The Realization

The second year of medical school resembles drown proofing. Drown proofing involves taking someone beyond their fears into the realization of drowning. The 'training' involves many methodologies, but ultimately it involves a 'swimmer' (combat swimmer or rescue swimmer) inhaling water while being forced to perform a series of maneuvers such as treading water with your hands in air or correcting scuba gear while being harrassed. Anybody who as had the pleasure of experiencing drown proofing or has come close to drowning for any number of reasons can tell you that the experience is pretty much a full-up conversion with God. Those who survive such experiences have a will, a desire, a drive to go beyond their fears in the name of something more important than their fears. But, along the way, the individual learns many valuable lessons, to name a few:



1) Life is precious and can be taken away very easily. Therefore, respect life at the highest of all levels.

2) Fear will always be there, but it can be overcome.

3) Believe in yourself.

4) Swim. Sinking is not an option compatible with life.



Although the second year of medical school is riddled with time on the books, my thoughts often drift heavily in the direction of one overriding realization: All this stuff I am learning is not just to be learned; it is to be applied, where mistakes can have ultimate consequences.



I work in the ER/ED from time to time with a physician, a mentor. He will hand me a chart and off I go into the unknown, into the world of patient's complaints, worries, pains, illnesses, and that damn dark shadow breathing down the backs of some patients. Death has a certain way in the Emergency Room. Sometimes, it strikes with such gestalt to the point that there is no arguing with death. But, other times, he rears his ugly head when we are not ready, and in those moments the continuation of life relies heavily on the action of the team, i.e. of those who can. In such times, all that stuff one learns in textbooks, in training, in practice becomes a sobering reality. In the blink of an eye, life can come to a screeching halt, while those who can try their best with focus, hope, and a silent prayer in the middle of a battle.

Thankful for CPs

With every career field, lifestyle, hobby, etc, there exist acronyms, and medicine is no exception. Moreover, every physician, nurse, therapist, or technician at one point or another walks the ever so thin line of the patient versus the illness. The vision of treating the patient becomes fogged by the solving the problem, and so the problem becomes larger than the life before them. "Mr. Smith" is replaced by "Chest pain" in Room 2. It happens. No matter how much you, as a physician, care it will happen at one point or another.

A day and half before Thanksgiving I worked the night shift in the Emergency Dept (ED), a welcomed change of pace from the full up firehose of information being slammed down my throat everyday in lecture. The shift was filled with Chest Pains, moreover, "CPs" as the appeared on the chart. Literally, every single one of my patients had a Chief Complaint of chest pain. Most of the cases were complexed by communication issues such as advanced dementia and short term amnesia. The laundry list of medications and perplexing past medical histories left me scratching my brain on more than a few occasions (ended up with a hole through my calvaria, aka skull). I felt the pull of psychosocial issues from each patient; each patient desperately in need of a loved one and/or friend and perhaps even a restart on life. In ED psychosocial issues can be the most frustrating; it boils to time and priority or lack thereof. Unless the patient is suicidal or homicidal, they are not going to die or become acutely ill. You only have time for a few words, a recommendation, and a referral. This is the sad truth for most occasions.

As I left the ED that night at 2 in the morning, I drove through quiet DC streets with my brain cranked up on one question: why so many CPs? It took me a few minutes and then it hit me. The sad truth sobered me. A while back, I learned about a phenomena, where the number of heart attack / chest pain cases jumped up over the holidays. Many of the cases were genuine heart attacks perhaps precipated by the heightened stress of the holiday season, diet, etc. On a side note, I have always found it quite ironic that the 'holiday' season is such a stressful time. When I started thinking back to every single CP case, of which none were heart attacks, a certain condition seemed to haunt almost every single patient: loneliness. These patients were alone, and nothing reminds an individual more that he or she is alone than perhaps a holiday of togetherness such as Thanksgiving. My realization left me with a chill and more importantly a reason to be thankful for my family and friends.

The Guilt In My Education

I love to run, because it is my time to meditate…just me, the path, a slight breeze, and the faint background noise of my lungs keeping pace with my feet. During a recent run, I had a thought that I haven’t been able to shake, but what is more is that perhaps I should try to shake it and instead just embrace it. I have come to the interesting paradox: my education, my training in the explicit field of healing and doing no harm comes at the price of causing some pain and absorbing emotional distress. In other words, the sad truth of becoming a physician or surgeon comes at the hand of making mistakes, eliciting pain, learning the boundaries of a salvageable situation, and most importantly learning how to put myself in my patient’s position. The patients I come in contact with are already in a great deal of discomfort and pain, and to think I could add to their dilemma kind of scares me a little. I’m okay with the fear. Such a fear is completely natural and expected. I have learned to take my fears in stride and not let them stop me, although I still find it easier to address and overcome fears where the end item only affects me and not others. But then again, I think life should be lived altruistically, at least most of the time. When at all possible, life should be paid forward. This is the philosophy I choose to undertake. Pay everything forward. Do your best for others and only hope they can do the same for someone else. Holding true to this philosophy, I find dealing with the aforementioned paradox and fear to be a little more manageable. But, what about all the stupid people in this world? What about them? Charity. Just realize we are all doing the best we can. Protect those of us who are vulnerable and stricken, then remember, “We are all doing the best we can do.”

On a side note, during the same run, this thought was premised by wonderful realization that I was in medical school and working towards something I full-heartedly believe in. It all still feels like a dream that I am going to wake up from. The truth is I hope I never wake up.

Does Everyone Deserve A Second Chance?

If necessary with no other resolution possible, I could and would pull a trigger. I believe in punishments worse than death. The case found below strikes to the very heart of the matter. Justice for the acts committed by or under the command of the dictator, Manuel Noriega, who claims to be a military general, will not be served until the man has breathed his last breath from behind bars. Soon he will be released from a U.S. federal prison. I have dreaded the day for quite some time, although it is very likely he will be killed by a hitman upon his release onto the streets. Luckily the french government to my astounishment has stepped up to the place and has moved to trial him in french courts for criminal acts committed on french soil. He is a sick, twisted poor excuse of a human being, who does not deserve another chance. I pray he never sees the light of day again.

http://www.cnn.com/2007/US/law/07/26/noriega.parole.ap/index.html#cnnSTCText

Here I Sit

So here I sit. After almost a full year of studying, I have nothing pressing. Right now, my life should be all about fun and relaxing, and I sit here paralyzed. Perhaps this is Murphy's last stand, an effort to thort a chance to breathe and reflect upon the year. When you take a race car to 100 mph and then slam on the breaks, it doesn't just stop. The laws of physic smile down upon you, and the car pushes forward otherwise. Apparently, God intend the law of inertia to perhaps be more broad and resilient than Sir Isaac Newton intended, as my poor brain has a certain affinity for such a law as well.

Youth In The Eyes Of The Dying

Nothing in this life is guaranteed except that we will die. We think we have control, but we really do not for the most part. Our thoughts and perspective we steer but beyond that all else can be striped out of our hands. A youthful, inquisitive, joyful mind slays the demon of this gauntlet. This is the lesson I learned this week. From meeting the real Doc Hollywood, to spending thought provoking conversation with a beautiful woman out to change the world for the better, to the drunk forcing his way into a family’s conversation at a birthday meal, this week I learned the importance of being young at heart.

My friend managed to arrange for Dr. Neil Shulman, professor, medical doctor, author of Doc Hollywood, but more importantly advocate of the being young at heart, to come talk about humor and medicine. I jumped at the occasion…sat front and center and even got up and told a joke myself. His messages were quite simple: 1) Stay young at heart, 2) Mend your passion(s) with medicine when possible, 3) Do not lose your sense of humor, and finally 4) Do not take yourself so seriously. With humor, circumstances become manageable. With being young at heart, life doesn’t shine it sparkles.

Today was a day of polar opposites and as such the message amplified all the more. For a late lunch, I met a very wonderful, beautiful person. She reminded me of the importance of maintaining an inquisitive, child-like perspective of the world we traverse. The good in her radiates in such a way to be contagious in the most epidemic of ways.
Her eyes kindle a fire of hope and prosperity for all. A purpose determined by opening one’s heart and allowing life to take you up. I left this late lunch and conversation with an uplifted feeling. At the moment it still carries me despite the ‘fun’ to follow. For dinner, I met up with a good friend and her parents for her birthday. During the course of an awesome dinner, a rather out-spoken man and his date sat next to us. He quite rudely injected himself into our conversations time after time. At one point he reminded that the NSA (National Security Agency) has ears everywhere. I wanted to tell him, “No shit, perhaps I should drive up the street and knock on their door and ask them,” but I remained in reserve. As if his interruptions weren’t enough, he later went on to insult the truck I drive, my intelligence, my character, etcetera…all except insulting my truck seem to be a going theme in my life right now. I wish I could say I provoked the guy, but I didn’t say a damn thing to him. I guess the child in him was crying out for help as he poured the alcohol down to silence the screams. I pitied the man, and I hope he finds his way back to his childhood.

The Red Line To Our Salvation

After an interesting and very, very early day in the Emergency Department, I made my way back home. As I waited for the bus to get to the Metro, a couple approached me, which bus to take for the Red line. They were in luck as I was heading to the Red line. Their little girl sat there beside her mother, cute as button and very inquisitive. Today, she would see the circus, lions, tigers, and bears, oh my! She confronted me on my PJs, and rightfully so, scrubs must look quite funny if you are not used to seeing people wear them. Her mom repeatedily told her that I was working, but she knew better...how could it be work? My day was coursed with fun stuff and good people helping me along the way. Caring for people always makes me feel good, and generally I enjoy myself in doing so. Although, missing an IV stick due to a history of drug use is not fun. I guess a body covered in track lines spelled out a little bit of a hint of my impending failure...maybe not so fun.

I savior my time traveling on the buses and the Metrorail. I see it as a time to reflect on the day and to interact with a wide variety of people. Today was extra special. As I sat at the Dupont Circle D6 stop, I watched people and the occasion happy dog walking his/her owner. Time kept on spinning by. I started to grew a little curious as to where the bus was, but I didn't pay it much attention as I sat there completely content, just happy to be. Out of what seemed nowhere, a gentleman younger than myself, seemingly recently from Mexico, approached me. In broken English but with much resolve, he asked what bus I was waiting for. I told him the D6 bus. Excitedly, he said I need to get to Mass. Ave as the D6 bus ran out of a completely different stop despite bus stop sign. After a couple rounds of "Are you sure," it sunk into my thick skull. The guy must have thought I was crazy. I thanked him and took off toward the bus stop labeled for a completely different bus. A minute or two later when the D6 bus arrived at the 'wrong stop', the man's words rang true. Plus, he saved me from a rather long stay at the original bus stop and from eventual long-winded cursing of the D.C. transportation system.

Wonderful to think, salvation links us. A myriad of individual events throughout the lives of many crisply flows as one interdependent course of action. We need each other. It is just that simple...we need each other.

Ravage

We live in a ravaged world. Our songs echo pain as much as they do joy. Why is this? Why is it we allow ourselves the misfortune of drowning in a sea of troubles? Why not oppose them? Here we sit on this rock. Depending on perspective, we are the most advanced, most adapted creatures on the face of the Earth. We have surpassed the gauntlets of most terrestrial environments and furthermore look to the stars as our next great adventure. Some might say space is it, but think for a moment. How could we be so bold, so arrogant to believe it ends at space? No my friends, space is not it. Space is just another chapter, another wonderful, daunting chapter from the sea of our birth. The adventure resides not just in where we are and where we are going but more completely also inside, i.e. in the nuts and bolts of who we are and who we want to become. I believe many of us have forgotten this aspect of the adventure. We are more concerned of greed. Now, although I can take this commentary to places that I would rather, I will not. In lieu of my favorite topics, this time it is health care policy. Before you run away from this commentary, read the next few sentences, and then do as you wish.

In our country, roughly sixteen percent of society has no insurance; moreover, every one in ten children does not have insurance. In an elementary school class of thirty children, as they exist in every state, country, city in this country, three children oppose a great wall, a lack of health care as you and I know it or should know it. We have let them down. We have always let them down. So I ask of you, the reader, as I ask of myself, let us find the solution. Leave it not to politicians, for such vehicles care more of themselves than those they serve, although I will admit exceptions here and there. I shall present two views as headings, then I will very briefly tell you why I believe one has extreme ethical issues at its core and why the other, although ideal, has it downfalls. Our goal should be universal coverage. Simple, right?

An economist’s approach to solving the aforementioned health care problem: Take the government complete out of the financing, let them regulate, but leave them out of paying for it. In this view, insurance companies are the vehicle of payment and coverage. They would compete with each other over plans and payment systems, coverage systems could be completely different from each other. All Americans would be covered by law. My question for the economist: Is health care a basic human right or is it a privilege? You may ask yourself, “How does the writer’s question have anything to do with this approach to solving the problem?” Simple: justify an ethical standpoint allowing for insurance companies to make a buck off of caring for someone. Still not clear? On average the overhead of Medicare (funded primarily by tax dollars) sits at about three percent; however on average the overhead or ‘administrative’ costs of an insurance company can be around twenty percent. In the case of the private sector what constitutes ‘administrative’ costs? Let’s say they that private insurance companies for some reason or another are less efficient than the government at covering their true administrative cost. I’ll give them five percent of their budget. What is left of the pie? Fifteen percent is profit, money in their pocket. Money spent by you and it to make sure we have health insurance that goes right into their pocket. I wonder if we could at least cover the children who live everyday without healthcare insurance with the money insurance companies place in their pocket. It is all about greed; never mind denying healthcare to our future.

The utopian solution to our health care problem: We all (i.e. those who can afford to pay) contribute funds to the government. Everyone is covered, no matter their employment status, their health state, their ability to pay. Is it possible? Ask the U.K. Oh and by the way, their per capita spending on health care is about 1/6 of our spending on health care. Do they have the best health care system in the world? No, apparently Canada owns that title, according to the W.H.O. Don’t ask where the U.S. resides on that list. The U.K. takes hits for queues (lines for care or elective surgeries) and lacking the latest and greatest technology, but then again, remember right now we spend six times what the U.K. spends on healthcare…surely we could ensure shorter lines and the latest and greatest technology with such spending. My challenge for you the read is: can you deal with paying the health care bill of others? Oh and by the way, we already pretty much do. I’ll leave this perspective with two reasons why and one food-for-thought. Reason 1: About half of the bankruptcy cases in this court are attributed to paying for healthcare. People still need to get paid. Guess who foots the bill in these cases…the government, but more importantly you and me. Reason 2: Medicare and Medicaid are primarily government funded entities. Food-for-thought: About half of the uninsured people in this country have jobs.

Please feel free to challenge my views or statements. In the end it is all about learning and getting it right. A bruised ego heals.

Cheers.

The Red Line To Our Personal Hell

I spent last night working at Washington Hospital on the northeast side of the city. In doing so, my travels took me aboard the red line Metrorail. I have found my time on the Metro to be an opportunity to reflect on the day. Grant it on the way back from the hospital this morning my time was mostly spent just trying to stay awake...I stood and watched the buildings in the crisp morning's sun. Irony of Washington Monument being in the same field of view of run-down housing can really put a spin on your day if you let it.So last night I worked in the Emergency Room (ER) or Department (ED) (pick your poison). Now that the shift is over I can say this, it was a surprisingly, relatively quiet shift. I worked with a really cool attending physician. The guy sincerely cares, which tends to be the theme around here, mind you. He and his staff worked hard to teach me, which was great in itself. He allowed me to do as much as I want to do, so I was prepping patients in no time flat. Fortunately, I will be working with him throughout the rest of the semester. Last night, I saw a lot of different diseases. What sticks with me through all the minutia is mostly the images of scared patients. Fear rests on our shoulders and grabs at our throat, perhaps one of our most important signs of humanity. I feel as long as I can identify with the fear associated with each patient, whether he/she be conscious or unconscious, dead or alive, sick or healthy, I will be guided. Things become complicated when drug addicts faking pain looking for a score, child/spouse/elderly abusers, individuals trying to get out of work, or looking for a reason to sue, etcetera enter the mix. Patients can have 10 of 10 pain no matter how bad it really is, which is frustrating but also very enlightening. Patients can be extremely scared despite what their disposition 'looks' to be, and fear can drive a person to do many things they normally wouldn't do. The patient with the perirectal abscess in Room 10 may be a jerk to everyone. He may be homeless. However, he needs help, so you jock up, try your best to overlook the fact that he is practically screaming at you, because he has had to tell the same story 4 times in the last 4 hours. By the way, waiting times of four, five, six, seven (you get my point) hours are the norm for non-immediate life-threats in major city hospital ERs. The truth of the matter is that he has probably lived with a bleeding abscess for quite some time, but last night was pretty damn cold. So you tell me, if you were in his shoes, which would be an extremely difficult image to picture, then what would you do...cold night out with a slow bleed in the area where sun doesn't shine or a warm Emergency Department with a bunch of questions thrown at you after a 4-hour wait followed by some medical student sticking you, swallowing some barium filled cranberry-like juice, and then being taken off for an image study and a likely surgery to fix a persistent abscess...oh yeah did I mention receiving a few meals. So, the Emergency Room is a place of battles. Some battles are fought and either won or lost in minutes, while other battles are almost purely ethical. The fact remains: people need help.

I Just Want To Be A Doctor.

I Just Want To Be A Doctor.

When standing face to face with a demon many thoughts may surface once you get over the whole shock and awe factor. I found my Achilles heel thus far on my journey through the world of medicine. Apparently, biochemistry takes the helm of this demon’s ship. Undoubtedly, another beast will replace this sinister creature, but for the time being biochemistry will do. After just barely passing the first exam as did most of the class, I stood there face to face with this vile gatekeeper. In all its wicked breath, it haunted me through the winter break, through January, and into February. Over a slow course consuming the last two weeks, the beast lies still, slain at its throat. Unfortunately, this story does not hold true for many of my fellows. The beast won many times over, a sad fact of the matter. I’m left with distasteful thought. At times when I can reason no rationale behind some of the necessary conquests on the horizon of a medical student or resident, a few thoughts come to mind. Most presiding of which remains to be: “I just want to be a doctor.”

I just want to be a doctor. At three A.M. with my notes and flash cards spread out all over my desk and highlighters gone wild, I just want to be a doctor. Spending an entire day in the same lecture hall listening to lecturer after lecturer speed through their bit, I just want to be a doctor. With my arms shoulder deep in somebody’s bowels, I just want to be a doctor. At eight in the morning running off of 5 hours or less of sleep for the sixth day in a row, I just want to be a doctor. As I slowly accrue more debt than I care to admit, I just want to be a doctor. While I put my life in a holding patter at 10,000 feet, I just want to be a doctor. Watching my friends, at times, struggle right along side of me, I just want to be a doctor. Damn it you wretched demon, don’t you get it…it’s going to tell a hell of a lot more to get me to even budge.

I’ll leave this commentary with one final thought. Why is it that we allow some of America’s brightest and finest students to walk such a gauntlet? These souls live so that they may make the lives of others at least just a little better, so why is that we try to bury them along the way? I just want to be a doctor.