Voice of a Physician
April 5, 2022
The sick-sick patient and the anesthesiologist
By Audrey Shafer, MD
He was sick-sick but he had broken his hip, and if you put a broken bone and an orthopedist together, you have an operation. It wasn’t as far afield as the classic ortho-anesthesia video where ortho calls for an OR for a dead patient, but believe me, all kinds of badness can occur that turns sick to dead.
A good sign was that the patient was ornery. He didn’t so much as sit up in his gurney, as hold court from there, waving people off who spent too much time asking questions. It looked like he had experienced his share of bar fights and yelling matches in his time, but now, the only thing spewing from him was hair. His nose, ears, and even ear lobes sprouted it. He had a grey and white stubble beard and stringy, crazy hospital hair. He looked like a perfect setup for a Fab Five make-over.
According to his chart, he repeatedly refused oxygen at home in his remote trailer, and slept in a recliner. I imagined his easy chair slick with grease from his near-constant presence, and I felt depressed at his not-easy life of isolation. He lived with an oxygen saturation in the 80s, and his carbon dioxide level not far below that. These numbers should never be neighborly, but his liked hanging out together.
But, another good sign was that he was there, completely there, understood he was going to have surgery and that he could die.
He chose his words since it took so much effort to just breathe. I felt he could have given me a good lecture on life, the muck of war, and that he’d whip open those pearly gates when he was good and ready, but instead, he just said, “Let’s get on with it, doc.” He couldn’t put any emphasis on his declaration due to his lack of breath, but I sensed he would have snarled it at me if he could. However, I took the fact that he could muster six words in a row as a good omen.
“OK,” I said, “let’s go,” when everything was ready for him. He was too sick for any premedication, and we had to start the anesthetic with him sitting up, but lines and tubes went into their respective targets and orifices just fine.
He was sick and I made sure everyone understood that. During timeout, when you can add anything to the checklist that includes standard items like surgical site and blood crossmatch, I said he would go to the intensive care unit with his breathing tube still in place. Even before we put it in, he didn’t meet criteria for having it out. Surgery and blood loss and anesthesia weren’t going to help matters. The surgeons, in their special don’t-breathe-on-the-patient’s-wound blue hoods, shields, and air filtration system, simply nodded.
And to prove how deeply they understood the situation, the surgeons stayed on point, efficient, focused, and did not allow a medical student closure. Hallelujah.
The patient did pretty well during the case, just a tweak of blood pressure support, as I nervous nellied over every little thing. Everything an anesthesiologist normally does, from keeping the patient warm, to monitoring urine output, to tracking blood loss, to measuring gases in arterial blood and exhalations, felt charged with purpose.
In the end, we had to disconnect the endotracheal tube for a moment, while all hands on deck helped slide him to his ICU bed. My resident knew to quickly reconnect, and apply just the right amount of pressure between breaths to keep every little alveoli open – recruited – for the ride to the ICU and their fancy ventilator.
He looked pretty good; I was happy. I glared at the ICU fellow when he started to say let’s pull, and he swallowed the rest of the sentence. I hoped the patient would be able to breathe on his own later, but over the course of hours, not minutes as required in the operating room. The slick anesthesiologist can slide out the tube as the last bandage goes on, but that doesn’t work when the patient is sick-sick.
We had a couple more cases, so it was evening by the time I went to see my feisty patient. There he was, in a slouch sit in his ICU bed, tube out, positive air device strapped firmly to his face. The respiratory therapist was there at his side, carefully observing and adjusting what she could.
My patient’s shoulders hunched up and down with each breath, as he moved whatever muscles he could muster. He didn’t look bad enough that I felt he should have the tube back, but it wasn’t pretty either. He and I made the briefest of eye contact, and he did a quick nod. But I’m not sure he knew who I was, where he was, or anything other than he needed to turn that air into breath. His brow and bushy eyebrows were furrowed with a determined not-nobody’s-gonna-stop-me look. His expression was a dead ringer for Elmer Fudd’s when Bugs Bunny was in his sights – he just needed a big ol’ gun in his hands.
I told the anesthesiologists on call about him so that they could check on him later. I walked out of the hospital, once again grateful to be able to do such a thing.
The truth is, I never saw him again. But, from my electronic chart stalking, I surmised he actually did OK. He not only made it out of the ICU to the regular surgical ward, but he also eventually made it to a skilled nursing facility. At that point, I completely lost track. I don’t know if he made it back to his recliner or not.
It’s one of the hard things about anesthesiology. A window opens, you work like all get out, doing all sorts of things while the breeze blows in, then it’s shut again. Sometimes, you see your patient once more; sometimes, if things go awry, you might see them multiple times. Or your colleagues step in to help out if you are not there. Or the critical care or perioperative anesthesiologist work their magic for awhile. But basically, you welcome the orneriness in, and then, after the bustle and harumphing, you miss it.
This essay was originally published in KevinMD, April 3, 2022.
February 24, 2022
The Other Side
By Angela Lumba-Brown, MD
I went to the Emergency Department
Through the same door
That reflected my face set in determination
At the beginning of each shift.
But this time, I was wearing sandals
And my mom was with me.
Or rather, I was with her.
The glass door mirrored my glassy eyes
And my furrowed brow
Just as it reflected the distraught faces of loved ones
All. Day. Long.
On the Other Side, time moves very slowly
The air is heavy, the room is so small.
The patient – my mother’s breathing
Is loud and fast
And I count it out reflexively.
On the Other Side
The dark knowledge of a physician
Feeds growing unease.
Her doctor is very kind.
She pats my mom’s hand and sits with her - listens to it all
And my heart startles with humanity and hope.
“This person is going to take care of my mom,”
I sigh inwardly with relief and gratitude
For her compassion.
On the Other Side
Compassionate care is not a slogan;
It’s a miracle drug.
Before we left, I told her doctor
It echoed in the memories of medical school libraries
And bleary eye-ed overnights.
“Thank you,” I said.
Reverberations of love, and worry, and hope catching in my throat.
“You’re very welcome,” the doctor said.
But I could tell that she didn’t know
The depths of my thanks
Among the bog of muck and mire
Bubbling up from grief
So delicate that if I said anymore, the words would POP
Here, on the Other Side
Where humanity is reflected in glass.
This essay was originally published in BMJ in 2021.
February 1, 2022
How Pregnancy Unmasked My Internalized Ableism
By Megan Winkelman Creasman, MD
Two general organizational approaches dominate the US preclinical medical school curriculum. The traditional program sequences physiology prior to pathology, while a newer model teaches organ systems in integrated units to highlight the spectrum of functionality, from health to sickness. For example, the dance of an operational adaptive immune system would be taught in the same unit as its missteps, such as rheumatoid arthritis.
As a disciple of the latter system, I often struggled to disentangle the pathology from the physiology, sometimes reviewing material for one subject when I should be focused on the other.
I suspect my personal journey is at the core of this confusion; for most of my adult life, my body has also struggled to disentangle the two. With an autoimmune disease characterized by flare-ups and remissions, my lived transitions between healthy and sick are subtle, and the boundaries between the two often blurred. Self-sabotage is the natural metaphor for autoimmunity, but I prefer to think of my immune system as an over-protective friend who just doesn’t know when to give it a rest.
Regardless of the framing, it’s undeniable that I have never been a completely healthy medical trainee. When faculty attempted to compare a theoretical “sick” person with the “normal” audience before them, I found myself implicitly excluded. These moments gave me pause.
For example, someone joked that though no one in my cohort had experienced the agony of a bone marrow biopsy, soon we would be ordering them from our oncology colleagues left and right. Was I supposed to laugh? Should I volunteer my story, the time that the biopsy needle got stuck in my hip? Should I describe the kind nurse who fed me her own lunch after I collapsed postadrenaline surge, once they’d pried the needle from my marrow? Caught in the memory, I lost the thread for the rest of the lecture. I blinked in surprise when the auditorium lights flickered back on.
And yet, over the course of medical school, I thought I had found a balance between my professional and personal identities. I learned to code switch, sensing when it was appropriate to mine my patient persona and when to hide her beneath a white coat. I connected with other health professional students with chronic illnesses and started a support group. I learned so much from the people I met, and because I wanted others to learn from them too, I helped develop elective courses on disability in medicine and spoke about adaptive technologies and self-advocacy strategies. I joined institutional and national committees on disability representation in the health sciences.
Finally, after much anxiety and deliberation, I disclosed my disability status when I interviewed for internal medicine residency and found a program that welcomed the diversity I added to their community. Together we defined the accommodations I needed to be successful, and for a moment I celebrated how I was navigating my training as an “out” student and a clinician with a disability.
Then I got pregnant.
The experience of being a pregnant resident exposed hidden prejudice I had been holding myself hostage to.
In many ways, being a sick trainee prepared me to be a pregnant trainee. I had practice in altering my environment to fit the needs of my body. When my arthritis had attacked the small joints of my fingers, I gave away everything I owned that required buttons, clasps, or laces and found replacements with elastic and fat zippers. In comparison, adjusting my work wardrobe around an expanding belly was small potatoes. In the prenatal period my U-shaped pregnancy pillow, purchased years ago for hip and knee pain, finally fulfilled its manifest destiny. After a decade spent finding productive pockets between episodes of pain and fatigue, I instinctively adapted to the strange rhythms of pregnancy, like waking up at 3 am to soothe my stomach with an Eggo waffle and finish precharting. I popped sublingual Zofran at my workstation while carefully renewing my patient’s antiemetic orders. I have always tried to use my own experience as a patient to inform patient care, and pregnancy offered plenty of new experiences.
More unexpectedly, being a pregnant trainee made me better at being a sick trainee. While I would delay appointments with my rheumatologist or physical therapist during busy inpatient blocks—sometimes deferring until frantic emails and phone calls poured in from dedicated clinicians—the appointments with my obstetrician were set in stone. I would not compromise the health of my child because I felt sheepish about switching call days or emailing my program coordinators about the schedule. Just a month before conceiving I had developed and ignored a urinary tract infection because I had wanted to be a good intern on a busy rotation, which I thought meant not pausing work to go to the restroom for long stretches. Subsequently, I spent my vacation—the first time seeing my family in more than a year—recovering from pyelonephritis. In pregnancy, I took timed bathroom breaks without a hint of guilt or embarrassment. Where it had been difficult to share my symptoms of pain and fatigue due to my autoimmune disease with coworkers and mentors, I freely—sometimes too freely—complained of the nausea and backaches that cursed my first trimester.
Why did I think of myself as a physician differently being pregnant vs being sick, when the practical accommodations required were so similar? I tried to understand the discrepancy in my response. Surely some component was the consideration that my actions affected more than me. Just as it can be easier to fight for a patient than it is to fight for yourself, it was easier to fight for my baby. But that didn’t feel like the only truth because although my disease is pathology, pregnancy is physiology.
In pregnancy, symptoms are a reaction to a body making a miraculous transformation that it has been programmed to achieve since we were zygotes ourselves. Because I produce antiphospholipid antibodies, my risk of miscarriage is higher than average. Every time I rushed to the bathroom with morning sickness was evidence that the baby was still there, that it hadn’t become a victim of my overzealous immune system. In contrast, when you have chronic pain, the sensation is no longer an important signal your body uses to propel you into action, to avoid a hot stove or protect from an aggressor. With chronic pain and inflammation, the signal is lost in the noise.
When I met with the program director to discuss the structure of my maternity leave, she mentioned that my health experience might have prepared me in a way that others in my position had not been. She explained that in medicine we love control and that parenthood is an exercise in surrendering control. Having lived with disease, she suggested, was an asset in maturely tackling the unpredictable process of becoming a parent. I felt seen in that moment in a way that rarely happens within hospital walls.
As hard as I had worked to exorcise the shame and stigma of having a disease that affects my daily activities, it still lives with me. Internalized ableism was and continues to be a constant companion and one with the potential to compromise my health and my career.
I’m grateful that my experience as a pregnant resident helped expose this companion. By rendering it visible I hope to fight more effectively, reasserting the value my identity adds to the field and that I do deserve to be a physician, pathology and all.
This essay was originally published in JAMA on December 28, 2021.
December 7, 2021
By Korina De Bruyne, MD
1989 San Francisco General
A new deadly virus is ravaging the City by the Bay
The hospital wards fill up with young men,
many barely older than I am,
emaciated, covered in dark spots-
Lungs filled with fluid-
Fear in their eyes.
What do we have to offer them
but to hold their hand as they lay dying?
Drawing blood and starting IVs are the medical students’ jobs.
We stare at the needles and the blood carrying the deadly virus
and pray we will be saved the same fate.
I’ve been tasked to bring the news of an AIDS diagnosis
to a tall young man who used a needle to escape life.
Earlier I had met his wife, toddler and infant child.
I cannot help but grasp the enormity of this conversation.
This is a terminal diagnosis likely destined for the entire family.
No amount of indiscretion could possibly warrant that.
Yet, the media is abuzz about the consequences of “immorality”
Come see for yourself, I want to scream.
Nobody deserves this, not the worst criminals.
But these are not, these are regular people,
being true to themselves in a city that embraces them.
My research colleagues are feverishly working,
a race against the clock to stop the tally
of those who are leaving an emptiness where they once thrived.
A cure is elusive, but little by little we are able to give them hope;
of surviving the next opportunistic infection
and ultimately AIDS itself,
albeit with a daily army of medicines leading the defense.
For most of us, this virus has blended into the background,
only rarely grabbing a headline anymore,
but for many it is still a daily reality they have to live.
January 2020 Stanford Medical Center
News arrives about a severe respiratory virus in China,
in the province of Wuhan.
We marvel at the response- Chinese New Year’s celebrations interrupted,
millions of locals locked into place.
Meanwhile tech workers are being called back
from the epicenter of a new epidemic, soon to be a pandemic,
arriving at our clinic with fear in their eyes.
“This cough I have, could it be COVID?”
We are unprepared, not yet donned in PPE,
tests frustratingly not available.
We reassure them; “it’s likely a winter cold”,
but silently we wonder, did we just get exposed?
Soon enough we do find out our region
had the first case in the country
and now it is spreading through the community
the way the fires do during the summer,
relentlessly and unpredictably,
leaving destruction in it’s path,
disrupting people’s sense of security.
We go into hiding.
Suddenly there are no more patients walking into clinic.
Instead their faces appear on a screen,
and we have them examine themselves.
“If you push there, does it hurt?”
When someone does come in,
I look at them through the fog of mask and face shield,
as if I am living on the moon.
I give lectures sitting in an office,
staring at my slides with no one looking back.
“Am I reaching them?” I wonder.
My own children are at home,
attending college from their bedrooms.
I follow the daily tally- in the world, the country, the state, the county-
of those who again are leaving an emptiness where they once thrived.
In June, when someone close to us succumbs,
the one COVID death in our county that day,
that number seems so much larger than one.
The days prior were filled with volleys of texts and calls,
with ever more desperate news.
This is a cruel disease, taking the unsuspecting
with efficiency and determination,
even depriving them of the company of their loved ones
as they lay dying.
We watch with impotence the callous response above
Masks save lives, why make it a symbol of political affiliation?
My clinical colleagues at the front lines are my heroes.
They are waging war, with few tools, overwhelmed by the shear numbers,
by the shear misery of the daily battles fought valiantly but too often lost.
Again, my researcher colleagues are working feverishly
on preventives and therapeutics.
In record speed they develop vaccines with great efficacy
I count myself among the lucky few to receive it early on,
and as my immune soldiers stand at the ready,
I utter a sigh of relief at this perhaps temporary,
perhaps longer lasting reprieve.
I wish for all the world to feel this too.
Korina Feb 2021
A special thanks to Gail Wright MD for the inspiration
October 7, 2020
Stethoscopes are Listening Devices: On Music and Medicine
By Megan Mahoney, MD, Chief of Staff
Dr. Megan Mahoney made these remarks at the beginning of the September 3, 2020 Stuck@Home Concert celebrating Women in Medicine.
It is an honor to share the wonderful offerings of Medicine and the Muse featuring a roster of our talented colleagues. Medicine and the Muse is the perfect program to affirm our most powerful affinities. Medicine and art are allied agents of inspiration and connection. Healing and creating are inextricable. Doctors are often multi-talented artists. We wear our stethoscopes as tools or badges of authority. But most importantly, stethoscopes are listening devices. Listening to the symphony of life is primary care. Anton Chekov, a classic example of the physician/ writer, said that, quote, “practicing medicine alongside writing significantly broadened the scope of my observations, and enriched me with branches of knowledge whose true value for me as a writer can only be understood by someone who is a doctor.”
Chekov actually ended his thought with the phrase “who is a doctor himself.” Yes, he lived in a world where a doctor was a man. Today, we live in a world that shows progress is always possible, even if obstacles are entrenched and embedded power structures. In this year we honor the centennial of women’s right to vote, and the past months of overdue examination of race, gender, and economic equity, it is a time of structural stress and opportunities to evolve. We have come a long way from the battle for women and minorities to even be admitted to medical schools in the last century and a roster of great accomplishments propels us forth.
September is Women in Medicine month, a time to honor Elizabeth Blackwell, first female doctor, Becca Lee Crumple, first African American female doctor, Susan La Flesche Picotee, first Native American female doctor and Gerty Cori, first woman doctor to receive the Nobel Prize. Maria Montessori became the first woman in Italy to earn a medical degree. It was so unheard of for a woman to go to medical school that she had to get the approval of the pope in order to study there. We have had three female Surgeon Generals and women’s admission to medical schools has gone from 5% to 55% in fifty years.
And yet, the odds still favor privilege and this month launches a campaign called #HerTimeIsNow. This campaign is for gender equity, to address longstanding, well-documented disparities for all women in medicine, and particularly underrepresented women in medicine. While the number of women in the medical field increases every year, the discrepancy in leadership, income and influence is still dramatically disproportioned. I am a beneficiary of the long struggle for participation, especially in the professions and the sciences.
My mother became one of the first black women with a PhD in math and rose to become one of the first black female college presidents. She modeled mindful observation of people and the ways of the world as a thinker and a protector, and most of all – she modeled calm tenacity. It will take more than wearing our stethoscopes to gain full respect and for every achievement we must prepare for new struggles. We are a long way from full equity across gender, race, or economics. In the current health and systemic challenges, this reality has been blown into full view. Now is an exquisite opportunity to enjoy the power of medicine as an art of mending and art as an act of healing.
We are lucky to have many talented women send their songs into the world tonight. Dr. Diana Farid merges science and poetry, music and art. Posing the central health question of the moment, she writes, “What happens when you breathe? Breath—the very air, stardust, the grand molecules of the universe—blossoms in the upside-down tree in your rising chest, animating and enlivening you. And when you breathe out, you send your song out into the world.”
Dr Amy Alexander has chosen a haunting uncanny song for our moment, We Can Never Go Back to Before from the musical Ragtime, we will hear “Back in the days when we spoke in a civilized way.” We ache with recognition. Or, we might find ourselves in the double bind that Kyla Kent will sing about. She is Technical Director of the SAMBA Center researching the muscle bone unit and she is a kickass bluegrass musician. The song “Somewhere Between”, is a musical version of the 7 ½ floor in Being John Malkovich, coping with being dropped in a position hard to fathom, and maybe too easy a metaphor for our collective challenge. Like most good country music, the song hits the hard truth. Gastroenterologist Dr. Alexandra Weingarden will sing about people we can’t tell if we like or can’t stand. Vanilla Ice Cream, is the classic from the musical She Loves Me. And we are lucky that Pediatric Anesthesiologist, Dr. Alyssa Burgart, will sing “Vote them Out” this evening.
Human Biology major Gaby Li has selected the cello masterpiece, “Après un Rêve,” by Gabriel Fauré. Dr. Lynn Gerber Ngai, an accomplished violinist, who completed her anesthesia fellowship at Stanford this year, will play an excerpt from Jean Sibelius’ violin concerto. This famously difficult piece of music speaks to the precision and passion required to be a physician. YES!
Doctors have long excelled in the arts, for their own sustenance, balance, healing and for nurturing others. We work in a soundscape of electronic pings and human sighs of all tones - from agony to relief. We can translate them into the purity of music, to energize, soothe, inspire or rally. One of the many talents a doctor needs is a good ear, being in tune and creating harmony. I look forward to the pleasures we are about to share. And the generosity of our doctors, performers and music in our lives in celebration of Women and Medicine.
September 1, 2020
A Shoeless Hike
By Anthony Fleg, MD
We had escaped to hike, a Mother’s Day celebration.
I was depleted, finishing a 7-day stretch of hospital medicine in the new world order – face masks, globs of hand sanitizer, lonely patients, and some conversations reduced from in-person to tablets.
So depleted, in fact, that I worried if I could muster energy to make Mother’s Day special for my wife.
“Get the kids ready, pack them in the car,” I texted as I left the hospital.
I knew if I could avoid slumping into a chair or onto a bed, I had a chance.
So it went – “Dad’s home” followed a minute later by the car starting our escape into the Sandia Mountains that shadow our city of Albuquerque.
We arrived. The ritual of checklist that comes with having four children began. Water bottles? Check. Sunscreen? Check. Hats? Check. All children present? Check.
All looked to be in order until my personal check. Shoes? Shoes? In my haste to leave, I had left shoes behind.
Leaving me with a quick decision to make. Option 1: Smile and enjoy a shoe-less hike, saving our Mother’s Day adventure from crashing to a halt. Option 2: “Everyone back in the car. Wave to the hike that would have been.”
Option 1 is our world.
Making the best out of the less-than-optimal, far-from-normal options. Option 1 is virtual birthday parties, graduations, and weddings. Option 1 is our decision not to give up, not to give in, but to get creative.
So we hiked. Passerbys trying not to stare too long at my socks. A few made jokes. One family with young children asked “What happened to your shoes?” as they headed up the trail as we made our way back to the car.
“A bear just jumped out of nowhere and snatched them. Said he wanted Nikes.”
The “really??” look on the faces was a small victory for my defeated feet, stinging from the rocks and roots incessantly poking from underneath. My wife, citing social decency and Navajo tradition that says by naming an animal you call them to you, gave me that look, ending my shoe-less victory dance.
My feet survived, the hike was saved, and Mother’s Day happened. Maybe my feet were even strengthened by the uncomfortable experience.
Today will give us such moments, with an Option 1 in each case that does not feel like the right answer, but which is the best option.
Pick Option 1. Be proud. Get excited for what this path might hold. Feel free to laugh - at yourself, at your feet, at the moment - if needed.
Option 1, as a friend reminded is simply this: “Don’t fight the current, find the current and flow with it.”
August 12, 2020
By Sujana Bhattacharyya DO
It was April 5th, 2020. In the months prior, I imagined, she had been grappling with the isolation of her newfound unemployment. The pandemic’s solidarity was possibly a relief: the rare solace of the permission to take a pause. Her new days were partly spent with long walks near Baker Beach, saluted by the loyal, majestic Golden Gate, the cool San Francisco sun embracing her and her spirited two year old son. Nearby, rainbows of tulips dappled grassy fields and perfect sunrays streamed through the California redwoods, a beauty typical of the area.
We had been playing the proverbial phone tag between two coasts. Missed calls took form in hey- how’s-it-going texts, elongated voicemails with humored venting, and exchanged pictures of our everyday happenings. As COVID loomed across the country, our lives and responsibilities were different. I began to fear for my patients’ lives in New York City, for my elderly parents in the Bay Area, and for the consequences of having to halt my fertility treatments. Meanwhile, partly due to necessity and partly to her enjoyment, she cradled the full-time art of motherhood. It was the longest we had gone in our 20 year friendship without directly speaking.
Overnight, sometime between a jovial Saturday evening family Zoom and an anticipated Sunday morning breakfast, her heart stopped. 100% blockage of her proximal left anterior descending artery they said. Medical school had taught me that blockage of this artery was the classic “widow-maker,” and rarely thought to be a “widower-maker.”
So rare in fact, the idea of a cardiac arrest in a 30-something female, was not considered, and even less so in the panic of the pandemic. At first, when she woke up from sleep and strained for air, the paramedics surely thought her symptoms were “just COVID.” She was treated cautiously, with no medical workup, and taken to a hospital with ironically only a few COVID cases. She was secured in an isolated Emergency Department room--no guests permitted--left alone to the sounds of her own slow gasps and uncomfortable bouts of nausea. Her lifeline seemed to be her sister, a physician, who was a phone call and an hour away. She vomited, felt misleadingly better, but as pain crushed her chest and classically radiated to her back and down her left arm, she called her sister back in terror.
Something’s really wrong. I can’t breathe.
Get. Help. Now.
With steel strength and sheer will, she somehow stumbled to the nurses’ station, as nutrients and oxygen stopped flowing to her most vital organs. She collapsed on the cold ED ground, finally, finally, finally getting the attention of medical staff, now credulous. Forty-five to ninety minutes of desperate CPR ensued, I was told.
By this time, New York was swimming in COVID. At my hospital, the sights of people piled in the ED, heaving for air, breaths away from intubation, had become familiar visuals; for survival, as many physicians did, I numbingly focused on the tasks of patient care.
I got the text from her husband during morning rounds: she had a massive heart attack an hour ago. Shocked out of my numbness, I excused myself, pain searing my chest, to call him. Words blurred and news shattered. “They are rushing to put her on something called ECMO.” ECMO?? I screamed silently, equating this life-sustaining machine with ultimate death. “I’m here with you,” I said bravely. Decades of friendship and rainbows of memories flooded my mind, tormented by the prospect of life without her; tormented by her present day image, body fighting on ECMO and breathing by ventilator, a now hauntingly common fate.
Only a miracle could turn this around, we said. Just pray, her sister whispered, brokenly.
In the deliberated weeks that followed, waiting took agency in fervent texts, get-well-soon videos, Zoom chats, GrubHub gift cards, fresh meals, care packages, candlelight yoga. GoFundMe triumphantly raised tens of thousands of dollars overnight. In silence we waited, sometimes eagerly and often helplessly, mulling on every update. She’s had multiple strokes. She may never regain neurological function. She opened her eyes once today. She spiked another fever. She’s getting a tracheostomy. She’s being transferred to a new hospital. No, visitors are still not allowed.
On May 1st, I tested positive for COVID; the suspense of waiting for her prognosis became a definitive intermission. My thoughts forcibly migrated inward, while my body fearfully battled the virus of the pandemic. Body aches rendered into relentless fever, aching to the bones, unshakable chills, and leaden bedbound fatigue. In my quarantine and my illness, I wept for my deceased COVID patients and families, for our ED doctor who tragically died by suicide, for my friend, an indirect casualty of the pandemic. As I lay prone to offset my wheezy, precariously shallow abdominal breaths, I wondered: would my husband get ill? Would my lungs deteriorate? Was I forming ominous clots? Then: could the virus ruin my reproductive organs, still aching to bear a child? Would my insides ever be the same; would she ever be the same?
It was May 27th,. My fever had broken, aches subsided, breathing eased. Two days prior, George Floyd had been killed by asphyxiation and the nation erupted through lockdown in fires of protest. Amidst it all, I felt the desolate silence of her absence.
Then her number appeared on my phone. I accepted the FaceTime, exhaling. There she victoriously sat, an unassuming symbol of mercy. A neck bandage sealed her previous tracheostomy, a tube dangled casually from her nose, a telemonitor with a low battery beeped auspiciously. The strokes had impaired her vision. But life was returned in her brilliant smile and characteristic laugh. On the hospital patio, adorned in a cotton gown, gently hugged by the California sunlight, tulips speckled near her wheelchair, she squinted her tired eyes happily towards the phone, listening carefully to my voice.
It is so good to see you again, we said.
June 3, 2020
Emily Aron MD wrote this epistolary response to a Writing Medicine Workshop prompt: Write a letter of advice to recent graduates.
Dear Incoming Residents,
Congratulations, you are now going to be responsible for the lives of others. You will learn to touch these lives. Physically, yes--but you will also leave an indelible emotional fingerprint. You will learn about the human psyche, defense mechanisms, cognitive distortions, phenomenology. You will hear about suffering and it will all be important and it will fill your office and your stomach like an ever-expanding balloon. You will walk home with your patient’s voices and their problems, cloaked in their invisible suffering.
And you will build a callous in order to show up for another day, otherwise you will wither like a flower on a hot August afternoon. It will feel impossible sometimes. You will feel angry and disengaged. Made cynical by the sociopaths and burnt out by the grunt work, the paperwork, the health system that is broken and the insurance companies demanding your time and energy to wait on hold again, it will feel beyond what you can manage.
But then, one day, you will wake up and walk back to the hospital. The patient will be sitting there, heart beating and eyes blinking. You will feel confident. And you will feel privileged to have a window into humanity, this person’s life unspooling before you.
You are a healer and the world needs you.
May 27, 2020
By Cynthia Nguyen MD
I am wearing my black pencil skirt by some designer that cost more than 6 months’ rent and a couture shirt with an asymmetric collar and a cashmere sweater with mother-of-pearl buttons down the front. I can’t remember the shoes I have on, but they had to have been unbelievably beautiful and handmade, so I know at least I am well-dressed to end my career in literature.
I am on a panel at the Association for Asian Studies conference, the meeting anybody who is anybody in the field attends annually which I have avoided like the plague, being the impostor that I am.
Nine years of burrowing in the carrels of Widener Library, I am giving up my PhD in East Asian Languages and Civilizations. In my defense, I know colleagues at Harvard who are in their 14th and 17th year of their candidacy, but in their defense, they aren’t quitting.
To parse a 4-line poem in Classical Chinese, which is a dead language none of the billion people in China can read today, I’d have to consult a half-dozen dictionaries, looking up each word not by a simple 26-letter alphabet, but by the 217 radicals that make up the zillions of Chinese characters. This task takes me a day or so. So now the nine years is beginning to make sense.
To do my isolative work which I am perfectly ill-equipped to do by my outgoing nature, I have to step into a 12 by 12 heavy gauge steel mesh cage set in the middle of the basement of Yenching Library where all the Vietnamese books are locked. Vietnamese is a neglected stepchild of the department. The Chinese, Japanese, and Korean volumes are not locked in a cage. To challenge me more, the dusty Vietnamese books are not lined up by author or title, but by size.
I am tired of being reminded every day that I am illiterate or as the Vietnamese say mù chữ (mù meaning “blind” and chữ meaning “word”) in Mandarin, Classical Chinese, Japanese, French, and most of all, in Vietnamese.
My practical mother says, “You’re three-quarters of the way done with your dissertation, why not just finish it?” But I can’t.
There is sheer fear of having to face my father’s disappointment that I will not become a scholar contributing to the field. He is a prolific linguist who is considered the dean of Vietnamese language and literature. Every literate Vietnamese knows my father because he writes Vietnamese-English and English-Vietnamese dictionaries. He is the Webster for us.
So before leaving the field in defeat, I decide that giving a talk at the AAS would be a fitting face-saving move. I apply and am accepted to a panel.
I look out at the standing-room-only audience at the Boston Marriott. I recognize some of the faces. Most are strangers looking very much like they belong in the field and are ready to pounce on me.
I am the last speaker. The distinguished chair of the panel who is impeccably dressed in a seersucker suit and his trademark bowtie gets up to introduce me and my stomach drops with intense anxiety. I hear him dropping this tidbit, “By the way, she happens to be daughter number 2.”
Now that he acknowledges in public that he’s my father, I feel more pressure that my performance has to not be terrible.
I give my talk and move to sit down, but hands in the audience shoot up, wanting to reveal what a non-contributing-to-the-field scholar I am.
After I stumble through the Q & A, I shakily (in those awesome heels) sit back down next to my father who whispers "được" which in Vietnamese is like the French passable or you could translate this in English as “not bad” which is high praise coming from him.
My father owns student visa number one from Indochina to America in 1948 but (or because of this) is an uber-traditional Confucian Vietnamese father who only 2 other distinct times ever does anything obviously supportive of me à la Western modern parenting methodology.
Once as a teenager in a small college town, I plaintively asked him why did he have us here in America when we had to be so Vietnamese? And why didn’t he ever praise us to our faces? He was dismissive and impatient, “You are so ignorant, why, don’t you know the most basic things? Vietnamese parents never praise their children to their faces. That’s an American habit.”
This is the story of my switch to medicine from literature, never having the approval of this father who was an actual celebrity scholar who said medicine was mere “carpentry.” This is the story of how I told him to come to my renowned school and hospital for his cardiac by-pass surgery because he’d be in the best hands. This is the story of how my father who expected to be back at his desk in a week to finish an article he was working on, died at the hands of those I trusted to care for him. This is a story of how I am still breathing after my father went from 47 breaths per minute (incompatible with life) to zero.
May 20, 2020
By Francesca Monn MD
Planted gingerly as lockdown went into place in a jaggedly cracked, ceramic planter. No leaves. Short, scraggled, dry roots. More twig than future tree. Rooted now in a strange apartment with a wall of a window and two feline predators. Slowly developing into this new world. Sprouts appear but remain minuscule. The gnarled, solid branches remain steady.
But suddenly the buds flourish. After four weeks of tender care, soft singing voice, curious purring, eyes peering, water nourishing. And they unfurl gloriously. With palmate-lobed, fuzzy leaves brilliantly colored as if to camouflage Amazonian frogs yet shaped as an emerald hand ready to grasp. Each day expanding and multiplying, forever gazing to the window where the sun adoringly falls upon them, beseeching them to continue evolving into their fullest selves.
A fig tree it is rapidly becoming.
May 13, 2020
The End of Twenty Nineteen
By Chwen-Yuen Angie Chen MD
Bob Dylan said:
I watched His head,
In a Murder Most Foul
In the telly that moment
as Camelot faded
We stepped through the looking glass;
this funneling wormhole
emerging, half-century passed,
when the world stood still
and we all fell down
the children all grown,
Trapped on the other side said— “good bye, good bye, I love you good bye...” through the window
there’s nowhere to hide.
May 6, 2020
By Khushboo Sheth, MD
I am a rheumatologist. I am NOT on the front lines of the pandemic, yet, but I AM scared.
I am scared for myself. I am scared when my husband and I discuss our advanced directives as he awaits a ‘deployment’ to the Intensive Care Unit. I am scared for my family, my friends, my colleagues and my patients. I am scared for the new normal.
I cope. I cope by maintaining a level of normalcy by conducting tele health visits. I cope by attending virtual yoga classes, making fresh pizza, doing silly dances with my nephew and listening to music. I am fortunate to be able to cope with all the above.
I break. I break when I learn my patient’s wife passed away from COVID-19 after visiting Disneyland. I break when I hear about my friends and family members working on the front lines without adequate personal protective equipment. I break because patient’s family members are not able to say goodbye to their loved ones. I break because there is a story in each death which has instead become a statistic.
I try. I try to examine for synovitis on a video visit. I try to calm my friends down when they call in the middle of the night, concerned they have contracted COVID-19. I try to stay optimistic.
I rage. I rage when my lupus patients cannot get hydroxychloroquine. I rage when people do not follow social distancing guidelines. Sometimes, I rage without a reason.
I grieve. I grieve each time I hear the news. I grieve at the loss of the warmth of a hug.
I am thankful. I am thankful for everyone who puts their life at risk to save us. There are way too many people to be thankful for. I am thankful for the altruism and love that surround me.
I cry. I cry because the enormity of the situation is too difficult to absorb. I cry at the surge of cases around the world and the surge of emotions inside me.
I contemplate. I contemplate about life, death, the uncertainties and the future. I contemplate about the collective experience we are all going through, courtesy of an invisible virus.
I contemplate about my identity as a rheumatologist and my role as a physician during a pandemic. My conscience pulls me to be on the front lines and help my colleagues. Dr Louis Lasagna mentioned in the modern Hippocratic oath, ‘I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug’.1 I do my part by being there for my patients and by commiserating; I heal myself in the process.
I hope. I hope that once on the other side of the pandemic, undoubtedly damaged and scarred, to be more appreciative, humble, grateful and thankful.
I adapt. I persevere. I trudge onward.
Originally published in the Annals of Rheumatic Diseases.
April 29, 2020
Seeing past today, futurizing tomorrow
By Henry Curtis, MD
We will look back at our role in history and know that we did everything we could. We valued each other and ourselves. We prepared. We donned PPE. We rushed to the side of the critically ill. We telehealthed to the stable. We worked as a team. We attended to the needs and wishes of our patients and when they could not express them, their family members. We basked in their stories and saw them as more than just COVID positive or COVID negative room numbers.
We will remember our feelings. We felt the frustration of practicing shifting, evidence-based medicine in an evidence poor environment. We felt the loneliness of doffing our work clothes when arriving home. We felt the incertitude when sharing stories with our loved ones, wondering if they really got it. We felt the tragedy of those who fell ill. We felt traumatized by those who died. Despite daily uncertainty and intense emotion to attend to, we still got out of bed and returned to the front lines.
We will gaze upon this reshaped, post-pandemic landscape. We will doctor the wounded. We will restock our resources. We will treasure the good and fight the bad, as is right. We will place our humanity out front and work towards a new vision of ourselves.
April 22, 2020
Dr. Anu Gorukanti’s wrote this epistolary response to a Writing Medicine Workshop prompt: Write yourself a letter two weeks into the future
I wish for you, two weeks for now, to be filled with the same gratitude, drive, and desperation that fills your heart now, taking up space in all of your cells. I hope you remember how it feels to know that one person can make a difference, no matter how small. That all the phone calls, emails, pleading tones to make changes in your residency program mattered.
Our world feels so immense and us, just a tiny piece. I shudder to feel both the magnitude and the minutia.
Every day, may you continue to feel this way: deeply grateful for those in your life who are safe, devastated by those who are suffering, angry for those who are not willing to hold others as highly as themselves.
I hope that anger shifts into kindness but that your drive and passion remain intact: a preserved space in the middle of the chest unaffected by the turbulent storm around it.
You matter, no matter what you do or do not do.
You are loved, no matter what you do or not do.
And you will look back at this time knowing that you were who you wanted to be in the midst of the crisis. And you are doing what you are meant to do.
Continue to be kind to your parents as they learn to let go of the life they had envisioned for you and as they struggle with loneliness that they can’t define for themselves.
Continue to reach out to your friends and family to check in, as you’ve always done, outside of this pandemic.
Fill yourself to the brim with kindness and self-appreciation so that the love you feel for yourself can overflow to others.
April 15, 2020
We Are All Immigrants Now
By Erick Messias MD
We are all immigrants now
No matter our color, no matter our creed
We are all immigrants
Bodies thrown in a new land with old memories
Welcome to the new country
Here the streets look different
Here the words have new inflections
Here the people greet each other differently
You will miss the old country
For that's how it will be known from now on
You will miss how people were
You will miss its parties and its gatherings
You will find yourself saying "in the old country..."
You will also make new friends in the new country
They will look different, keep their distance
They will greet each other with funny gestures
In the new country
There are no old country roads leading back anywhere
Nothing but old memories from the old country
Those may survive in your selfies, phones, stories and songs
We are all immigrants now
Learning together a foreign tongue in an alien geography
New choreographies to work and to love
Until one day the new country is just our place
Where we work together
To love one another
April 8, 2020
Returning to the front lines of COVID-19 in NYC:
My First Day Back at the Hospital
By Nasir Malim
Tonight will be my first night shift in the Medical ICU (MICU) since COVID-19 began ravaging New York City. I was on the hospital floors as an internal medicine resident during the early period of the COVID-19 pandemic reaching New York City, before it became this ubiquitous.
At that time it became obvious how rampant the virus would become, but there was still a sense that with adequate preparation perhaps we could mitigate much of the loss. That hope, perhaps naïve, is now a fleeting remnant of a former life. Since then my clinic block was cancelled and I was placed on sick call to fill in for others. I felt uneasy in the days leading up to my return to the MICU, and the hours before, were filled with angst.
6 hours to go before my shift:
I try to nap so I don’t tire out of sleep deprivation overnight but feel too anxious and just lie in bed for an hour. How do people sleep at a time like this?
3 hours left before going in:
It’s hard for me to do anything productive. I convince myself to do a quick home workout before taking a shower. I then do something I’ve been dreading for days. I shave my beard. My beard has existed in one form or another for over a decade. It’s hard to recognize the face now staring back at me in the mirror, without the beard that provided a centering element for me both religiously and physically.
2 hours left:
Dinner time before the 12 hour shift. Cooking is now one of the few things I can control.
1 hour left:
The depth of emotions really starts to settle in. I don't want to move, I can’t bring myself to get off the couch, and I certainly don't want to go in to the hospital and fight what feels like a losing battle with death. This feeling is terrible, this risk I’m about to place upon myself feels surreal. Every single bed in the MICU is filled with COVID-19 positive patients struggling for their lives. I know the limitations we have with adequate protective equipment because of severe shortages, and I know the current policy of reusing masks and gowns just makes it that much easier to spread viral particles to my body, my hands, and to my face. What if one of those particles reaches my lungs? It is not outlandish to envision myself in an ICU bed as a result.
30 minutes left before the shift:
I hug my wife extra tight for what must have been a minute but felt like mere seconds, for what feels like one final time. I wonder how risky it will be to hug her after tonight. I change my clothes at the door into a pair of hospital green scrubs, carefully placing one arm and leg into the scrubs at a time, avoiding touching anything else. This will be my new routine leaving, and upon returning, diligence to an extreme of scrubbing down every surface of my body and personal belongings, removing all clothes and objects which touched the ICU air, and scrubbing every inch of my body down right after in the shower before I can truly consider myself home.
Time to go:
My heart is pounding and it is difficult to take a full breath in and out. I can’t describe the sensation in my chest, it’s something I haven’t ever experienced before. I know I'm scared, but is this also anxiety? Everything is so hard to do, my body feels heavy and it takes my focused efforts to walk to the doorway. Putting on my shoes is now a challenge as I fumble to get my feet in. I put on my hospital badge around my neck, which now feels like an out of place metal weighing me down. I enter the elevator in my building to leave, it’s just me and my racing heart. There is not a sound except my quick shallow breaths. I cross the street to the hospital and enter what now feels like a foreign space. I’ve spent what has felt like years here, why am I now afraid to walk its white halls without running back outside?
I hurry to a different part of the hospital where an N95 mask was set aside for me, putting it on for the first time, now beardless and wondering if the fit is appropriate. “This better work,” I think to myself. I get to the MICU where my co-intern is ready to sign out the current patients so I can take over for the night.
"This is a 54 year old patient, no past medical history, COVID-19 positive with acute respiratory distress syndrome.
Next is a 38 year old, no past medical history, COVID-19 positive with acute respiratory distress syndrome…
29 year old, no past medical history, COVID-19 positive here with acute respiratory distress syndrome…
73 year old, history of hypertension, COVID-19 positive here with acute respiratory distress syndrome.”
The only thing that breaks this monotony is the rapid response called overhead for another part of the hospital, within just a few short minutes of my shift beginning. Someone, mostly likely a COVID-19 positive patient, given the reality of the current hospitals in New York City, is in the process of dying or is already dead, and a team of doctors and a respiratory therapist is rushing to attempt to save them. It may just be a matter of time before this happens to one of the patients in front of me. I finish my sign out, as I watch the rise and fall of my N95 with each breath.
I make a quick round to visualize the patients from behind the glass wall enclosing them in solitude and glancing at the number outputs from the various machines connected to them. The entire unit is sedated on medication for comfort, nearly all of them have a breathing tube in. I rejoin my senior resident who has fielded phone call after phone call from worried families requesting information about their loved ones, answering every question with a soft and comforting voice that provides me some relief. I cannot imagine the fear they experience knowing someone dear to them is on the brink of death secluded from the rest of the world. As I monitor my patients and do my tasks, each minute feels drawn out but somehow two hours have passed, with the quickness of my breathing also now normalizing.
There is a young patient who is on a breathing machine though his body is still struggling to get enough oxygen despite this. We are nearing the end of medical options that can help him improve. We decide to turn him from his back onto his stomach to help his lungs get more oxygen, but before doing so I try some osteopathic manipulative therapy a doctor friend showed me from a clinical trial. There are no more medicines to try, so I decide to try whatever I can offer with my hands.
I go in first to try the therapy, with the rest of the team watching from outside the room. I try to be as careful as possible to make sure my gown and gloves cover my entire skin as I approach his bed. Time feels as if it has halted, and my body is now in slow motion. My desire to preserve life as a doctor is somehow overcoming my fear, as I maneuver myself and begin the manipulations. I see the beads of sweat running down his face, almost as though each bead is timing the duration of my therapy. By the time one flows from his forehead and reaches his chin, I should move on to the next. I do as much as I can with the position he is in, and other doctors and nursing staff join me to help flip him over safely. As we finish I notice the TV on in the corner, tuned to CNN. Anderson Cooper is talking about how today was the deadliest day from COVID-19 in the country to date with over 500 deaths. I return my gaze back at the 29-year-old in front of me, he is my exact age.
I cannot recall the total number of rapid response codes called overhead that night, there were too many to count.
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