had brought. I saw success stories, I participated in cures, and I shared happiness with many patients. I was learning what it was like to be a doctor who sees one end of a spectrum to the complete opposite end.
I left before Faith was discharged. I was transferred to the VA, but each day I pulled up her chart to see how she was doing... and each day her values began to normalize and her kidneys began to regain function. I was a little saddened by not being able to follow her through to the end and by not being able to witness the transformation, but I smiled nonetheless. I still think about her from time to time and I wonder if she's cleaned up her life. I must admit that I've logged in a few time to check up on her when I sit at the desk of my new clinic with some spare time. I quickly peruse her chart in hopes of finding something, but all I know is that she never showed up to any of her follow up appointments. Like the name I've given her, I'll continue to have faith that she'll come around. I'll have faith in the goodness of people and their willingness to survive, because without faith I have nothing else to offer my patients.
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