Tough Beginnings

I didn't really know what to think when I walked in to his room in the east wing for the first time.  Alone in his wheelchair, he sat isolated in one corner of his hospital room.  Eyes lightly closed, his tracheotomy tube inflated, his bowed and bandaged feet peeking out from under the blanket.  Tubes and lines of all sorts ran to and from him, connecting him to vital support systems he could not live without.

Around his room, scattered paintings and photos were tacked to the wall, telling a piecemeal story of the strong man he once was and who I hoped to discover still existed.  His half-eaten lunch rested on the bedside table near him.  His aerated bed was silent for the moment.  

It was day 273-some of his hospitalization, and it didn't look like he was heading home --- or anywhere for that matter --- any time soon.  

I walked up and lightly touched him on his shoulder.  "Good afternoon," I said tentatively, not wanting to jolt him.  "I'm Dr. Hughes, the new intern on the team taking care of you.  It's nice to meet you."

He rolled his head toward me and nodded slightly.  

No words.

I kept it brief that day asking if he had chest pain, was worried about his tracheotomy, whether the pain regimen was adequate.  Quite frankly, I didn't know what to say and couldn't wait to exit.  I had heard from the previous intern that his care and situation was challenging, at best.  His wife, rarely seen and who only conversed with attending physicians and not house staff like me, dictated his health care decisions, even though psychiatry confirmed he had full capacity to make decisions on his own.  The wife particularly blew up early in the summer when she learned of his plans to remove himself from the ventilator.  He had told his eldest son of his plans, who subsequently told his mother, and all holy hell broke loose afterward.

He had told many nurses he wanted to die ... and so I walk in to meet him for the first time knowing all of this.

The Writing Class

“Please open your notebooks,” the doctor asked.  “You will write for five minutes, never lifting your pen from the paper.  I don’t care if you write the same sentence over and over again, but I want you to keep writing.”

The eight of us folded back the covers of our fresh notebooks, gifts from him, poised and ready for our topic.

“The first exercise is to reflect upon a special patient, someone you can’t forget ... you may begin now.”

We all, including the guest professor, began scribbling furiously, turning our blank slates into memories worthy of sharing and learning from one another.  I knew from the moment he started that I was going to like this class.  Sandwiched in our month-long didactics and procedural skills training month, our course organizers invited an alumnus of our program to return and lead a writing workshop.  After growing increasingly disconnected from his patients and frustrated with challenges of the health care system, this doctor turned to writing as a way to seek fresh meaning and gain perspective in his life's work.

“All right, five minutes is over.  Please finish your last thought,” the doctor smiled. 

We moved from memorable patients to the best and worst moments of residency thus far, therapeutically recording what we had not yet processed. 

"Would anyone like to read theirs aloud?"  he asked.  

We glanced at one another somewhat nervously, wondering who would begin.  But soon, the anxiety gave way to presence and peace as we laughed, cried, and compared notes.  

One colleague wrote about a sickly child in the emergency department who gave her a fist bump at the end of the visit, a two-year-old boy who could not walk or talk and who had seen the operating room far more often than the playground in his short life.  Another friend described how she congratulated a couple who married in the intensive care unit ten days before he died; the woman gave her husband a kiss on the forehead because he could not breathe on his own and was intubated.  And yet another fellow intern shared how shocked she was to admit her patient to the wards, only to attend to his death a mere few hours later from an extraordinarily rare adverse drug event that caused hardening of the lungs and heart tissues.  She was even more horrified, however, a few days later when her patient's case was excitedly discussed at pathology rounds ... and ended with one of the professors stepping on the autopsied lungs on the ground to demonstrate their rigidity.  

"I'm sorry," she said, tears welling in her eyes.  "I haven't talked about this yet.  I remember sitting stone-faced at rounds, just watching.  That was my patient on the floor," she paused, her voice catching.  "... not just another case report."  

I slid a small box of Kleenex across the table.  

   

Raw words, raw emotions, raw experiences.

"Superb.  Thank you all for sharing," our instructor encouraged.  “You have to work hard to get to the good stuff,” he said.  “And I don’t care how you do so --- whether you paint, meditate, exercise, or simply talk it out, but find your voice, and tell your stories."

"What did you learn today?" he continued.

We sat in contemplative silence for a short while until one of my colleagues quietly said, “I had been worried that we had lost the ability to connect, to be present, to be human … that we were just learning systems and management and forms.  I see today that my concern couldn't be further from the truth.”

I have long believed that my greatest teachers are my patients, people who invite me in to their lives and allow me the privilege of caring for them.  But, the writing class revealed something new --- that my classmates are phenomenal teachers themselves.  

Brett, Daniel, Daphne, Elisha, Margaret, Megan, and Tyler --- it is a pleasure and an honor to be your colleague.  

The world is quite lucky to have family doctors like you.

Residency Survival Tips #1

Code blues are fairly commonplace events on acute care medicine floors.  In my two months of wards at Harborview, I've managed to take part in a small handful of emergency responses where patients' hearts stop beating and lungs stop breathing.  As an intern, the best job I can hope for is to pump on the chest, check the femoral pulse, or lend my watch to the nurse who is recording details of the scene.  Glamorous?  No.  Intense?  You bet. 

The last code I attended taught me two very important lessons:

(1) Take the elevator.  Although sprinting multiple floors is an excellent way to exercise, it does not bode well for the patient if the doctor herself codes on floor 7.5 en route to said code on floor 9.  Burning calves and lungs are painful, and moreover, panting ferociously at the bedside does not portend a great deal of confidence.  It's simply obvious the doctor needs to exercise a bit more frequently than the codes she attends.

(2) Remove the stethoscope.  Pumping on the chest at a rate of 100 per minute (to the tune of "Staying Alive") at a depth of 1.5 inches for two-minute compression cycles is hard work.  Believe me.  And having the stethoscope drum you in the face every time you pump the chest deducts major style points.  At this particular code, one of my favorite nurses stepped up next to me and quickly removed both my stethoscope AND name tag ... saving me from embarrassment and quite a few bruises!

Failure

"Lauren," my female co-intern said.  "I'm sorry to have to do this to you, but I just picked up this sexual assault case a half hour ago, and I still have to finish up some laceration repairs before I go.  Do you mind taking her?"


"No problem," I replied.  "I'm happy to help."  I quickly reviewed the face sheet she had started about the patient, scanning the sparse details of the 6-day-old assault, location of her cuts and bruises, and basic vital signs.  She was homeless and newly arrived from California and had not yet found work.  She had already been given a hefty dose of IV Dilaudid in the emergency department and apparently was asking for more. 


"Why did she wait so long to come in?" I asked, knowing at this point that a critical 72-hour window had passed.  Our highly specialized, sexual assault response nursing team could no longer conduct a thorough pelvic exam and collateral investigation that could be dissected in any legal proceedings she may have wanted to pursue.  The evidence, so to speak, would have been washed clean so far removed from the attack.


"She was raped in January," my colleague shared.  "She went through the formal exam, and it sounded pretty traumatizing to her, so much so she didn't want to repeat it this time."  


"Makes sense," I offered.  "I just can't imagine ..." 


"I know," she nodded. "I appreciate you taking her.  I just haven't had the chance to spend much time with her, and she keeps wandering the halls asking for pain medications, a warm blanket, soda.  The nurses are growing a bit impatient, but it's been nuts down here."  


"No worries," I reassured.  "It's not like you've been sitting around twiddling your thumbs!"  


I glanced at the infamous board, a massive flat screen monitor situated across from the fishbowl and near the charge nurse's station that continually updated the patient roster ... those trauma cases that had already arrived and been triaged and managed and those that we anticipated rolling in any given second from the nearby environs to those due in a few hours, being flown or driven in from the expansive recesses of the WWAMI region.    Harborview Hospital, as the only Level One trauma center for the entirety of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI), operated at a steady hum year-round and at a high-pitched scream in the summer months, when daring and dangerous exploits resulting in harm increased in number and severity.  


As a family medicine intern, I spent two weeks on the trauma service in July, learning how to manage literal and figurative train wrecks --- motor vehicle accidents, gunshot wounds, stabbings, shaken baby syndromes, bicycle and motorcycle spills, overdoses, wood chopping and woodworking mishaps, bear attacks, crush injuries, drownings, hangings, vertebral fractures from falling out of trees, children who found and played with their father's guns, suicides, homicides, and buffalo "gorings" (although not in my rotation).  The Harborview ED also provided care for rape victims ... the most chaotic of places to discuss the most intimate of intrusions.


"Why don't I introduce you to her?" my friend suggested.


"Great idea."  I replied.  We walked together in to her room, as stretchers and paramedics scurried by.  Sirens wailed in the distance.


She perched on the edge of her bed, her hands shoved between her knees, rocking gently back and forth.  Her dirty brown hair fell in matted chunks against her face; her arms were littered with cuts and bruises of different ages, colors, and sizes.  Her few possessions were wadded in to a bright, orange bag sitting behind her on the bed.


I squatted down and took her hand in mine, noticing her dirty, split nails, caked blood, and years of calluses.  


"Ma'am, this is Dr. Hughes," my friend began.  "As I shared with you earlier, we change shifts now, and Lauren is taking over for me."  I asked her a few questions to clarify what I had already learned, allowing her to share the story in her own words.  


Our patient's eyes welled with tears.  "I don't ..." she trailed, biting her lip.  "I, I don't want to be a burden ..."


I broke in, perhaps a bit more swiftly and sternly than I should have.  "You are not a burden to us," I said, looking her directly in the eyes.  "No one deserves to have this happen.  You are in good hands here, and we are going to do our best to care for you."


"Okay, doctor," she said.  "But, but I'm in a lot of pain.  Can I get something for it?"  


"Let me take a look at what you have already received tonight, and we'll go from there," I replied, standing to leave.  


"But, hurry, please," she pleaded, swaying a bit faster.  "I hurt ... I hurt so much ..." 


"I will be back soon."  I touched her shoulder and exited with my colleague.  


Back in the fishbowl, I reviewed my plan with the ED attending --- find the pelvic cart, locate a private room in which to perform the pelvic exam, and discuss shelter options with social work, as she had expressed worry for her own safety if discharged back to the streets.  


"Sounds good to me, but I'd run your thoughts by trauma doc, too," the attending physician said.


I quickly found trauma doc, a second year surgery resident who ran the codes and was in charge of the trauma interns, including me.  For twelve hours per shift, trauma doc called the shots, placed consults to other teams, and kept patients moving along toward their dispositions --- home if not seriously injured, psychiatry if suicidal, upstairs if sick enough to be admitted, operating room if in need of surgical repair.  A full Level One emergency department was problematic in many regards.


"I'll do what I can to move her along," I said to trauma doc, after sharing my plan.  "I know we're busy, but she is a priority for me to package and send someplace safe."  


"No," trauma doc cut in, looking at me sharply.  "Your priority is trauma."  


Somewhat stunned, I watched my boss turn abruptly and stride toward the radio room to answer an air lift call.  


"Dr. Hughes," a nurse practitioner yelled toward me.  "I found your pelvic cart.  It's down by the observation wing."  


"Thank you," I nodded.  I quickly studied the board.  Ten minutes to a multiple victim van rollover.  My window of opportunity was now.  


I told my attending where I was heading and cajoled my patient to follow me to her pelvic exam with the promise of more pain medication once done.  Unsatisfied with her fragmented and dismissive ED care, I was even more unsatisfied with myself and my inability to properly understand and address her physical versus psychological pain, knowing that the latter, years in the making, was not going to unravel in any meaningful way tonight.  I just had to ensure there was not something medically dire we needed to treat that would cause her harm if left unchecked.


I managed to finish her luckily benign pelvic exam, obtain a urine sample for a pregnancy test, and begin my conversation with the social workers about shelter options for her before being summoned to the van rollover victims rolling through the front doors.  The codes kept coming, and in between patients, I swung by her room, telling her that 'soon' I'd finish finding her a safe place ... 'soon' I'd be back to talk with her ... 'soon' I'd discuss her wish for more pain control, sounding more and more hollow and less believable with each 'soon' I uttered.


In a moment of relative calm, I ran in to trauma doc in the hallway.  "How's it going?  Anything you need help with?"


"I'm doing all right," I said.  "Just drew my third hemoglobin on resus 2, bed 3.  And, by the way, I finished the pelvic exam on our lady.  Once I touch base with social work, she'll be heading out so that we have that bed free.  Just thought you'd want to know."


Hands thrust in the air, trauma doc leaned closer and growled, "Frankly, I really don't care."    


Trauma doc disappeared into the radiology reading room, and I simply stared as the door swung shut, slowly lowering my blood draw to my side, breathing forcefully through pursed lips.  I wandered in search of the social work team, who was able to find a shelter bed for her, unusual at such a late hour of night.  Despite the relatively positive news, in their conversations with her, she told them she may leave for Swedish Hospital, as she thought she may receive better care there.


As I typed her discharge paperwork in the fishbowl, I noticed my patient walking slowly by in opposite direction of the main door, dressed in her street clothes.


"Where is she going?" my attending asked.


"I don't know," I responded.  "Probably the bathroom.  I'm almost done with her papers.  We found a place for her tonight."


"Good work," she said.  "I wish our sexual assault nursing team could have seen her.  It would have made it a lot easier for us all."


I looked up from my desk to see another stretcher rolling through the main door, bound for the trauma bay.  A young toddler had been ejected from his stroller, after being hit by a car traveling 35 mph.  I grabbed my safety goggles and X-ray shield and ran.  


Twenty minutes later, I returned to the fishbowl, retrieved my discharge paperwork, and scurried to my patient's room.  Her nursing chart and ID stickers had been removed from the metal table.  A janitor quietly mopped the floor.


"Did you see where she went?" I asked.


"No, I'm sorry, doctor, but I was told she's gone.  I think she may have eloped."


I didn't move for a few moments, watching the janitor pull taut clean sheets where my patient had once sat.

Trans Bodies, Trans Selves

Let me tell you a thing or two about my dear friend Dr. Laura Erickson-Schroth ... and her brilliance, her passion, and her incredible project, Trans Bodies, Trans Selves.

Currently a resident in psychiatry at New York University, I had the great fortune of working with Laura last year at the American Medical Student Association.  After long days as AMSA's Director of Student Programming, she spent many evenings and weekends drafting plans for her upcoming book that will serve as a resource guide for the transgender population, spanning legal issues, health, social, and cultural topics, history, and theory.  She is the book's editor and has amassed an impressive team of fellow authors and advisors.  She was even featured in the New York Times' City Room section in April where she responded to readers' questions about transgender people over an entire week.  (And I am thrilled to report that I, too, was 'published' in the NYT --- for her headshot was one that I had photographed!)  Read all the details on her website, http://transbodies.com/home.php.  Please stop by, stay a while, and learn ... and share the link with others you know.  Through her scholarly work, Laura is filling a niche in trans health that has not existed before, and I could not be prouder of her or her important initiative.   

But even more remarkable than the forthcoming book is the woman, the doctor, and the advocate behind it all.  Laura is one of those colleagues that I am grateful to have in my circle, someone who is genuine in her approach, comfortable with her perspectives and her experiences, and willing to ask critical questions in a non-judgmental, matter-of-fact sort of way.

As doctors, it's pretty incredible the access we have, by necessity and role, to the most intimate and crucial details of our patients' lives.  Beyond history of the present illness, past medical history, and medications, we ask about drug and alcohol use, safety in relationships, state of mental well being, sexual practices, hopes, fears, and dreams.  As you can imagine, these types of conversations could grow uncomfortable fairly quickly if not approached in a frank, sincere, and positive manner.  I have seen these discussions go poorly, and I have seen them go well.  I work hard to achieve the latter, but it's not always easy. 

I credit Laura, however, with teaching me a great deal about how to do just that --- how to address what often are sensitive subjects, particularly those relating to lesbian, gay, bisexual, and transgender health, in a normalized, open-minded fashion.  Honest questions, patience, humility, and a willingness to learn go a long way toward achieving mutual understanding between doctor and patient, toward creating a safe dynamic in which to care for the intricately and wonderfully complex person sitting before you in the exam room, someone who is so much more than simply a patient.  I thank Laura for demonstrating this to me on numerous occasions, and through Trans Bodies, Trans Selves, she has the opportunity to shed light on these issues for so many more.  I hope you enjoy her website, and I know she would love to hear from you.  

And, as for you, Dr. Laura, I simply cannot wait to receive my very own, autographed copy!  Thank you for teaching us all. 

It Takes All Kinds

I love people, plain and simple. I love listening to their stories, understanding them, connecting with them through common history. I love all ages, all experiences, and all walks of life.  And I most certainly appreciate the laughs we share ...


For many reasons, one of my favorite patient groups to care for are the grumpy, old men --- and the grumpier, the better, as far as I'm concerned. During my last inpatient rotation, I took care of an 80-something-year-old man who had fallen and broken his hip in his adult family home. Along with orthopedic surgery and his two doting sons, we literally got him back on his feet within days of his accident. Every morning when I entered his room to see how he was doing, he eyed me with suspicion and answered most of my questions with a grunt or two. A fairly staid individual, he grew the most animated when I asked him how he was enjoying his meals.  


"Terrible!" he would reply, wrinkling his nose and flicking out his tongue. Believe me, I became quite adept at swallowing chuckles pretty darn fast.


On the morning of his discharge, I walked in to his room in my normal fashion and found him scrunched in his bed, sporting a green stocking cap and off kilter glasses, the label on which the nurses had applied jutting perpendicularly from his face. Before I could launch into my routine of questions, he squinted his eyes at me and grabbed my name tag, slowly drawing it back so he could get a better look.


"Oh," he said. "It's you again," promptly releasing my badge and sending it hurtling back toward my chest.


I couldn't help the laughter this time.


When I turned to leave, I bent down and told him it had been a pleasure to take care of him.


He smirked, "Yeah, right."


I shook his hand and grinned all the way out the door.

-------

Depending on my rotation of the month, I work one to two half days at my outpatient clinic right around the corner from the main hospital. I typically see 3 - 5 patients per clinic and occasionally see walk-ins, particularly if my regular patients do not show.


One recent morning, I was handed a chart for a walk-in patient, a man with abscesses in his groin. After not disappearing on their own as he had hoped, he decided it was best to have them evaluated. My attending physician had briefly stopped in to see him before me, and we discussed the most likely definitive treatment of incising and draining the abscesses, especially if they were large and tender. An understandably painful procedure, I nodded my head in agreement and headed in to greet the patient.


"Good morning, sir," I began. "How are you today?"


"I'm all right," he replied. "I've sure been better ..." he paused, looking me up and down. He shook his head ever so slightly.


"What's wrong?" I asked.


He smiled. "You sure aren't the ugly man I was hoping for!"


(I tell you ... you never know what is waiting for you behind that door!)

Dusty Old Books

A special box arrived today from my parents, one I'd been waiting for all week.


I quickly opened the box after I got home from work but slowly examined the contents, pulling out one fragile book at a time.  I studied the titles, waved dust away as I turned pages, and noted the name inscribed in delicate calligraphy inside the front cover of each.  The earliest book dated 1892; the latest 1928.  I reviewed some of the content within, surprised at how well the facts and drawings correlate with our body of medical knowledge today.  There's no telling when they were last opened.  


I cannot tell you, though, how much I would have loved to have a conversation with the owner of these texts.


The name so carefully penned in her Practice of Medicine, Obstetrics, Diseases of the Brain and Nerves, Handbook of Physiology, and Dr. Potter's Quiz-Compends Anatomy books is Dr. Forrest Phillips Fleener ... my great-grandmother.


One of three women graduating in the Hahnemann Medical College Class of 1910 in Chicago, Dr. Fleener became licensed to practice general medicine in Illinois, Iowa, and Texas, before settling down with her practice in and around New Sharon, IA, a few miles from where I grew up.  My grandmother, Forrest's only child, told me that her mother would travel the local countryside, exchanging medical services for fruit and meat if her patients couldn't pay cash.  She died in her early fifties from a diabetic coma, leaving a few remembrances of her livelihood behind.  


I never knew a great deal about the only person in my family to be in medicine before me, and sadly, I know little still.  Nonetheless, I am grateful for what I do know.  For my white coat ceremony when I started medical school, my parents had my great-grandmother's class photo framed as a gift to me.  Forrest has never been far from my sight since --- she hung over my desk while I studied into the late hours in Iowa City, traveled with me to Reston, VA, where she resided on the wall in my AMSA office, and has now settled in Seattle.  I am quick to talk about her when friends come over to visit.  Her story, her experience, her legacy are a source of pride and inspiration for me.  


And, now, I have seven dusty, old books to add to my growing collection of medical antiques.  But so much more important than the knowledge contained within are what they have come to represent --- Dr. Fleener's perseverance, potential, and pioneering spirit.  I remind myself that if she could succeed as a doctor 100 years before her great-granddaughter ... then surely I can, too.