In Patience

I am now two days into my internal medicine rotation and I am feeling somewhat unsettled. My surgery rotation, thankfully, taught me more about internal medicine than I'd thought and I arrived yesterday (Monday) spry, excited, and ready to go.

That was, until I met my first patient...

A bit of history: I became interested in Palliative Care about 5 years ago while living in Denver, CO. While doing research at the University of Colorado, I discovered that, on Christmas Eve, 12 patients died at the University Hospital. Now, I realize that people die every day and I'm not such a bleeding heart to deny that death is a natural part of each of us existing on this planet and experiencing life. But, what caught my attention was one glaring detail: Each of these patients had a terminal injury or illness--a car accident, progressive neurological disease, aggressive cancer. And, each of these patients died in their hospital room. In the middle of the night. Alone.

Palliative care is NOT end of life care. It is not hospice, although hospice is part of it. Palliative care doesn't focus on comfort care and end of life issues as much as it focuses on the individual and every aspect of their healing--spiritual, psychological, emotional, and social. Palliative care applies to any individual with an acute or chronic medical condition that doesnt necessarily have to be terminal (ie a young person with liver failure, someone with leukemia, a cancer patient exhausted and unwilling to continue with chemotherapy). It is designed to alleviate a patient's suffering while also acknowledging and enhancing the patient's quality of life.

I greatly appreciate palliative care because it doesn't just focus on the physical part of healing and pain: which we have pain meds for. When we are sick we are suffering, on so many levels that a lab slip will never pick up. I think about those 12 patients dying alone on Christmas eve--one person's family was too far away and he was in a motor vehicle accident and would die within hours, another man was estranged from his family and none of them knew he was hospitalized, yet another patient, simply, had no one.

Soon after this happened, I volunteered at the hospital to help set up a palliative care volunteer system, mostly made up of retired nurses. If a patient was on the floors and was very sick, or terminally ill, or just plain lonely, one of these "volunteers" would be available to sit with him or her, read books, watch movies, talk, cry, essentially be present.  It was a powerful offering and experience for the patients and the volunteers. And it was necessary. One of the best indicators of good health, and healing, is social support and human interaction.

It's kind of amazing that now, years later, I'm here not as a palliative care volunteer in internal medicine, but on the other side, as a consultant, a medical professional in training, a woman in a white coat faced with a plethora of pleading eyes asking me at nearly every turn--How am I? Can I go home? Will I get better? Will you help me? I have very few answers because most of the time I'm scrambling to fulfill lab orders, or follow up on a newly admitted patient, or follow up on a current patient that has just taken a turn for the worse, or--sometimes, but not often enough--get paperwork ready to discharge a patient home because they are on the mend!

But I have limits after all, because internal medicine breaks my heart in a way that nothing else ever has. It breaks my heart with its exquisite suffering...AND its insufferable hope. I vacillate all day between hope for a particular patient and his or her family, and despair. This roller coaster is exhausting, exactly like it is for the patients.

So I try to focus on the medicine, but its difficult with ill people, who are extraordinary and unique in their own right, wishing to impart a life's worth of advice in the few moments I have with them.

Advice from my patients today:

"Listen to the person who is talking to you. If you don't agree, that is okay. We all have an opinion. But don't forget to listen."

"Don't argue. I have never believed in arguing."

"It's true, laughter is the best medicine."

"My parents raised me on nothing but love and kindness."

"I may be sick and dying, but I have several beautiful sons and daughters and am rich beyond measure."

"I hope I get out of here for one more beer. You don't appreciate a good beer until you realize you can't have one whenever you want."

Tomorrow I will sit in on two palliative care consultations--for patients who no longer want to subject their bodies to harsh medical treatments for their conditions. I get that. And I get that they are not giving up by making such a decision. What I don't get is that we live in a society that allows people to die on Christmas Eve, and every day of the year, alone.

I'm going to go grab a beer now, and tell a few people I love them, and listen to the soft patter of the rain and the wind rustling outside. Because I have the time. And because this life is so goddamn amazing.

Colorado Healing

There are places I go to heal. These places are usually out of reach for most of humanity; they are  hidden, sacred. They take more than expendable energy to get to. Trekking to them may elicit a bit of blood, sweat and sometimes even tears. These places remind me how grand the world is, how much beauty a spacious vista can hold, and they also provide a certain amount of affection that a lover never can.

Even though I was physically born in Wisconsin, I was "born" in Colorado. The first time I laid eyes on the Rocky Mountains while driving along I-70 with my uncles I was awestruck. The expansive view through the windshield near Lookout Mountain was one I had dreamt of for years, since I was a small girl watching Swiss Family Robinson, or Little House on the Prairie, or any of a handful of other rural/mountainesqe type TV shows. Even at 18 years old I knew I would move to Colorado the first chance I could. And I did.

Now, the North Cascades of Washington are fulfilling the role that the Rocky Mountains did when I was living in Fort Collins and Denver, CO. These are now the mountains I drive towards when I need to get back to who I am.

When I think of mountain healing, I think of Sue Fear, a mountaineer I met years ago on a plane from Tasmania to Sydney, Australia. Sue was a striking woman in her 40's, drinking a beer in the airport --which was allowed -- but the beer she was drinking they didn't sell there. So, she was escorted outside of the terminal until our flight boarded. I thought it was a bit silly that the Tasmanians, in all their kind heartedness, would be so strict with beer, but there it was. I went outside and gave her one of my beers, which they also didn't sell at the airport. It was over the next hour that I began to realize who she was.

Sue Fear, in 2001, became the first Australian woman to summit Mount Everest. And here I was, an American mountain lover, looking into the blue depth of this woman's eyes and trying to imagine all the glorious glacial beauty she had beholden. She told me she went to the mountains to live, and went back home, to Sydney, only when she was drained. At home, her nest, she filled her reservoir back up - her hopes, her desires - and once it was full again, she went back out into the world to tackle another high peak. We stayed in touch and she sent me a copy of her book, Fear No Boundary. I was back in Australia and trying to track her down to meet up for dinner when I heard, through a friend of a friend, that she had fallen through a crevasse on K2 a week prior. Her body was never recovered.

I think of her today, because the mountains are where I go to heal. Where I personally go to BOTH fill and empty my reservoir.

After the last month in my surgery rotation, I didn't realize how much I needed a bit of healing until I said goodbye to that last patient on that last day. And what resonated about that final meeting was that that patient was going home to die. And the mountains were also a place of healing for her. She would never get to hike in them again. I told her I would take her with me next time I went.

So, my question is: Where do you go? What heals you? This is something I want to think about, and respect, as I move forward through this next week "off" from school and patients, because one week from today I begin again, and my next rotation is in Internal Medicine. I am most excited for this next rotation because I am ready for it. And I want to remember that the patients are more than medical enigmas, more than bodies in a bed. They are humans with memories, and places and favorite spots to have picnics or to watch the sunset. They are people with mountains, in every sense of the metaphor imaginable.

As medical providers I believe we can offer more than we think we can. Sure, we can provide diagnoses (hopefully sooner than later) of complicated medical conditions, we can provide comfort care. But we can also acknowledge and nurture the emotional and spiritual lives of our patients--some of which are most important in the healing process. 

So, this week I am healing. In some of my favorite places.

Ask me sometime, and I will take you there.

For Now, Forever

I don't usually write poems in this style, but the morning after my surgery rotation ended, I felt like playing a bit out of bounds. This is a free form process reflecting on all that I gained during the past 4 weeks, and also a few things I lost. It seems that every great endeavor has a few sacrifices. We weigh these carefully, do the best we can, and have faith that things are all working out according to some plan. Or not. Who knows. But I pray a bit each day that the sacrifices I've made will some day be worth it. Thanks for reading. ~ lk

Beginning
            doorways closing, swinging
shut            the morning

after a struggle               when I already
promised
not to struggle anymore.

                            ~ ~ ~

Medicated sleep anxious belly.

                               ~ ~ ~

What love did was find me running
up and down hallways
                  through days
in between photographic moments
of death birth
                                                             my own.

                               ~ ~ ~

What love took was everything I had
to learn                a trade
                      admire             a  heart
          from within        to mercifully
                                                      gracefully                  
                                                                  thrive.

                               ~ ~ ~

Losing my step        on the stairways pushing
wrong         elevator        buttons
knocking          not knocking
on wrong doors            losing
Faith                 every night           that I could
do this
           and do it well.

                               ~ ~ ~

At the end
with the doorway still swinging
wiping blood from both hands
and tears that come so easy
these days
                                         Proof I am
exactly
              where I need to be.

                               ~ ~ ~

The doorway swings         whoosh             for now
                                                                           forever
closed.

What Cancer Looks Like

I'm going to answer this because I've been asked several times in the last few days by friends and family, "What does cancer look like?"

During this last week, the third of my surgery rotation, I was having a hard day. I was tired. I hadn't slept well. The case we were working on was scheduled to be a 2-hour operation and we were in the 6th hour of it. There were complications managing the patient's vitals. And I had the most horrible cramps in my shoulders from helping suction, retract, and generally just staying the hell out of the surgeons way. A fellow PA came into the room to assist. We had both already put in a 12 hour day of nonstop rounding, operating, and trying to stay afloat. So, when I asked how she was doing I was somewhat expecting the standard, "Okay", or "Damn, I'm tired, too."

What I got instead was, "Awesome. I am having an amazing day!"

When I replied, "Really?", she clarified with, "Absolutely, we are actually saving lives. Today we cut cancer out of three people's bodies. This is an absolutely amazing day." And she was right. I stood up straighter for the last two hours of that surgery and forgot how tired I was.

Cancer looks different from anything else I have ever seen, because it is something that is not supposed to be where it is--in our bodies. What it mostly reminds me of is a smooth piece of fabric or a rope with a knot in it. That knot is made of cells that are very good at doing one thing: growing. And there are different types of knots. Some are super tough and hard to get out, some are more loose and easy to undo. Some knots begin to collect more knots around them, using up more of the surrounding material. But, most of all, with a knot in the fabric or rope (or tissue or skin or organ) it makes that area (organ, etc) look different. And in the body, things that look different usually act differently than they are supposed to, and cancer is one of these things.

But aside from looking different and acting different than other tissues in the body, cancer is so many other things.

I get to the hospital before everyone else, before my preceptor, the 5 other PAs I work with, before all the surgeons, the residents, and the attending. I do this for two reasons. First, I want to have a handle on how our patients are doing so I can not only present this information during rounds, but also so I can gain a better understanding of each patients post operative management. It is much easier to learn, I have found, if I understand the medicine being discussed. So I get there early and I leave late and in between and every chance I get, I study.

Second, I get to the hospital early because I have my favorites.

Sal (name changed) is one of my favorites. I was in on her surgery several days ago to remove a cancerous polyp from her sigmoid colon. We bonded a bit after surgery because she was in pain and her son wasn't available to come see her right away. Unfortunately, Sal had a few post op complications and we had to bring her back into the OR. Of course, this frightened her, and we still had not heard from her son. So I sat by her bed and talked with her about her kids and her grandkids (I know from my own folks that grandparents ALWAYS want to talk about their grandkids!). I even prayed with her a bit because that is what she wanted to do. I asked to scrub in on her case because I wanted to be in the room and follow through with her from start to finish. When they wheeled her back into the OR for her second surgery about 20 minutes later she was praying quietly, and clutching a red rosary in her hand. As the anesthesiologists did their thing and the RN and scrub tech situated the operating field and prepared the room, Sal was given a general anesthetic. As Sal began to fade to sleep, the RN grabbed the rosary to put it back with Sal's things, in another room, down the hall. I stopped her, clutched the rosary back, and tucked it into Sal's hand. I taped it into her gentle fist. I told the nurse, "I think she wants it with her."

When I checked in on Sal at 630am the next morning, she mentioned to me that someone had taped her rosary into her hand and that is why she thought her surgery, ultimately, went so well. And I smiled. Because I knew what Sal didn't know, and actually what I didn't know until today, and that is that we removed all the cancer from her sigmoid colon. The cancer we found wasn't metastatic, it was removed cleanly with excellent margins, and she was going to recover fabulously.

Unfortunately, the biopsy results for each patient are not always so promising. Today one of my other favorites found out that we removed a metastatic tumor from his lung. Metastatic means it has most likely already spread to other parts of his body, and we might not know exactly where those areas are until they grow tumors of their own.

The hospital, and this rotation, is a constant rollercoaster of emotion. One minute I am assisting on a major repair in an OR, the next I might be sitting bedside laughing about a patient finally passing gas (this is a BIG DEAL after surgery! It means things are getting back to normal!) The next moment I might be in the middle of a 6 hour surgery thinking about how tired I am or maybe thinking of absolutely nothing at all. Or I might be thinking of how I want to hold every patients hand, whether we are giving them great news or some of the most difficult news they will ever hear.

In talking to friends and family, I compare this rotation often to the tv series, Grey's Anatomy. In many ways, the show is a fairly accurate portrayal of working on a surgical service in a hospital. I don't walk behind my attending, I run. I utilize every neuron trying to come up with logical complicated explanations for a patients new symptoms. I often fail. I often look frazzled, unkept, and so put my hair under a surgical cap and a smile on my face when I go see the patients. And I glance at the cases (surgeries) for the day first thing each morning to see if I can somehow weasel my way into some of the cooler ones that I haven't seen. And when I get home I am tired to the bone, more tired perhaps than I have ever been. But I am also so exquisitely in love with the experience.

I probably identify most with Izzie, from the earlier seasons of Grey's Anatomy, because I think the greatest challenge for me working in surgery is going to be managing boundaries with patients. Because I won't always have the time...to catch up, to say hello, to follow each person all the way to discharge. I may have to find a way to hedge my desire to care too much about who they are being discharged too, if anyone. Do they live alone? And, perhaps most importantly, are they emotionally ready for the real healing, which begins once they walk out that door?

Hummers, SUVs and Honda Civics

I drive a 1999 Honda Civic with a gigantic dent in the passenger door. That dent, like most of the dents in our lives, has a history. About ten years ago, in Fort Collins, Colorado, I was side swiped by a blue car on my way to a party. The car didn’t stop. My friend Big Smiley and I gave chase to write down the license plate number. About 5 miles and 75 mph hour later (through town), we had enough information to go to the police. An investigation ensued because the driver of that car denied running into me (even with my car’s silver paint smeared on the bumper) and also didn’t have car insurance. There wasn’t much I could do and somewhat forgot about it, deciding I didn’t have the funds at the time to bother fixing it. About a year later I finally received a check in the mail, enough to fix the door. I promptly took that $1,000, deposited it in the bank, and bought a ticket to New Zealand instead.

I bring this up now because one of the prominent surgeons I work with knows me only as the “girl with the dent in her car.” She drives a convertible. I know this because before I knew she was a doc I was going to work with regularly we had a conversation about reckless driving, accidents, and people with SUVs. When she mentioned she had a small sports car, I quipped that she should get a Hummer.

I’ve been rounding in the hospital with the surgical service this entire weekend, and I really (really) like rounding. It’s when I get to see the patients off the surgical table, awake, pink cheeked, sitting up, recovering. I usually meet them in the OR, after the anesthesia has kicked in. Sometimes I scrub in after the procedure has begun and I am only met with a few inches of skin until there is a space enough in the operation to ask, “Who is this patient?” These are things I should know prior but often times my preceptor shuffles me into a cool or unique case because he wants me to see the anatomy, and the techniques, and gain a broader experience in the short month that I’m here.

This weekend, the topic of cars kept coming up. One of the patients—my first patient, the one I have seen all the way from pre-op through surgery and for 5 days in the hospital afterward—is being discharged tonight. She was as happy to leave as I was kind of sad to see her go. It's amazing how kindred one becomes to a complete stranger after spending nearly a week together in a hospital...She told me about her best friend who is a nurse, and how she talks to this friend regularly about her ailments. I told her I am often that “medical friend”—diagnosing friends and family with this or that, whipping out my stethoscope and otoscope (for the ears) at the slightest cough or sniffle. She mentioned that must get old, having people calling or asking me about medical stuff all the time. And I thought about that, because I have always somewhat been this friend, even before I began studying medicine.

I tried to explain it to her this way: I used to get really frustrated with mechanics. I don’t know enough about cars to know if I’m being swindled. Do I need a Johnson rod replaced? What is that and is that even a real thing? I used to want to study up on cars, on engines, so I would know a bit, like my brothers and dad do, about what it takes to fix them. But then a mechanic friend told me, “Find what you love to do and stick to that. Find a good mechanic that you can trust and don’t worry about knowing everything under the hood. Let us take care of your car.“ That resonated with me because I reckon my love of medicine, and sharing what I learn, is similar to anyone who is excited to teach something they love to do. I imagine my love of medicine is similar to someone who likes to work with cars and I find comfort, I guess, in the fact that most mechanics probably don’t know much about medicine. Therefore, they have to trust me too.

During the middle of this quiet revelation, the surgeon found me, the convertible. She had been rounding with my preceptor, who rides a bike. Us three shuffled around the hospital all morning, at the same pace, arriving at conclusions at different times, using our own unique neural pathways but with a similar thought trajectory. Because this is how we are trained. When I was allowed to pull a few chest tubes out of a patient who had drains from a major thoracic (heart and lungs) surgery, my preceptor said, “I don’t usually let students do this.” And the convertible quipped, “Why not? She's a superstar, she has a dent in her car, she has been around the block a few times. Literally.”

Used car or not, dent or no dent, I’m taking that as a damn fine compliment. 

A Thing of Beauty

Still so much a virgin (when it comes to medicine) I am currently discovering the most intimate parts of the human body--that of sinew, muscle and bone. I’ve met my match in the form of a cold steel blade held stealthily in a hand; in the quiet hallways during pre-rounds; while moving in the early dawn past walls holding signs that say: “Competence” and “calm” and “compassion.”

Aside from post op and pre op visits with patients, it is a quiet world in the operating room. Suction makes a soft whoosh in the background, machines monitor a patient’s vitals, a surgeon mutters as he or she contemplates the next move; the clicks of steel as one more instrument is picked up, put down. But, for each of us, this is a quiet space. Sure, we may talk about textbook anatomy, explore the abdomen a bit after a gall bladder removal, banter about cars, vacations, relationships, what we had for dinner, and make a comment or two when the bovie is working its way through a thyroid...but in each of us resides quiet anticipation, because what is happening before us is nothing short of surreal.

As early as 1850 surgeons were able to appreciate ether as a successfully inhaled anesthetic, and even before that, doctors would sometimes get patients good and drunk (among other things, cocaine was also used) to try and numb the effects and pain of surgery. Aside from sleep, surgery is our most vulnerable state. Once the last stitch is placed, there is a collective sigh in the room because what has happened has been years in the making—a disease, perhaps, dormant, for years. And we can fix it. Sometimes we can remove it. And yes, sometimes we can’t do nearly as much as we would like, but medicine heals. I think of the first doctors and assistants doing some of these procedures—open heart surgery, lobectomies, removing brain tumors—and how exhilarating and absolutely terrifying that must have been.

Leaving the OR yesterday, after a minor procedure (that looked pretty damn complicated to me) the scrub nurse clapped her hands when it was all said and done, all the equipment was accounted for, and the patient was being prepped for PACU (post-anesthetic care unit) and said, “TOB!” I asked her what it meant (thinking it was slang or a pneumonic for something I should know, or something I had learned but forgot, or, worse yet, something critical that would be on my board exam I’m hopefully taking this August) and she laughed at my curiously worried face and said, “That was an excellent procedure. A TOB. A Thing of Beauty!”

And through all four surgeries today, all of the TOBs, there was art and movement involving everyone in the OR, like a dance, regal with our hands to our chests or resting on the patient, we danced. And we had good surprises: An infection that cleaned up well, a tumor with excellent margins, and my last patient. After the last surgery, the circulating nurse (the one who makes sure everything is going well in the room) asked me to hold onto my patient’s arm to keep him from pulling at his tubing while he was coming out of anesthesia. I instinctively grabbed the man’s hand and held it instead. Like I would with a friend. Like a handshake. As he began to wake up, I was surprised to find him beginning to grip my hand--hard--then harder. When I told him he was doing okay, to take deep breaths and that he needed to let go of my hand so we could move him he said, “No! No. Don’t let go.” And I didn’t. And I won’t. Not even tomorrow when I’m walking the halls at 6am, an hour before everyone else because I want to not only impress the hell out of my preceptor and do a good job, but also because, even now, I wonder how he’s doing.

The beautiful thing about surgery that I never realized, never allowed myself to realize because I’ve always been so queasy with blood—is that it covers everything. As one of the surgeons told me today: “The great thing about surgery is you get a bit of internal medicine, infectious disease, cardiology, behavioral medicine, sometimes a bit of social work…and then, in the middle of all that you say, ‘Hey, today I think I’m going to do a little surgery and see if we can't help someone out.’”  

In the hustle and bustle of being in a hospital, with the machines and beeps and movement of patients and their families, I am learning to love the intensity of the OR, the focus and yes, even the quiet. As we work as a team. As I reach to hold all of the patient’s hands now as they begin to wake up. As another disease process is erupted and laid to rest, there is this reverie and this truth: This absolute and total thing of beauty.   

Poem: To Be Vital

Love is that splendid triggering of human vitality, the supreme activity, which nature affords anyone for going out of himself toward someone else. 

~ JO Gossett

What would it take? 


Losing

everything
? Every

one
.

Raising both fists to the sky
,

falling down

on both knees
,

hands full

of dirt on the grave…

Would it take loving so hard you lose

(you lose)

the parts of yourself you never liked

much any way, finally able to give the
best back in return.

Would it take not living

through all of the days

we are breathing,

falling short instead

of exploding

into each day

like sun on a mountain trail.


Would it take

animal fur

a lover’s skin

the taste of 
winter

on the tongue?


Because

I’ve had

these.

I’ve had these, and

other reminders

every day 
to be decent

to be good,

and memories

of long and lonely nights


mine and yours.




But there is a tale

in the turn of every wheelchair,

the knees I see bending down

the halls late at night, hands clenched so hard

they are white, whispers at

midnight, bodies exposed that

have been penetrated by

steel and my

own shaking

hands.

These bodies break

so exquisitely around

the soul. And some

will never want to let go.

But what the rest of us carry around all day:

our aching hearts

our fractured regrets

our best moments

greatest successes

our dreams

and failures

are just as intriguing—the flaws 


we expose to the weather

of the world

sometimes bare chested and screaming

sometimes whole and

silent

with tears in both eyes

rocking a newborn baby

to sleep.