Sunday morning I showed up to L&D for a twenty-four hour call.
As background, I spent the summer between my MSI and MSII year working at the West Roxbury VA as staff on a nursing service. One benefit of working with nurses for a summer is that you learn the power of bringing food for a weekend shift. So, I came prepared for the day with bribes (in the form of baked goods) for the nurses. I was happy to see that cranberry-orange bread was enough to have me welcomed to the team.
The floor was quiet when I arrived with no women in labor, so I spent my first few hours getting to know the nurses and the midwife on the floor. This is a rare chance as everyone normally has their work-plate full and can't spend much time getting to know the students who pass through; I liked the opportunity to get to know them a little bit more as people.
Around 3 hours into my shift, a patient arrived! The patient, however, was being followed by the midwife. Students are not normally involved with midwife-patients; my hopes were dashed for a brief second. But, perhaps due to the low-volume nature of the day, the midwife on call told me if it was alright with the patient, it was alright with her for me to observe.
I walked into the patient's room and introduced myself. (As another aside, I enjoy the intentional "at home"-feel of the L&D rooms - the lighting is softer, each room comes with a jacuzzi, and sometimes I swear you can hear smooth jazz playing quietly in the background). She was here for the birth of her second child - she had delivered a baby girl years ago with a midwife in this very hospital. She was surprisingly friendly for someone having contractions every five minutes, and welcomed me to stay for the whole process of the labor. With the floor empty of other patients, I took a seat in one of the overstuffed chairs and used my iPhone to start timing her contractions.
We spent the next 4 hours talking with each other - she asked me my birthday and quizzed me as to whether my personality traits matched with my astrological sign (they did, she concluded). She shared with me about her move to America for opportunity; how she learned English; how she met her current husband; what it was like to be a mom.
Somewhere around 4pm her contractions were 2 1/2 minutes apart and the pain became overwhelming for her - she kept her eyes squeezed shut and could no longer talk in full sentences. She made the decision to get an epidural. I watched as the anesthesiologist on call tried once, twice, three times to get the needle into the correct space in her spine. With a sigh of relief, he succeeded in finding the epidural space; within minutes of medications, she was back to her bubbly and friendly self.
She slept for a while and I used the opportunity to read. Somehow 12 hours total had gone by and the shift of nurses changed. A new midwife came on call - she introduced herself and I marveled at the mirth and gentleness she approached the patient with - she smiled as she described how the tentative schedule of the night would go - the excitement and expectation of was building.
A few more hours passed - at some point, the midwife came back into the room and sat down in another one of the over-stuffed chairs. We all chatted for a while longer, and then with minimal introduction, the midwife stood up and began to prep the patient and the bed for the delivery. She worked effortlessly and with such a calmness that if I had no context to the event, I would have thought she was a massage therapist.
She dimmed the lights until it seemed as if the room was lit by candlelight. Then, with a similar confidence and gentleness that she had approached the entire night with, she softly gave the patient instructions - when to breathe, when to bear down, when to relax. I stood near the foot of the bed, lending support to the patient's leg and watching in awe. 10 minutes of pushing passed with a similar rhythm - breathe, bear down, relax, repeat. I'd almost forgotten what the end goal was until the crown of the baby's head appeared.
That's the last part I remember clearly - everything from there on happened so quickly - within a few second, the entire baby was out and into mom's arms. 10 fingers - 10 toes - a healthy, crying baby girl.
~~~
There is a song by Minnesotan Folk Artist - Peter Mayer - called "Holy Now". In the song, he remarks about how when he was growing up, his parents brought him to church where he heard stories of the divine and miracles retold from the bible; he recounts feeling sad as a child that miracles didn't still happen; it took reaching adulthood for him to realize that miracles were everywhere, "the challenging thing becomes, not to look for miracles, but finding where there isn't one... Everything, everything, everything is holy now."
I am filled with gratitude for my first experience on L&D. The slowness of the day afforded me the ability to be fully present with someone during a sacred event in their life - the calm persona of the midwife helped me feel at ease and enjoy the miracle of being human and being born. We are delivered into this world - the more I hold that thought, the more I agree with Peter - everything feels like a miracle.
~~~
The next morning, before leaving the hospital sleepy-eyed, I went back into the patient's room (now in post-partum) to see how she was doing, and to say thank you for the gift of being able to participate. She seemed surprised that I was thanking her... I guess it's hard to explain how, but for a third year med student, the reminder that life is bigger than writing your notes correctly / knowing the cardinal movements / nailing your shelf's, and that doctoring is much more about being a human being - present with another human being - well, it's a miracle in itself.
(that's all for now).
Monday, August 16, 2010
Wednesday, August 11, 2010
bring hope where it once was forgotten
Yesterday in neurology clinic, I saw a patient with complex regional pain syndrome. To spare the HIPPA violations that haunt me in my dreams, I will only provide the information that the patient I saw was young and that his life was devastated by chronic severe pain throughout his entire body - allodynia to even the slightest brush to his skin - a reality he lives with each day since his minor accident several years ago.
Before the visit, I read briefly through his chart - filled with a phonebook's size of notes and consults. The most recent consult note from an outside neurologist ended with a simple sentence: "The patient has been informed that there is nothing more that can be done for him." I noted the dismissal as dreary before entering into the room with the patient...
~~~
In younger years, I day-dreamed about what it would be like to be a doctor. In my aspirations, I dreamed of being competent, perceptive, and compassionate. Patients would come to me and I would be able to use my clinical acumen to make a diagnosis, prescribe the best treatment, and by golly, my imaginary patients would get better.
Several years later, and I am somewhat surprised to see what vain fantasy the above really was. What catches my mind tonight is how often it occurs that we in medicine really don't know what to do to serve our patients. Despite all the "classic" or "textbook" cases we memorize throughout the first two years of med school, I've yet to encounter a patient whose symptoms fit neatly into a Harrison's chapter. In addition , there are patients like the one from neuro clinic yesterday - the patient has a recognized and labeled disease, but for whom standard treatments have failed.
"there is nothing more that can be done for him"
I am trying to imagine the person who wrote that sentence to this patient. I am wondering who he wrote that sentence for. I can't imagine it was to console the patient - lines like that only make sense when someone has passed on and truly, no more can be done in this world. But the text closes the consult letter - its finality thuds like a gavel in a court room as a sentence is pronounced. It is a door shut closed - 'don't come back here, we're done with you'. The sentence somehow tries to relieve the physician of further responsibility or duty to this man.
I am grateful that the physician I was with disagreed. Not in words - she didn't mention the consult letter at all. Instead, at the start of a busy and overbooked clinic, she spoke with this patient and heard his story from the beginning. She listened to him speak about how it has affected his life - what he fears - what interventions he has tried, what he is still willing to try. And, as it happens, today he is not at a point where he is willing to attempt new treatments or changes to his care. It didn't matter - she stayed with him for more than 80 minutes - taking time to understand the details of his story and his person. At the end of clinic, she gave him her card, and instructed him to come back if he reached a point where he was interested in pursuing new avenues of care.
~~~
While perhaps its true that no TENS unit or spinal cord stimulation could alleviate this mans pain, I am not convinced that our duty as physicians ends. We are not mere vendors of medical merchandise - we agree to accompany our patients . If nothing else, we bear witness to suffering and prevent it from being faced alone. In my mind, it is not unlike the calling of a fire-fighter. Good fire fighters don't run away from fires - they run towards fires. Likewise, it seems good doctors should not run away from suffering patients, but rather run towards them.
~~~
The rest of clinic was spent in an uphill battle of trying to get caught up (it didn't happen and dragging a medical student in tow, I am certain I didn't help). I had to leave for my next clinic long before we were done, but I dropped by the office hours later and peeked in - my preceptor was at her desk, looking drained from what had been a challenging day, still attempting to finish paperwork. I wanted to note that because it struck me that stopping to take time to listen to this man was not without cost - a cost that is certainly not rewarded within our medical system. Additionally, you could argue that no tangible improvements came out of the visit. But her action was radically compassionate and demonstrated a commitment to hope and to solidarity. It may never be re-imbursed by an ICD9 code, but perhaps its true that not everything that counts can be counted.
I feel like there is more to say, but for now I just want to make sure I don't forget this.
Before the visit, I read briefly through his chart - filled with a phonebook's size of notes and consults. The most recent consult note from an outside neurologist ended with a simple sentence: "The patient has been informed that there is nothing more that can be done for him." I noted the dismissal as dreary before entering into the room with the patient...
~~~
In younger years, I day-dreamed about what it would be like to be a doctor. In my aspirations, I dreamed of being competent, perceptive, and compassionate. Patients would come to me and I would be able to use my clinical acumen to make a diagnosis, prescribe the best treatment, and by golly, my imaginary patients would get better.
Several years later, and I am somewhat surprised to see what vain fantasy the above really was. What catches my mind tonight is how often it occurs that we in medicine really don't know what to do to serve our patients. Despite all the "classic" or "textbook" cases we memorize throughout the first two years of med school, I've yet to encounter a patient whose symptoms fit neatly into a Harrison's chapter. In addition , there are patients like the one from neuro clinic yesterday - the patient has a recognized and labeled disease, but for whom standard treatments have failed.
"there is nothing more that can be done for him"
I am trying to imagine the person who wrote that sentence to this patient. I am wondering who he wrote that sentence for. I can't imagine it was to console the patient - lines like that only make sense when someone has passed on and truly, no more can be done in this world. But the text closes the consult letter - its finality thuds like a gavel in a court room as a sentence is pronounced. It is a door shut closed - 'don't come back here, we're done with you'. The sentence somehow tries to relieve the physician of further responsibility or duty to this man.
I am grateful that the physician I was with disagreed. Not in words - she didn't mention the consult letter at all. Instead, at the start of a busy and overbooked clinic, she spoke with this patient and heard his story from the beginning. She listened to him speak about how it has affected his life - what he fears - what interventions he has tried, what he is still willing to try. And, as it happens, today he is not at a point where he is willing to attempt new treatments or changes to his care. It didn't matter - she stayed with him for more than 80 minutes - taking time to understand the details of his story and his person. At the end of clinic, she gave him her card, and instructed him to come back if he reached a point where he was interested in pursuing new avenues of care.
~~~
While perhaps its true that no TENS unit or spinal cord stimulation could alleviate this mans pain, I am not convinced that our duty as physicians ends. We are not mere vendors of medical merchandise - we agree to accompany our patients . If nothing else, we bear witness to suffering and prevent it from being faced alone. In my mind, it is not unlike the calling of a fire-fighter. Good fire fighters don't run away from fires - they run towards fires. Likewise, it seems good doctors should not run away from suffering patients, but rather run towards them.
~~~
The rest of clinic was spent in an uphill battle of trying to get caught up (it didn't happen and dragging a medical student in tow, I am certain I didn't help). I had to leave for my next clinic long before we were done, but I dropped by the office hours later and peeked in - my preceptor was at her desk, looking drained from what had been a challenging day, still attempting to finish paperwork. I wanted to note that because it struck me that stopping to take time to listen to this man was not without cost - a cost that is certainly not rewarded within our medical system. Additionally, you could argue that no tangible improvements came out of the visit. But her action was radically compassionate and demonstrated a commitment to hope and to solidarity. It may never be re-imbursed by an ICD9 code, but perhaps its true that not everything that counts can be counted.
I feel like there is more to say, but for now I just want to make sure I don't forget this.
Tuesday, August 3, 2010
up and down and up and down and up again.
The first partial birth abortion I ever witnessed came hours after the first birth I participated in. The same doctor performed both procedures.
~~
The birth was a Cesarean. Dad was in the room. Miraculously to my eyes, the whole procedure was uncomplicated and swift. A baby girl seemingly popped out from mom's lower abdomen, was swaddled and APGAR-ed, and delivered to Dad. Healthy and crying. Cue tears from mom, dad, and the third year medical student.
~~
Later, down in the OR suite, I watched a young woman drift into peaceful unconsciousness under the effects of sevoflurane. Satisfied that she was unconscious, nurses guided her legs into stirrups while preparations were made for a D&C. A machine not unlike a vacuum cleaner was then inserted in through her vagina and into her uterus. For the next seven minutes, the Dr. maneuvered this contraption into all the crevices of her uterus;
"You have to make sure you get every piece... You can't go leaving an arm in there"
When it was finished, he brought me over to a sterile table where the evacuated contents were floating in a metal container not unlike a bread loaf pan. We then sifted through all the pieces to reconstruct the basic skeleton of the fetus. Skull, both arms, both legs... 1 hand... where was the second hand? We passed over bean sized kidneys and a heart... ahh, there it was.
Satisfied that he had not left anything behind, he looked up and studied my face for a minute. I met his gaze.
"Good to see you're not one of those passing out-types"
He said it with a tone of approval; as if by staying stalwart had proven my courage; my readiness to enter into this messy business of doctoring.
But I felt strange as I came to realize my own lack of emotion. I mean, I am the passing out type. And I cry while watching episodes of the Biggest Loser; why now, when I had just witnessed the termination of a potential life, did I feel nothing?
This happened 2 months ago and I still don't know what to make of it.
~~
The birth was a Cesarean. Dad was in the room. Miraculously to my eyes, the whole procedure was uncomplicated and swift. A baby girl seemingly popped out from mom's lower abdomen, was swaddled and APGAR-ed, and delivered to Dad. Healthy and crying. Cue tears from mom, dad, and the third year medical student.
~~
Later, down in the OR suite, I watched a young woman drift into peaceful unconsciousness under the effects of sevoflurane. Satisfied that she was unconscious, nurses guided her legs into stirrups while preparations were made for a D&C. A machine not unlike a vacuum cleaner was then inserted in through her vagina and into her uterus. For the next seven minutes, the Dr. maneuvered this contraption into all the crevices of her uterus;
"You have to make sure you get every piece... You can't go leaving an arm in there"
When it was finished, he brought me over to a sterile table where the evacuated contents were floating in a metal container not unlike a bread loaf pan. We then sifted through all the pieces to reconstruct the basic skeleton of the fetus. Skull, both arms, both legs... 1 hand... where was the second hand? We passed over bean sized kidneys and a heart... ahh, there it was.
Satisfied that he had not left anything behind, he looked up and studied my face for a minute. I met his gaze.
"Good to see you're not one of those passing out-types"
He said it with a tone of approval; as if by staying stalwart had proven my courage; my readiness to enter into this messy business of doctoring.
But I felt strange as I came to realize my own lack of emotion. I mean, I am the passing out type. And I cry while watching episodes of the Biggest Loser; why now, when I had just witnessed the termination of a potential life, did I feel nothing?
This happened 2 months ago and I still don't know what to make of it.
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