Nic

When I was a little girl, there was one Christmas Eve where I couldn’t sleep. 

I was wired, the excitement of what Santa was going to bring overwhelming any possibility of being able to calm down. I had already come out of my room multiple times that evening, going back and forth from my room to my parent’s bedroom, hoping that each time I asked “did Santa come?!” or “is it time to open presents yet?” that my question would be answered with a “yes!” rather than a desperate, sleep-deprived urging to go back to bed.

The last time I got up, hopeful that this had to be the time, my brother was sitting on the living room couch right outside my bedroom. Upon seeing me he immediately stood up and ushered me back into my room. 

I remember reluctantly laying back down and I must have told him how I couldn’t sleep. He didn’t admonish or ridicule me. Instead, he encouraged me to picture clearing my mind and to take deep breaths…in and out. 

I gave it a try and was soon fast asleep for the rest of the night until morning. 

Reflecting upon it now, I find it comical that my brother was the first one that taught me what mindfulness and meditation was. 

For whatever reason, I have never forgotten that memory. Over the many years since then, whenever I can’t sleep – the anticipation of opening Christmas presents now being replaced by a myriad of adult anxieties – I have always thought of that moment from many years ago, along with my brother, and it has never failed to calm me down and lull me to sleep. 

A personalized ace up my sleeve. 

The first night of my brother’s death, I was too in shock to do anything but fall asleep, my mind numb. I woke up that way and spent most of the next day in the same state. 

The second night was different. I hesitantly turned off the lights and as soon as they flickered off, I felt an uncharacteristic fear of the dark and suddenly felt very alone being away from my hometown. Trying to quell the rising panic in my chest, I closed my eyes and thought of Nic’s words as I always have in those moments.

In and out. In and out. In and out.

Exhausted, I drifted off to sleep, my brother on my mind.

---

Over the years, my parents and I would say that we feared the next time we would hear anything about my brother, it would be from the police showing up at the door telling us that he was dead. Though it was a realistic sentiment given my brother’s history, I personally never actually believed it.

However, that’s exactly what happened. 

It had been about four and a half years since we had seen or heard from my brother. He had disappeared soon after his mother’s death (we’re half-siblings, and he was eleven years older), and we always knew that was an unfortunate sign that my brother had once again succumbed to his heroin addiction. It had been a revolving battle for two decades, and there were many times where I watched my brother conquer the slow descent up the mountain - fighting and working and struggling to get clean - and then something would happen and he would tumble down a precipice once more, all of the people in his life powerless to prevent or stop it. 

I was still at work when my mother contacted me the evening of his death and I was told the news. When I heard the words “your brother is dead, honey”, I immediately thought they were going to be followed by “he died of a drug overdose”, another realistic fear we always had in the back of our minds. 

What I didn’t expect for her to say was that my brother had taken his own life.

---

My mother would often say she had two very different kids.

One that never shut up – me. 

And one that never spoke – him.

Where I was all books and school and studying, he was all trade work and technical knowledge, and gritty, physical labor. However, we both liked working with our hands, and we both liked completing a job to perfection. 

During disagreements with our parents, I would be the one to stubbornly argue whereas my brother would be the one to silently (and smartly) acquiesce (I blame our age difference for his wisdom in those no-win battles; I’ve since begrudgingly learned the past few years). Nevertheless, we both never failed to have the same dry sarcasm and similar sense of humor through most of our endeavors.

We made a good sibling pair, our differences and similarities complementing each other well. 

---

I’ve had a hard time processing my brother’s death.

For much of the past decade, he had been a ghost, out of our lives more than he was in it, and it’s been challenging to fully grasp the concept that my brother is gone since there’s no change in my daily life. Transitioning from the natural thought of “when I see my brother again” to “I’ll never see my brother again” has – and will be - a fractured, lengthy process, and sometimes I still don’t fully believe it’s real. 

I always thought I would see him again. I wondered what he would say about the person I’ve become and the evolution that occurred in my life the past few years, though my brother has always supported me without condition. I had hoped for conversations framed by a more mature lens that I didn’t have before and that one day, I’d be able to sit with him and truly listen to him and his story. 

I had looked forward to the future. 

And I guess I had ultimately hoped that my brother’s story would have a happy ending. 

---

One of the last times we spent together that I can remember was when I wanted to go out for a run and he wanted to join me. However, given his hatred of running this inevitably meant that he jumped on a bicycle and ended up heckling me the entire time, much to my annoyance. 

Brother-sister bonding at its finest. 

The memory had nearly been forgotten until last week when I was out for a run in that same neighborhood along that same route. I stopped mid-stride and had to compose myself when it abruptly came to me.

I wonder if this is going to be the norm – random snapshots revealing themselves to me when I least expect it.

Frustration and sadness creeps in whenever I have a hard time recalling more concrete memories. The last time my brother was consistently in my life was when I was much younger, too far back to clearly remember most moments aside from glimpses of memories plucked from our timeline. And then the last decade my brother was out of my life more than he was in it. 

I remember the feeling of things sometimes more than the actual moments themselves, but sometimes fractured memories shine through. Our family dinners. A car ride here and there. Brother-sister dinner at a favorite Italian restaurant. That time he brought his obnoxious dog over and he shit on the carpet (he loved that dog – Rip…what a stupid, god-awful name). Putting me in headlocks. Him falling asleep in church. Going to the movies together. That time a horde of ants attacked me in your car. Christmas’ spent together as a family.

I even remember the smell of him…so clearly that it’s almost as if he was right next to me.

What I can’t recall is the exact last moment I had with my brother. Was it that bike ride-run? Or was it at his mother’s funeral? My last text to him was me taking a picture of one of our dad’s famous dishes and sending it to him to tease him, adding, “I hope to see you before you leave!” at the end. Was that it? Did I ever see him? Or did he disappear soon after?

I hope I gave him a hug the last time I physically saw him, because that’s one of the things I wish I could do now. 

---

I’ve had an even harder time processing that my brother died by suicide.

It speaks to something different - a lack of hope? A desire for control? A desperate bid to find peace? Perhaps a bit of everything…and with the apparent loneliness he felt combined with the heroin addiction that I knew he hated, I can imagine it was a recipe for major depression. 

My brother had been on my mind more than usual the past few months. I remember talking to a couple of my best friends that have known me – and my brother’s story – for over a decade and mulling over the idea of hiring a private investigator to find out where he had disappeared. I discovered after my brother’s death that my parents had been thinking of the same thing, and it turns out that he had been living in our hometown this entire time.

The logical part of me understands why we ultimately hesitated and didn’t try to find him. Heroin addiction doesn’t just affect the individual, it also inevitably affects everyone in the vicinity without preamble and without discretion, and multiple people in his life, including ourselves, had unfortunately been collateral victims to his disease in a myriad of ways throughout the years…emotionally…mentally…financially…the fact that we never quite knew whether my brother was caught up with dangerous individuals. Combined with the fact that he clearly didn’t want to be found, everything led to us deciding to leave him be, despite how painful it was throughout the years. 

After all, when does it become time to stop trying to fix an adult individual and give them the space and time needed to work through things on their own?

Still.

I can beat all of the aforementioned, sensible reasons into my brain as much as I want but at the end of the day, why didn’t we just do it? Despite my career, I believe in the concept of intuition and I can’t help but feel guilty at the “what if?”

I wish I had just done it. Life is too short.

I hope he knew how much we loved (and still love) him. 

---

My brother died on January 21, 2020. We had his funeral service just over two weeks later on February 5, 2020. 

After the shock and numbness of the first few days wore off, I strangely felt relatively okay. However, after gaining more of a self-awareness and understanding of myself and my coping mechanisms in the past few years, I knew that my “I’m fine now” was inevitably going to abruptly transition into “I’m absolutely not fine now.” 

About a week after his death was when that transition happened, and each day after was a struggle until I arrived home the day before the funeral, hugged my mom, and immediately started crying. And finally seeing mine and my brother’s dad was another step in truly fathoming that my brother was gone.  

The funeral itself was a blur and it was as emotional and draining as one would expect it to be. I met a couple of his best friends, one of whom was like a brother to Nic. He knew we were painfully aware of the bad aspects of my brother’s life but he took us aside to make sure we knew the good – how my brother was selfless and compassionate and caring…how my brother at one point had saved his friend and helped launch him into a successful life. Hearing his words had been more cathartic than most things up until that point, as was spending time with my family.

Since the funeral and being home, the heightened emotions have dampened some, but the pain and sadness certainly hasn’t dissipated. I’ve never truly experienced the loss of a close loved one before and it’s fascinating how grief works, especially in such a complicated situation – I’m fine most of the time until I’m randomly not. I imagine that will be the norm for some time to come. 

One thing I do know for certain is how grateful I am for the people in my life. 

If I wasn’t convinced before that my residency program is like a family, I certainly am now – the love, the care, the empathy, and the check-in’s have been a saving grace that has helped carry me along. The outpouring of love from everyone, old friends and new, has been immeasurably valuable as well. 

And to those few in my life that have traveled Nic’s journey with me the past years – that cried with me when I shared the news, talked with me through every dark thought and difficult moment, and spent time with me when I was home…they have showered me with the love that has consistently defined our friendships during our journey through life together, and I truly can’t express in words how much they mean to me.

---

After discussion, my family and I came to the conclusion that we were going to be open about my brother’s heroin addiction and death by suicide. 

We figured that’s one of the many ways that we could honor his memory…if sharing his story can help one other addict or prevent one more suicide, then the vulnerability and discussion is worth it, no matter how tragic.

I imagine that my brother would support it.

Most importantly, through all of this, I hope that my brother found his peace.

Until next time, bro. 

Intern Year: Stories, Part Two

9.

I once counted bullet holes in a patient.

1…2…3…where do these all go….4…5…is this the entrance or exit wound…6…7...wait wait wait, nearly missed that one…8…shit, did one go in his abdomen…9…10… hold up, what the hell is that– oh it’s just a bullet beneath his skin, keep looking for holes…11…I don’t understand how this just happens to a teenager…12…13.

He was 16, and he had nearly as many bullet holes as the amount of birthdays he had celebrated.

Since no bullets miraculously pierced his abdominal cavity, we didn’t have to take him emergently to the OR. However, the injury to his spinal column left him paralyzed from the waist down.

Stay in your lane, the NRA once said to us. 

But they haven’t walked through the blood on the floor or had it on their scrubs. They haven’t watched a family lose their parent or their child. They haven’t heard patients screaming in agony as we urgently examine and treat them, blocking out their curses with practiced detachment since we know that the temporary pain that they are feeling is a much better tradeoff than the morbidity and mortality that could await them if we gave into their cries.

Look for holes, look for holes…keep looking for holes. 

Later, once we had rolled the patient up to the ICU, my senior handed me a blank sheet of paper. I was confused at what it was for and she instructed me to draw a human sketch and mark where the bullet holes were, explaining that it was so the teams taking care of him moving forward would know exactly where the injuries were and so that none would be forgotten as time went on.

I started drawing – two crude, two-dimensional human outline figure drawings side by side, one to represent the front of the patient and one to represent the back. Now for the bullet holes. Head to toe, front to back. Hmmmm…do dots or X’s better represent bullet holes?13 marks littered across the sketches. It felt nearly surreal – as people moved around me in quick, chaotic fashion, I stood and awkwardly marked dots on my roughly drawn sketch, moving quietly amongst the multitude of people in the cramped room to recount where the holes were.

How many people, both children and adults, are going to be needlessly and brutally injured or murdered before something changes?

This is our lane,I want to say to them. How about you stay in yours?

10.

I once had a patient who lost his leg. 

He had developed an infection from hardware in his ankle that had been placed to fix an ankle fracture. After weeks of nonhealing wounds, antibiotic courses, and washouts to no avail, the next option was inevitable – amputation. 

It was a two-step process – an ankle guillotine amputation to remove the source of infection followed by a formal below-knee amputation a few days later after the infection had fully resolved to ensure that the stump would adequately heal. 

There’s something about amputations that’s hard to put into words. I try to imagine the mental and emotional process that patients must go through when we tell them that the best thing for them is to remove a limb, but it’s certainly not something I’ve come close to being able to fathom….the idea of going to sleep and then waking up with such a visible and important part of you missing.

Upon waking from anesthesia – is that the first thing they look for? Or do they try to ignore it for as long as possible?

It’s no wonder that it can sometimes take weeks for patients to consent for an amputation to be done.

I also have a hard time describing what it’s like to do an amputation, not from a technical standpoint, but from a mental one. Covering a patient in surgical drapes does a good job of helping with sterility in the OR, but they also sometimes serve as a helpful dissociation tool to some extent, allowing us to more objectively do our jobs. 

A metaphorical drape as much as a physical one.

Amputations are largely no different in that regard. I can cut and cauterize through skin and muscle, tie off vessels, and cut through bone with a whirring electronic saw with no issues. 

However, there is always a temporary, brief moment – right when the limb is fully amputated and I’m handing over someone’s detached foot or leg to the scrub tech – when the dissociation abruptly ends and the sudden awareness of what we’re doing is acutely discomforting. In my short career as a surgeon, no other procedure has given me that sense of momentary uneasiness.

I did both of my patient’s amputations. 

After my patient’s first operation – the ankle guillotine amputation – I went to his room one morning to change the dressing. The first operation, I feel, is particularly difficult for the patient since we don’t close the skin over the leg stump, leaving bone, muscle, and tissue exposed for a few days until we do the second operation and then close the skin.

He was an extremely pleasant and patient person, a perfect example of what healthcare professionals mean when we say that the worst things often happen to the kindest of people.

As I started unwrapping his dressing, I noticed him staring down at it. One layer down, on to the next one. He was still watching as I worked, and I noticed he was starting to cry. Oh no.I could feel my own eyes grow misty as I listened to his sniffles and saw him wipe his eyes out of the corner of my gaze. 

Go go go, as quickly as you can. 

I got to the last one and peeled it back quickly to examine the end of the limb and make sure everything looked as it should be, and then started to swiftly re-wrap it. When I was done, I took a deep breath. Okay, done. I stayed and talked with him for a few moments after, and I wasn’t able to stop myself from tearing up in front of him as we conversed, my voice intermittently cracking. 

Being able to quickly dissociate during a variety of situations has been an interesting experience this year – it’s certainly been a learned skill over time. My own mental drape, so to speak. It goes up when I need to get a job done. And then comes down when that job is done, or when I’m emotionally ready to process. There are instances where it feels as simple as turning on and off a new light bulb. 

But sometimes I just simply can’t detach completely. And that’s okay. On the other hand, sometimes it takes longer to reinstate the humanity back into my thoughts and actions; like an old light bulb that struggles and flickers for a prolonged moment before turning completely on with a steady, reliable hum. It’s the latter that worries me, and I try to keep that part which inevitably occurs with my job in constant check. 

However, the meaningful moments, whether good or bad, consciously or subconsciously, always catch up and bleed into our lives in some way.  

After I got done with work that day, I got in my car, thought of my patient quietly crying with his soft voice and kind demeanor, and I cried without restraint on my drive home.

11. 

I once had a patient who wasn’t able to find her husband. 

She was laying in her hospital bed during morning pre-rounds explaining this to us. It was said almost in passing, though certainly without a lack of bewilderment, before we moved on to discuss how she would need a drain placed for her ruptured appendicitis.

Later in the day, she found out where her husband was - he was one floor up and down the hall from her in the ICU. 

I can’t remember whether he had a stroke, a fall that led to a head injury, or a combination of both, but he came into the hospital as an unnamed Doe.  He was eventually identified and his wife went upstairs to see him. The prognosis was without hope and he was quickly placed on comfort cares to allow him to pass. 

Later that evening, I walked into her room once I had a lull to express condolences and see how we could help her. The room was dark and she was laying in the bed in complete silence, alone. I wonder if she had any other family in the area, or if her husband would have been her only visitor.

Her only request was to discharge her immediately in the morning so that she could take of arrangements for her husband. She cried, but also seemed, understandably so, shocked and overwhelmed. 

I can’t fathom the torment of not only being hospitalized and knowing a loved one is literally upstairs dying, but then to also have it happen unexpectedly in such a bizarre sequence of events. If he had fallen, could it have been something she could have prevented had she been with him and not at the hospital? It wouldn’t have been her fault regardless, but I hope that wasn’t the case…that she wasn’t grappling with guilt amongst everything else. 

She was discharged the next day, and although there has been no shortage of terrible situations since I started working clinically there was something about this story that still strikes a different chord for me. 

Perhaps it’s because even though it involved two people in a hospital for medical reasons, it felt - and still feels - like it really had nothing to do with medicine at all. I still have a hard time identifying why I feel that way when I’ve witnessed and heard other stories of death and suffering.

I suppose it’s because the potent combination of love, loss, and timing serve as reminders to not take life – and the people in it - for granted.

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October 8, 2017 -  Shades (1-5)

June 18, 2019 - Intern Year: Stories, Part One (6-8)

Intern Year: Stories, Part One

6.

I once told a patient that everything would be okay. 

He died, suddenly and unexpectedly, less than an hour later in the pre-op area waiting to have his gallbladder removed.

It had been an easy and straightforward Emergency Department consult. He was a young male in his 30s coming in with cholecystitis, an inflamed gallbladder. My resident team and I had tackled it together in a coordinated, well-practiced dance – gathering history, consenting him, marking him, and explaining that the best treatment was to remove his gallbladder.

The patient had answered our questions in simple, short bursts, an underlying tone of hesitation and trepidation lining his words. I had started to pick up on it during the beginning of our interaction but as I started to explain what the surgery would entail in order to consent him, the fear in his eyes was hard to ignore. I remember that it stuck out to me in the moment that he was more fearful than most patients usually are.

After he signed the consent, I squeezed his shoulder. “Don’t worry,” I said. “It’s an odd day when we don’t remove someone’s gallbladder; it’s pretty common and we see it a lot. It’ll be okay.”

He was rolled to the pre-op area within twenty minutes of us seeing him. Not soon after, he seized, coded, and died. 

The autopsy report was puzzling, the findings not consistent with what one would typically find in a young male. Other than that, it had been a freak occurrence that was out of our control.  A haunting reminder of the reality that routineis a word that one should hesitate to – or never - use in the context of medicine.

I felt stunned when I heard the news, the look in his eyes and the words I had spoken to him replaying in my mind. It’ll be okay, it’ll be okay, it’ll be – oh no.

“We’re going to take good care of you,” is what I try to say now to patients. I think of this patient nearly every time the words tumble from my mouth.

Medicine can bring cruel, swift reminders that there are no guarantees in life.

7. 

I once had a patient who was watching Harry Potter.

She was also crying, softly rasping how she shouldn’t be alive.

The patient was a young female that developed necrotizing pancreatitis. The disease had wreaked havoc with most of her abdominal organs and wall, leaving a literal hole in her abdomen, exposing her organs to the outside world. She was a perfect example of the dilemma that can come from modern medicine – kept alive and functional due to extraordinary medical and surgical feats, but yet a gateway into the overall ethical discussion of quality of life and whether medicine in this day and age can do just as much harm as it can good. 

I was on call one night when I received a page that her wound VAC – a device that essentially covered the hole in her abdominal wall – was malfunctioning, close to the midnight hour. I did my best to evaluate and troubleshoot it on my own, but I was still a fresh intern and the patient was in the tenuous portion of her hospital course. I texted my senior resident, uncertain of how to proceed. She came to look at it and after a few moments, she told me to stay in the room as she went to get a fresh set of supplies. 

Like any good intern would do, I sat down in the chair next to the patient’s bed and waited.

Harry Potter and the Prisoner of Azkaban was playing on the TV, illuminating the dark room. Ron and Hermione were confronting Draco Malfoy at the outskirts of a snow-covered forest, unaware that Harry was nearby underneath his Cloak of Invisibility.

“I shouldn’t be alive,” my patient uttered with a quiet cry.

Harry Potter was throwing snowballs at Draco in retaliation for the insults that had been aimed at Hermione. 

I had no idea what to say. 

I had never been her primary caregiver – I didn’t know her like the primary day team did or the nurses that took care of her. I felt like an intruder, the MD behind my name without meaning in a situation that required a natural rapport built over time between two human beings rather than a fill-in provider and a patient. 

Many don’t know that I almost chose Psychiatry as my career path; I have always felt a natural comfort with having difficult conversations in emotionally challenging situations, and I have never been one to shy away from digging deeper into the darker aspects of humanity in relation to medicine and mental wellbeing. But this was certainly pushing the boundaries of that comfort zone.

“It hurts so much, I’m in so much pain.”

Harry, still invisible, is messing with Draco and his two cronies, pulling the pants down on one and swinging the scarf around on the other, before tripping and dragging Draco a few feet. 

The stark contrast of the moment – between Draco getting up and running away in comedic fashion punctured with intermittent cries from my patient about how she essentially wished she were dead – created an indescribable feeling of surreal disbelief and the sobering reminder that life can just simply be cruel, piercing through distractions and attempts at minimization without preamble, without cushion, and without decorum. 

I attempted to offer some words of comfort in the moment, though I quickly realized the patient was in such a distraught state (understandably so) that it almost seemed like I wasn’t in the room. After a bit, I stopped speaking, figuring that sitting in silence was simply the best – and only - thing I could really do. 

Harry Potter continued to play on and I could only hope it was succeeding in distracting the patient, though a part of me knew it was most likely just a background noise filler in what must be an overwhelming, terrifying reality in the grand scheme of the patient’s life. The scene moved on and at that point, I wasn’t really paying attention either. 

In what felt like an interminable amount of time later, my senior returned and managed to fix the wound VAC. I lost track of what scene the movie was on when I left the room, moving on to tackle the rest of the chaos the call shift had to offer. 

I haven’t forgotten the discomfort and the feeling of woeful inadequacy from that moment, but I also haven’t forgotten the realization that those moments are normal, and okay, to have.

We’re human, too, after all.

8.

I once had a patient who cried about his breasts.

He was an older, transgender male with gallbladder cancer and a terrible prognosis. He had come to have a port placed so that he could begin chemotherapy. The patient and his girlfriend were kind in the pre-op area, offering smiles and warm introductions as I shook their hands. 

When we brought him back to the OR and moved him over to the operating table, we worked to get him ready and secured as anesthesia worked from the head of the table. Towards the end of the preparation, we rolled down his gown as we normally would to examine the site – his chest – and get it ready to be sterilely prepped.

He started crying as soon as his gown was moved down. “I shouldn’t have these,” he sobbed, clearly overwhelmed, nodding down at his still-female breasts.

At that time, anesthesia started to sedate him. “Try and think of a happy place,” she said from the head of the table, the oxygen mask starting to come down around his face. 

“I have no happy place!” the patient cried out.

I wonder now if the patient felt like he was devoid of hope. Perhaps having gallbladder cancer wasn’t the worst thing the patient had ever experienced. 

I stood next to him as everyone worked silently after his admission (confession?). A few moments later, the patient was under (if he were to dream – what would it be about?)and we were able to start the procedure.

I have no understanding of what it feels like to be transgender in this world – to be born with a body that doesn’t match your gender identity….and then to experience all of the misplaced, horrid, inexcusable hatred that society has to offer. 

“We’re about to roll he-she-it back to the OR,” I had heard out in the pre-op area. I’m still ashamed that I didn’t say anything then, a combination of letting my timidity as a beginning intern win out along with being shocked at the blatant rudeness and disregard for another human being.

The patient unfortunately passed away a months after the procedure. If the person that said those things were to find out about his death, would they wish they had said or thought anything differently? 

Why is it necessary to say such things? Even if one has their personal viewpoints, why be hateful or spiteful, especially about someone they don’t know? 

Why not still be kind and respectful, even when the person isn’t around or isn’t listening? Nobody’s perfect, we all make mistakes and sometimes fail at that concept - but that, in my mind, can be a true marker of integrity. 

Maybe if people would spend more of their time and energy trying to genuinely connect with and understand another human being, then maybe my patient might have had a different response – maybe he would have had a happy place. 

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October 8, 2017: Shades (1-5) https://mylifeasafuturesurgeon.blogspot.com/2017/10/shades.html

Intern Year: Errors

“I did this,” I thought to myself over and over again as I helped to roll my patient down to the ICU. 

“This is my fault.”

My mind was racing with the myriad of things that I could have mistakenly done – or not done – in the week prior to inadvertently cause my patient to suddenly decompensate out of nowhere on a Sunday morning. 

Was it the bed rest? Did I keep him on it too long? Oh God. The senior helping me just told me he should have been on a higher dose of clot prevention medication. Did he throw a clot in his lungs? Oh God. His heart. His kidneys. He just had surgery on his intestines. But what about his wound that’s basically been falling apart? Oh God. It’s a blood clot in his lungs, I just know it.

Oh God.

I don’t know what I don’t know, I don’t know what I don’t know, I don’t know what I don’t know.

It’s an intern mantra we repeat to ourselves, but it only goes so far when serious repercussions can happen as a result of knowledge gaps. And at the end of the day the phrase ends up sounding hollow and empty – laughable even - when those lapses in experience can be equated to us inadvertently rolling the dice with other people’s well being. 

I had been alone during my last week on the Colorectal Surgery service, playing a myriad of roles on a fairly busy service, but with only a portion of the knowledge to carry out even just one of those roles. I had been dreading the week for the entire month, but I somehow managed to make it through the week unscathed. I was grateful that the service had fewer OR cases than normal and I also lucked out with only one new patient consult the entire week. What had at first seemed like a terrifying week ended up being one of valuable use as an intern – one where I was able to step up, do a bunch of cool senior level OR cases (mine, all mine!), and make decisions with my big girl pants fully hiked up.

I went into the weekend with a 24-hour call on Saturday into Sunday, feeling like everything was winding down. I was ready to get it over with and be done with the stress of the week, the promise of starting on my pediatric surgery rotation just a few blessed days away. I made it through rounds and performing most of my tasks on Sunday morning with no issues and was about to leave within an hour or so, my excitement and relief swelling as the time continued to pass and I moved into hour 29 of working.

The irony of my patient crashing within that last hour doesn’t escape me. 

He had been a complex patient, one who had underlying, serious disease in a lot of his organ systems. I had been involved in this patient’s care since the early days of the month, and it had been a struggle from the beginning to gain control of the system-of-the-week that was having issues. By that last Sunday, everything had mostly resolved and he was on the upswing. My attending and I had even talked about discharge plans that morning.

Another irony that doesn’t escape me.

After I rolled my patient down to the ICU, the pressure of the week – and of the day – hit me. I’m grateful for the senior resident that took me aside to offer support, and for my co-intern that gave me a hug once I walked back upstairs. 

I went home soon after, and was somehow able to go to bed and fall asleep despite the knowledge that once I woke up, I’d probably be able to find out what had gone wrong. 

The relieved sigh that escaped my lips upon finding out that it hadn’t been a pulmonary embolus – the thing I thought I had caused – echoed the internal alleviation of tension that also occurred with the discovery, though I still felt awful and was still worried about what would happen to him.

Regardless, I did my best to unwind for the remainder of the evening, knowing that I had to reset and get ready to start a new rotation in a new location (the worst combination) the following day.

I checked my phone right before going to bed to look through the patient list one more time, seeing if there was anything else I could tidy up before the new residents took over the service, and also wanting to chart stalk one last time to see how my patient was doing.

I blinked once. 

My heartbeat picked up. I refreshed the screen. 

I blinked again.

…What? 

Another patient of mine had not only gone to the ICU, but was also in the process of being emergently taken to the OR.

I did nothing but sit on the couch in the silence of my apartment and stare off into space for a few moments, the gears in my brain frozen, unable to think, let alone feel, any emotions, having already devastated the majority of my reservoir earlier in the day (and the week).

Click. Click. Click. The gears began thawing. And it started coming to me in pieces. 

His labs. The nurse off-handedly making the remark that his room smelled a bit worse than usual in the morning. The fact that he had been clinically stagnant the past couple of days – not doing worse but also not really improving either. He had been another medically complex patient, but still…oh God. 

Thankfully, his serious complication had been caught by the senior on call that same day just a few hours after I had left, but it still was a terrible feeling to know that I had missed something on one of my patients….that I was unable to put the pieces of the puzzle together from the trickle of clues that had been left here and there along the course of the morning. What if it hadn’t been caught that day?

Hindsight is 20/20. Hindsight is 20/20. Hindsight is 20/20.

Another phrase we tell ourselves. It’s comforting and painfully true, but it also serves as a reminder of our human limitations.

The next morning, I woke up to start my first day on pediatric surgery filled with uncharacteristic anxiety and aversion to going into work. I remember staring at the computer screen in the OR lounge that morning, unable to focus on looking up numbers and information on the list of new patients. 

Thankfully, expectations were low on the first day and, since I wasn’t assigned to be the intern seeing new consults that day, I spent most of the day doing nothing but operating. While that normally would have excited me to no end – pediatric surgery is what I want to do with my life, after all – instead it felt unsatisfying, filled with brief moments where I just wanted to crawl out of my skin and hide. 

Surgery residency is always go, go, go.

And I just needed it to stop, stop, stop.

Which, of course, it never really does.

I deliberately reached out to one of my closest friends that day, telling her that I needed to talk to someone (an action I rarely do), and I was thankfully able to talk with her a couple of days later.  It helped, as did seeing that my two patients that went to the ICU gradually started to improve over the following days. I still felt slightly off though, and I spent my first couple of weeks in mostly solitude, not really wanting to socialize or talk to many people outside of work. 

I knew that what I was feeling was partly heightened by the fatigue that had gradually built up during the months. There was also the reality that I was also still a fairly new intern that had just recently moved to a new area with no partner and no family. And no matter how blessed I feel by my new resident family, at that time they were equally – if not more – busy and stressed as I was. 

The rational, logical part of me knew that it was all a perfect recipe for the way that I was feeling and possessing that knowledge helped me move through the days. If the concept of resilience was a moving object, I was trudging just behind it. 

Thankfully, the familiarity and enjoyment at being back in the pediatric world started to bring me back to my baseline. I started to feel a sense of contentment that increased day by day. It wasn’t until my string of four nights straight that I felt back to normal, resilience once again back on my side. 

Working nights can inevitably be chaotic, but I’ve also found that I enjoy them immensely. The solitude and limited interactions of the night were often a stark difference from the whirlwind rat race of days, and they provided a recharge to my introvert batteries that I needed. When combined with the fact that it was pediatrics, it was potent enough to snap me out of my funk.

As the weeks passed, both of my patients that went to the ICU were transferred to the floor and eventually discharged. I still intermittently check to see if they were re-admitted, something I don’t really do with other patients. 

Looking back now, I sometimes feel juvenile for feeling the way that I did – for having such a lingering reaction.  They hadn’t died.  In fact, one could reasonably make the case that complications were to be expected given their medical histories and statistical chance.

However, it doesn’t change the fact that on that day and the week prior, I had been the resident responsible for their care, seeing them far more frequently than the attending or anyone else except for the nurses.

The experience was yet another new one in residency – learning how to grapple with the reality and concept that not only do patients not do well sometimes, but they also end up not doing well because of the things we as doctors inadvertently do or not do, despite our best intentions and the amount of hours we put into taking care of them. 

We’re human, too, after all.

I know that this will happen again. And not only that, I know that there are worse things that will happen - worse events missed, worse errors, worse outcomes. I also know that in the future I will most likely look back on this entry and shake my head at my naivety. Even now, I look back at some of my entries from medical school with a wistful smile.

Regardless, getting used to the reality of complications, errors, and bad events happening to patients is yet another hurdle that we face as new doctors that unfortunately needs to be experienced. It’s not something that we can escape, no matter how hard we try. And with that comes the inevitability of learning how to cope and move on.

We owe figuring out that process not just for ourselves but also for all of the patients that will follow.

Intern Year: That Time I Cried in a Stairwell

Over the past four years of medical school, I’ve learned to strongly believe in the power of vulnerability. It’s a concept that I’ve embraced – though not without difficulty – and I try my best to not only incorporate it into my personal life but also my professional life.

(Though something I’ve discovered is that those two lives bleed into each more often than most of us have the courage to admit). 

With that being said, and rather ironically, I’ve always had a terribly hard time crying in front of others in the context of one of my weaknesses or insecurities being put in the spotlight, especially when done in a sudden and unceremonious fashion. Crying as a result of anger and frustration never - for whatever reason - leaves me feeling as bothered.

Perhaps it’s because I subconsciously feel that crying from the latter emotions is a sign of passion or strong opinion whereas crying from the former is a sign of personal failing. 

So when I found myself in tears in a hallway on the Friday morning on my first week of residency, literally unable to hold them back after barely succeeding in doing so for the prior hour, the first thing I felt was shame and embarrassment. 

I have a bad habit of bottling my negative emotions and stress. Usually, I can keep the bottle plugged and hidden until I’m able to sneak away and empty it out when no one is watching. There’s only a small handful of people that I would every willingly engage in a conversation where I know it will make me cry.

But sometimes the bottle gets filled too much, with so much pressure that just builds and builds and builds until it shatters. 

The first week of residency, being on call twice in one week, and having a relatively high amount of complicated patients (for my level, at least) was the perfect recipe for it to happen. I was disorganized and flustered on rounds on Friday in a way that I have never been before (literally), and the results of that were not pretty. 

My chief resident caught me as I was trying to hold a conversation with him a bit later, the dam holding everything at bay starting to crack more and more with each passing sentence. 

“Are you crying?” he asked me. 

Busted.

“Yeah,” I answered. 

He stood up. “All right, come on,” he replied, guiding me in my dazed trance into a nearby stairwell. 

“It’s okay that you’re crying…it’s normal,” he stated calmly, “But one of the rules of residency is that if you’re going to cry…always have your moment in a stairwell.” 

I laughed at that, immediately grateful for the genuinely empathetic way in which he handled the situation.

Noted, I thought.

“I just have too much botox around my eyes to cry anymore,” he also added. 

Pro life tips of an awesome senior resident. 

I felt better the next morning, but the main thing that lingered after was the embarrassment I felt in losing my composure in front of a person I barely knew. I felt exposed, transparent in a way that made me squirm. I still wince thinking about it. And that in and of itself made everything even worse.

Why is that?

Probably pride. Maybe a little bit of ego. Two concepts that have been stripped down, torn apart, and reset already in the few months that I’ve been a general surgery resident. 

I consider it to be a good thing. 

I’ve always thought that pride and ego is a double-edged sword for a surgeon – we need to have a certain amount to be able to do what we do (can I even include myself in ‘we’ at this point?), but on the other hand it can quickly become our biggest downfall. It’s a balancing act. For me, vulnerability has always been a way to maintain that balance. And perhaps embracing my weaknesses in a new way was one of the first necessary growing pains in figuring out residency.

“Be gentle with yourself” are words I often say to other people.

Perhaps I need to start listening to my own advice more.

That first rotation already seems a long time ago – even though it was really only two months ago. 

I started on a GI surgical oncology service where there was no shortage of patients with complicated medical, surgical, and personal histories. It was humbling to start my journey of being a doctor on a service where patients are often grappling with some of life’s hardest questions and curveballs regarding terminal illnesses, dire situations, and end-of-life care. And many of them did so with a light and hope and warmth that was incredibly authentic inspiring.

That rotation was followed by a month of nights – a crash course in surprises and everything under the sun. It felt like the wild west of surgical care. Overnight, another intern, a third year, and myself covered five services, about 60-70 patients, and new acute care consults (gallbladders galore!). It was, oddly enough, a very enjoyable month. Amidst the chaos that can occur at night, there was a certain peace to walking the empty halls of the hospital at night. 

Getting adjusted to the rigor and intensity of residency has also been an adjustment in and of itself, filled with moments where I was tired, up for more than 28 hours, and my brain function felt nonexistent in situations where it was desperately needed. 

Thankfully my capacity to think while being exhausted has continued to improve. And now when it feels like I’m learning about 50 new things in the span of five minutes, approximately 27 of them stick in my brain as opposed to the measly 10 at the beginning of July. 

Progress, people.

During night float, I started to see how easy it could be to become callous and robotic – how empathy and patience can be some of the first emotions to be put toward the wayside. In moments where I’m trying to do an admission, am getting new consults, still have 5 postop checks to do (yay Vascular!), have a patient unexpectedly start to decompensate, and am getting hammer paged seven times within five minutes, it would be so so easy to just snap at somebody. Especially since I’m still trying to figure out how to respond to, do, and handle all of those things (yet another growing pain) without asking someone or without being slow.

At least I know where the food, coffee, and bathrooms are. 

During the past few months, I’ve learned how to make empathy more of an active process rather than to just let it be a subconscious, passive driver like I have in the past.  The simple, cliché statement of “putting yourself in other people’s shoes” really does hold true. 

If I’m being paged, it’s because someone is concerned, they’re trying to help their patient, or they’re trying to make their own lives easier (all things that I can empathize with, even the last one). If someone is snapping at me or being hard on me, perhaps they’re having a bad day, someone had just got done yelling at them, or that’s how they were, unfortunately, trained. Or perhaps that’s what they strongly feel will make me learn the best.

It’s all an interwoven, never-ending cycle. And I’d like to think that most people are trying to do their best in a complicated, difficult system that never sleeps and rarely lets up. 

I’ve also learned that stopping – both physically and mentally - in the midst of the chaos and just taking a deep breath can help immensely. I can’t control the things going on around me about 90% of the time but I sure as hell can control my own actions and thoughts. 

Be present.

My patients help with that. When I walk into a room, I do my best to ignore the list of things that still need to be done so that I can just simply focus and be in that moment. 

Most of the time I succeed in that endeavor. Other times I unfortunately don’t. I have a feeling that will continue to be a perpetual struggle for the rest of my time as a healthcare provider.

The residents, midlevel providers, and nurses that I work with also tremendously help. They’re a wonderful group of people and I feel very blessed to be in the residency that I am in. It’s a comforting feeling to know that you feel safe to ask questions, be vulnerable, and learn in front of a group of people. And to have fun, enjoyable times along the way as you do so. 

As I near the end of my third rotation (Colorectal Surgery!), I look back and am in awe at how quickly the past few months have flown by and how much I’ve grown in just the few short months I’ve been an intern. I can only imagine what the next three months will hold and where I will be then. 

I haven’t had any other moments of crying in a stairwell since that day (okay okay okay, I did cry one more time post overnight call in my car a couple of weeks after), but there most certainly may be more.  

And that’s okay.

But for now…one day  - and experience - at a time.  

Medical School: Four Years, Four Parts

Year One. 

A year of self-discovery and uncertainty. 

Who I was as a person intrinsically changed, shifting my perspective in a way that was both exciting and terrifying. I’ll admit that the terror and anxiety outweighed the excitement a significant portion of the time, and unfortunately a lot of my decisions on whether to engage or not engage with the people in my life, both old and new, were based off of that fear.

Along with those changes came the overwhelming feelings that inevitably go hand in hand with starting the daunting path of pursuing medicine, meeting new people, and being in unexplored places.

Most people probably don’t know that I questioned my decision of becoming a doctor nearly every day that year. 

If beginning the journey of medical school was a white line, I stood with my feet firmly planted on both sides – one in my old life and the roots that had taken hold, and the other in a staggeringly overwhelming new life, resistant and hesitant of everything it entailed.

As the year progressed, however, a chasm started to split along that white line, slowly widening more and more day by day until balancing both my old and new life became increasingly difficult. I stubbornly persisted in trying to maintain that balance despite subconsciously knowing how much I was failing at it. 

However, it was also a year of laughs and of joy. Of refreshing moments and allowing myself to open up to people who were, at that point, strangers. 

I learned – and for the first time truly believed - that vulnerability is strength.

I learned of deficient areas in my life and made goals on how to improve them, most of which included opening myself up more to people about my thoughts, my feelings, and myself. Professional and personal development all in one – two birds with one stone. Easy, right?

If only I had known that my first year of medical school was the slow ascent to the pinnacle of what would become a downward slope.

Year Two.

A year of pain.

Suffocating and heartbreaking pain. 

It was rare that I went a day without crying, and it’s possible that I was clinically depressed, something I had not experienced before and, despite my adamant belief in mental health care, never admitted to myself when it was happening. 

I used to think that being able to maintain a normal, even positive, external façade in tough circumstances was a strength of mine, but I’ve learned since that it can also most certainly be a weakness.

One of the worst feelings I think I have ever experienced is feeling alone in a crowded room filled with people close to you, and my second year of medical school consisted of far too many of those moments.

The overwhelming newness of the prior year’s changes had settled into multiple harsh realities, none of which I was equipped to deal with, especially when dangerously combined with everything occurring during one of the hardest years of medical school. 

The chasm had widened to a point where now I had no choice but to fully embrace this new life of mine, both feet on one side, and I often felt a shadow of my former self. Looking in the mirror was difficult and some days I almost expected it to crack, a true reflection of what I felt was happening inside myself.

I marvel at the friends and people in my life that kept me afloat (and still do) on the daily, often without even realizing the depth of their impact.

There was a notable transformative, bright spot that year – a classmate who came into my life and helped me laugh through it all…somebody who found sinking pieces of myself and dug them out until I started to recognize them again, though they were certainly still cracked and caked with grime. There’s something to be said for letting a person figuratively pick you up.

By the end of my second year of medical school, and before moving to Pennsylvania, a few situations had thankfully resolved, and my world started to spin in a direction closer and closer to a purposeful, positive axis. It wasn’t the same one as before (nor did I want it to be), but was instead something different, an intriguing and curious new start. 

One that, thankfully, would only become stronger, better, and more meaningful with time. 

Year Three.

A year of growth. 

The pieces of myself that had been chipped away at in the prior years started to repair themselves. I started to polish the dirt off slowly but surely.

What I found underneath was surprising – on the surface there were parts that had always been there – certain character traits, strengths, and weaknesses. But there was something else…a shimmer that hadn’t been there before. A newfound strength and comfort that I didn’t know what to do with at first.

My academic drive and motivation returned, something I hadn’t truly fathomed that I lost until beginning my third year. But along with that, there was a humility and empathy that hadn’t been present prior. 

I used to joke to people that met me during my medical school years that if they had met me beforehand, there’s a good chance we might not have been friends. I was judgmental, cocky about it, and also lacked any sort of understanding for those different than me. I needed humility and a wake-up call. 

All of the pain I experienced was completely and absolutely worth it to rip that horrible, inexcusable part of me away. Some of the things I have said and done to people in the past, all in the name of religion, are some of my biggest regrets. Maybe one day I’ll find the strength to send apologies to people in my past I no longer talk to and treated poorly.

In a year defined by caring for patients for the first time in a clinical setting, I feel like I truly started to grasp whatever it is that connects each of us through our human fragility. We are all capable of having moments of both utter joy and overwhelming suffering, no matter our life circumstance. 

For every time a patient looked at me and said “thank you” I wanted to say “No, thank you” right back. I strongly feel that being open to learning from each other will always be the true foundation of humanity.

During this year, I also became wonderfully aware and open to the value and concept of community – of truly creating a family with people unrelated to you – as this was my first time living outside of Florida. As the growth continued, and for the first time since the beginning of medical school, I was able to put my guard down and allow myself to connect with those around me. 

And what a blessing it was. 

Because for all of the dirt that I wasn’t able to polish off or the cracks I wasn’t able to repair, my patients, my program’s faculty, my classmates, and other friends…they did it for me, finishing and touching up the repairs in my life with a care and compassion and acceptance that I don’t think they realized they exuded.

Thank you.

Year Four.

A year of self-acceptance and learning to love myself.

If the first three years involved discovering more of who I am and the person I want to be in the context of other people’s support and drawing on their strength, this past year involved this same discovery, but instead drawn from my own fortitude, self-love, and resilience.

It was the year that I truly felt healed.

For years, I had forgotten what it was like to feel at peace. It didn’t occur to me until the end of third year going into this past year, that an inner contentment had returned. It had occurred so gradually that I almost didn’t realize it until one random day I thought to myself “Wow, I’m truly happy”, paused to reflect on the notion, and then had no subsequent feelings of anxiety or despair creep back in.

The nature of fourth year contributed to that.

Whereas third year involved the stresses and challenges of clinical rotations in a setting where I could fall back on my classmates and familiar faculty, some of fourth year involved doing clinical rotations alone in a foreign environment. It was one of the most intimidating things I have done in my professional career so far and I was blessed to meet new people and sharpen not just my clinical skills, but also my character. 

After, I spent months traveling around the country for interviews, which was equally as isolating and intimidating. I was left with just myself in unfamiliar places. Hours and hours spent wandering new streets. Eating alone in restaurants. Filling the time in my day however I wanted to, often only speaking to strangers. Or not really speaking much at all. 

The parts of me that had been cleaned off and repaired to reflect the positive growth in the prior year were now becoming more refined…more confident and more content. 

I’m stronger now. 

I don’t recognize the person I am now when compared to the person I was starting my first year of medical school. However, I have a feeling that I’m not alone in that sentiment. My journey is just one amongst my classmates – each having their own stories that defines them. 

Even as graduation nears, I’m still learning. I’m still conquering fears and insecurities. And truthfully, I hope that part never becomes stagnant. I hope that as I begin residency in a few short months that the layers never stop being peeled away, testing me to continue to push to be the best version of myself that I possibly can be. 

For now, I’m simply content with being able to say that I’m proud of the person that I am. 

-

Here’s to the next journey.