Year in Review: My Bad News

8/20/2013 As much as being a resident sucks with the shitty schedule, nothing drains the happiness out of my bacon-flavored soul like delivering bad news. Yeah, I get upset when I have to miss out on seeing friends, going out, or what have you, but I'm over it quickly. With this, it's like you have to recover from it. I'm not sure if there is another job-related activity out there that even comes close. Not only do you have to deal with whatever reaction the patient or their families go through, but you have to deal with yourself. If we were robots, then it would be a piece of cake, but we're not. Our own emotional and psychological fortitude, if I may, is just as important in survive this conversations. There's two conversations that come to mind that relate to this. The first was a gentleman who presented with lower abdominal pain and lack of bowel function for about 3 days. He came into the ER and got a CT scan which showed an obstructing lesion in his colon. Yup. Cancer. So, I get called from the ER to see the patient and and I diligently gather all my information before meeting him. He was a very nice guy with an equally nice wife. After talking and examining him, I asked him what his understanding of the situation was. He tells me that was just told that "there was something with his colon and surgery had to be consulted." Now something that vague turns people into nervous wrecks. Unfortunately, this seems to happen a lot in some hospitals. Whatever doctor saw the patient first just decides to pawn off any responsibility of actually talking to the patient and explaining their condition whoever they consult. I'm sure it's happen to people who read this. Why? Probably because they themselves are not comfortable with these conversations. And yes, they may be attendings who have been practicing for years and still won't bring themselves to it. So guess what? It falls on me. At least I'm awesome and can handle it. I explain to the patient that he has a mass in his colon of which I cannot say is cancer with absolute certainty, but it's very likely. And, it took me a little bit to use the word cancer, because I was uncomfortable doing so. I don't want to bring distress, pain, or worry to my patients. Words like cancer and death shock someone. Thier mind locks up and focuses on that one word. They don't listen to anything else you have to say, because to them, their life was just given an end point. I don't want to be the cause of that, but I have to be honest. I owe it to them. I'm not going to pawn off that responsibility to someone else. I don't think anyone ever gets comfortable with this situation. In time, we deal with it better, but it is tough. Imagine the awkwardness and hesitation you have when you want to break up with someone. Not fun, huh? And as technology has gotten better, we went from breaking up in person, to over the phone, to email, to text message. Sometimes we kind of just avoid the person until whatever relation fizzles out. Though, probably guys do this more than girls. We try to distance ourselves as much as we can from the other person so we don't have to face their reaction and the consequence of our decision. We want to avoid feeling bad when we see the pain we cause the other person. And that truthfully makes us selfish as hell. But now imagine that same feeling but multiplied with the fact that instead of ending a relationship with someone who will eventually move on, you are talking about a life ending. And you can't do it through texts. I don't think they've come up with the right emoticon for it. So with this guy, the positive was he was a surgical candidate. The mass could be resected and he could undergro whatever treatment he had to. After going through the barrage of questions from his and his wife, I feel like I was able to help them understand the situation and give light to the fact that there is something we can do. It was hopeful. I was on service during his stay and it was always nice when they would specifically say hello or bye to me when we rounded as a group. For whatever it was worth, however I led that conversation, I did it in a way that they felt they could trust me and felt a connection with me. And that's invaluable. The second conversation was actually with a patient's family member. The patient was an unfortunate soul who fell and suffered such severe brain trauma that he had to be given CPR out in the field. By the time he got to me in the ICU, he had no neurologic function. Brain dead... though not confirmed so we did what we could to prevent further injury. I was the chosen one who had to call the sister. What I wasn't aware of, was that I would be the first person to talk to her. She had no idea her brother was in the hospital. She was shocked, of course, and confused as the story didn't make the most sense. At first, I tried to cushion the news of her brother's situation, but I quickly realized it wasn't right. She was under the impression he would be waking up and getting out of the ICU in a few days. So I had to just say that it was extremely unlikely he would ever wake up. The metaphorical bus hit her. Her voice cracked and I could amost hear the tears start pouring out. Her words stammered non-stop. The tone of worry in her voice was replaced with fear, dread, and panic. I had caused that. She was going about her day until she got the call from me. I tried to comfort her as much as I could but a person can only do so much, a person can only take so much. Her last words were, "I'm sorry I have to go, I'm about to throw up." I felt like crap. And it's not like when you break up with someone, you feel relief. A weight has been lifted. Freedom tastes so nice. On to the next conquest. No. Instead, you carry it, and it's on to the next dying patient. I don't imagine doctors carry all the bad conversations, deaths, and mistakes they've had, but I'm sure its a lot of them. I'm sure they can remember patients right down to their full names, ages, and hobbies. All that weight on our backs keep us grounded, focused, and attentive--wary of the pitfalls and mistakes of the past. And that's good, but it can destroy us. Having reminders of those lives lost is like having dementors slowly draining us of a will to keep going. It is what it is. And luckily for every patient I have to say good-bye too, there's many more who will take my hand and thank me for whatever small part I played in their recovery. And that's invaluable. “I guess I came over here to tell you how proud of you I am. Not because you did the best you could for those patients... but because after 20 years of being a doctor, when things go badly, you still take it this hard. And I gotta tell you man, I mean, that’s the kind of doctor I want to be.”— J.D.

Year in Review: My Forgetfulness

7/7/2013 Looking back, being in residency is kind of out of this world. Everyone outside the medical profession wants to know what it's like. They don't even understand what residency is. Are you still in school? Do you get paid? You're training? Is it only for a year? Are you really doing surgeries? It's easy to forget that this world is completely foreign to laypeeps (Not lay-springtime-delicious-treats, but laypeople). Working as a resident means being in a 3-???-year paid training program. We are overworked and underpaid. We are yelled at by angry patients. We are reprimanded by angry attendings. We get at least 15 different human bodily fluids spilled onto our already stained scrubs, yet we can't make a face lest we upset the patient. We sometimes get thanks. We sometimes get to eat. We sometimes get to sleep. We miss going out and having fun. We miss laying on a couch and doing nothing without worry. We miss being with friends and family. We do good. We make mistakes. Unfortunately, those mistakes can cost lives. And when we go home, we're kept awake knowing the hospital doesn't sleep, and the shitstorm will be waiting for us in the morning. Yet for all the crap, we get paid to save lives. Life would be grand with another career. A 9-5 job where work stays at work, weekends are off, and you can take vacation days and sick days. It's just not for us, I guess. I know I couldn't stand sitting at an office desk. My day is random and lovely: running around the hospital, flirting with nurses, seeing patients, operating, and shuffling down hallways. It's all chaotic, busy, tiring, unexpected, and exciting even if frustrating. Yet as it all becomes commonplace after a year, I had to stop and wonder that my life after all isn't the shitty one--it's the patient's. I forget that the patient is not just A patient. He is a father. A son. A muggle. She is a wife. A fancy CEO. A unicorn breeder. They had lives before meeting me and hopefully after we say goodbye. Their days weren't filled with concerns of being sick, getting better, or dying. Their worried about providing for themsevles and their families, and doing well at their job. When they get sick, they want to make sure they are okay. Chances are they will be. I've never been an inpatient. I've been to the ER a few times but only for a few hours, no biggie for gp. I can empathize patients, but only to a certain degree. I forget that when I introduce myself as a surgical resident (and 2-time winner of best mushroom haircut in highschool), the patient immediatlely tenses up and is afraid of me. Why is surgery involved? Am I being operated on? Am I going to live? My first job is to calm them down and explain the situation to them (You have a bowel obstruction and a surgeon is most apt in managing this, though most of the time it is treated non-surgically. You have free air under the diaphragm which means there is a perforation somewhere in your intestine and will need surgery). I forget the patient with abdominal pain is hoping it's just a stomach bug, but that hearing the word surgery is scary. Probably only second to hearing the word cancer. I forget that the patient is dressed in an ugly, standard, oversized gown that only covers half their body. I forget that people aren't used to being half-naked, even if home alone. I forget people aren't used to being confined to a room, or half a room and a bed. I forget they get nervous when a team of residents come in to round at 5 am. I forget they get nervous and scared when they are meetting multiple physicians and consultants and aren't getting straight answers. I forget they aren't used to having IVs and drains and tubes in them. I see patients with drains coming out of every orifice and skin surface, all day. They never had a nasogastric tube inserted into their nose all the way to their stomach to clear it out. They never had a foley catheter in their peepee to drain urine. They never had a grenade-looking (Jackson-Pratt) drain sticking out of their abdomen after an operation or a chest tube between their ribs. They NEVER had an OSTOMY! Imagine waking up from an operation to see a bag sticking out of your abdomen only to realize that it's there to collect stool because part of your intestine is now opening through your skin. Just.... imagine that. Look down at your perfectly intact flabby belly, filled with beer and bacon yet protecting washboard abs from the sun, and imagine this weird pink, bulging tissue with a hole in the middle. Then, realize that you are looking into your intestine and that hole is where stool will come out of. And if you can't properly take care of it, you will literally shit yourself. I can't. I know I see it on other patients. The first time I had to change someone's ostomy bag, stool come out and soiled the patient, his bed, and, fortunately, my gloved hand. He was very apologetic and embarassed. Anyone would be, but I had to calm him and reassure him it was just an accident and that it happens all the time. Plus, I was getting paid so i wouldn't have felt right if my job was too easy. But seeing an ostomy on myself? I'd freak the fuck out if I didn't know I was going to wake up with that. We consent patients and explain it to them, but it's not like we're pulling out Google Images to show them what it's going to look like. For the patients who we can't consent because they are intubated or unconscious, fuck. Or, maybe not even an ostomy but an open wound. It can range from a small one of about 5 inches after an open appendectomy because the appendix perforated, to one that travels the entirety of your abdomen requiring a wound VAC to close it. I once had a patient cry in the ER as we were packing the wound because she could no longer take the reality and broke down. A young pretty girl, in the midst of summer, now had a decent sized open wound in her abdomen that was not going to close for weeks. I forget how devastating it can be for a person. And you think, it's just a scar! I saved your life!The patient doesn't see it that way. They only see the finished product. Yes, they are alive and they are grateful, but now they have to carry this reminder on their body for the rest of their life. I'm sure they'd like for it to at least look nice. The patient comes first. They need to feel comfortable and safe. They need to know they are being taken care of and how. Their questions need to be answered (no matter how many times). Their fears quieted and their hopes lifted (if appropriate). We shouldn't take things personally, because as bad as our day is, theirs is worse, because sometimes we know that that patient on our service who can be a jerk and is ungrateful to everyone... sometimes, we already know they won't make it out of the hospital alive. I wish I wouldn't forget these sentiments, but chances are, I will. I'll be swept away by the chaotic routine of the day. NGT here, foley here, digitizing an ostomy here, etc, etc.... until a patient starts crying. And then I start crying. And then after a few moments, I ask, "Wait, why are we crying? Is Finding Nemo on? Did Marlin leave Dory?!" And she tells me that she can't deal with what's going on. She can't deal with having an ostomy. She can't deal with an amputated leg. That she needs to talk to someone. Honestly, I don't know how we don't have everyone talking to "someone" be it a chaplain, psychiatrist, or a friendly neighborhood Jan Itor, without his knife-wrench, of course. But, like I said, I'll forget. We all do. We might have to, in fact, once in awhile. Or else, we probably wouldn't survive. *If you read all of this... here's a prize: http://themetapicture.com/media/funny-T-Rex-toilet-paper.jpg

Year in Review: My Gratitude

7/1/13 At 8am I left Jersey Shore hospital after working my last shift as an intern. *happy dance* It's a great feeling to know I'm not the littlest monkey on the totem pole anymore. Though, if the intern is out then I'll be reverted back to my younger days and be forced to hold the damn pager (No other sound will ever instill as much irritation, panic, sadness, and anger as that ring... we even have nightmares on call where we think it went off and didn't answer it). Actually, every resident will still cover the pager if needed, but as long as you're not the intern, you can pass it off to a junior person as soon as possible (so much so, that you can throw it at the junior the minute you see them down the hall.... I mean, it's a curse. Why would you hold on to it?). And what does it all mean? It means I won't have to do these annoying months of alternating between day shifts and night float on a weekly basis, but instead will actually take real "call" and be at the hospital for 24 hours (which means I get a post call day, and get to sleep and be productive in my personal life). I'll get to operate more. I'll get some more days off a month. And as scary as it sounds (which is really scary), I'll be the most senior resident at the outside hospitals during the night when on call... but more on this later. Things are better for a second year (for most people), and that's exciting. Intern year was not the worst.... I had a great time, overall. I've formed some great friendships, made some great memories, and have done/seen some pretty cool shit. I mean, do you get to put in chest tubes to help re-inflate someone's collapsed lung? Amputate some toes? Use sweet instruments to take out an appendix or gallbladder? Or a wedge of a lung? Or delicately suture an artery to a vein? Probably not. So, yeah, as much as the long work hours, co-resident tension, ER frustration, and the more than ocassional grumpy, unappreciative patient annoy me, surgical residents do some awesome shit to save lives, and you can be jealous while you sit at a desk excelling. But, our social lives are sub-par, so there's a decent trade off, but we make the most of it. And, I'll still drink you under the table. But for what it's worth, I've decided to reflect on my past year, and before doing so, I wanted to start off by showing my appreciation and gratitude to those that have made this year what it is. However, this isn't to thank friends and family. (But, very quickly, I love my family and my friends. I thank them for always showing support. I also really thank everyone who keep inviting me out and understand that chances are I won't be able to make it, but they don't forget about me. So for that, I am very grateful. It's very easy to become a hermit in a job where you are working 80 hours a week, 6 days a week, day or night, and when you get home, all you want to do is sleep.) No, this is to thank the rest of the supporing players, and they are mostly at work. NURSES I would not do your job. NOPE. I'm not sure you need 3-4 days off a week, but I suppose it's well-deserved... at least to the good nurses. (By good nurses, I mean the ones who aren't lazy and work hard. I'm not a fan of a nurse who questions a proper order to replete a patient's potassium through an IV because "that'll take all day." I'm here all day, so are you, and the patient isn't going anywhere, so hang up the damn bags) I don't know if the ladies and gents currently in the profession would agree, but I think it's glamorized to the outside world. You have beautiful nurses who assist sexy doctors in treating good-looking patients... and then they start haveing sex with each other on the patient's bed... oh no, wait, that's porn. No, wait, it's not. But, I think it's true. You don't see the truth of what it is to be a nurse until you are hands deep in someone's shit trying to clean them up for the 3rd time on your shift. Their day is full of charting everything that happens, following orders from doctors (and sometimes, astutely, catching errors and potentially saving lives), cleaning up patients, holding their hand, talking with them and trying to answer their questions and comfort them and at increasingly frustratingly times, get a damn doctor to see them. They are the ones taking care care of patients. I would say we manage their care, but I'm definitely not the one giving medications (orally, intravenously, or rectally) or doing most of the aforementioned. I will most certainly talk to patients and try to comfort them or make them laugh, and of course put in orders and operate, but for the other 20 hours of the day, the nurses are the front line. When I first started, exactly a year ago, I would mentally piss my scrubs everytime the pager went off. I was responsible to call back and respond to the nurse. I had to make a medical decision, no matter how small. A great piece of advice when starting off was, "Just ask what the nurse would do." And by golly, I did. Of course, this is only appropriate in certain situations. But, the nurses have been around for years and they've seen a lot of this before and know what's usually done. And, especially for that first month, thank God they do. Can you imagine having to deal with interns as a nurse each year? Here you are working at a hospital for at least 10-15 years, and in comes some sexy, cocky yet self-deprecating, nerdy surgeon straight out of medical school who hesistates at whether to put in a foley or straight cath a patient, and you have to call HIM for orders and answers? Right there I'd want to kill myself. Is that patience? Understanding? I don't even know. And that's another thing. Nurses can't do much without an order from doctors. I guess in an era of malpractice and lawsuits, everyone has to cover their asses. Honestly, I would feel so constrained not being able to take care of things without an order. Can you put an order for tylenol for a headache? Can you put an order to flush the foley? Can you put an order saying it's okay for the the patient to shower! Of course the patient can fucking shower, I don't want to smell him at 4 am in the morning when I'm rounding! (It's a him, because girls only smell like roses... and they don't fart or poop. So much the superior race.) Yet for everything they have to deal with, most nurses love their job and their patients, I think. And I'm sure they have the best stories at parties. If you're going to be a nurse, you have to be truly altruistic. You have to deal with a lot as much as we may complain about their attitudes, and work habits, and what have you, patient care wouldn't be provided. There'd just be orders in a computer... (they're in the computer?!) So for all that, I thank you. PLUS, some of you are attractive... or funny. Or both! I thank you for that, too. NURSE TECHS You help out the nurses and that is invaluable. Thank you. PHARMACISTS An invaluable resource. Many times, especially when starting out did they help me with medications and doses and antibiotics. And I love it when they teach why an order should be changed and then volunteer to fix it (I mean, I'm already busy putting in an Okay to Shower order). The pharmacists at RWJ are great and extremely helpful, and I love them for gladly adjusting and re-ordering TPN for my patients. It's a slap to the face when I'm at the outside hospitals and they are not as helpful or generous. So for that, I thank you. ORDERLIES Thank you for wheeling my patients where they need to go. Surgeons need pictures, and pictures are taken down in the basement at radiology. Patients need to get there. Thanks, Wheelman. Your stretcher-handling skills, I will write home about. JANITORIAL ENGINEERS A hospital has to be clean. Everyone plays their part in making it run. And, for the 89 year old man who still cleans our call rooms, you are an inspiration. Thank you, gramps. CAFETERIA PEOPLE Thank you to the people who don't charge me a nickel for a cup of water. Shit adds up. OPERATOR How do you know the know the numbers to any office/department I ask for so quickly!? How do you know everything!??! Thank you and your witchcraft. PATIENTS Thank you for letting me stick a knife or needle in you. Most fun.

My Sun and Moon

We share this one moon no matter the distance And though I can't run across the ocean to you, I can sing from the dying sun to the blue moon. The crashing waves on the coast carry the beat As the twinkling stars above shine every note And I blow a gentle breeze to let you know that This song is from me to you. We watch this one moon Feeling at peace, as one. But there, the green flash of a new day And the feeling is gone. For the sun with all its warmth and light Feels too large and busy As if owed to all those awake Working, struggling, worrying. It's not the quiet moon With its soft glow That brightens dark corners And uplifts lonely hearts By reflecting the love of the Sun Even when they are apart ... draft, not finished yet. it's 430 am. its late. wompity womp 11/27/2012

My First Month

And it has begun. I officially started residency a month ago, on July 2nd, and it has been awesome.....ly tiring. Hospital-wide orientation began on a Friday... a day so hot I decided to wear a polo and shorts, because if all the other guys wore shirt and tie, the polo wouldn't make me stand out too much. Most of them did. I reveled in my comfort. The day preceded with a bunch of useless lectures, including one on how to avoid lawsuits and all, which was presented in a much better tone than Ted Buckleys. After the day ended for most people, we went on to the surgery department orientation which is when we first received our white coats. Obviously, we threw them on immediately and felt impowered.... a feeling that would quickly dissipate in a few days. After the weekend, we started our first day. Luckily I knew how things worked at the hospital because I was there as a student, but it took me time to realize that nothing happens in a hospital without an order.DAMN ORDERS. It's what I spend most of my time doing when I'm at a computer. Putting in orders for patients. Medications, foleys, nap time, imaging, lab work, and tickling sessions. Even though they know more of how to manage a patient from their experience, nurses really aren't allowed to do much without an order from a doctor. A doctor.A term that still feels unearned. For the most part, I introduce myself to doctors and usually nurses by my first name. I feel unworthy of it. I may have grown 1% more comfortable with being referred to as a doctor, but it's still weird, because when I'm addressed that way, it is because I have to make a decision. I have to give an order. And when I started out a month ago, that was overwhelming. But, going back to the first few days. I stumbled around a bit trying to remember that I have to put in orders for things to happen. Nurses would call me to put in orders. I would get paged cause I put in the wrong order.... "Doctor (there it goes again), the patient is NPO (nil per os, nothing by mouth) so they can't take pills, can you change it to IV?" (What? Are you not accepting my challenge?) "Oh, yeah, sorry. Changing it as we speak! Thanks." Obviously, the best part of doing this whole thing is the ability to operate. http://www.youtube.com/watch?v=2wZlqsw-VyY And as Dr. Turk Turkleton once said, "This morning, I had my hands inside of a guy's chest. I couldn't even see them! I should not be allowed to do stuff like that." As an intern, I'm not doing big crazy cases (though I did get to do a laprascopic appendectomy and cholecystectomy [take out appendix and gallbladder using small incisions and a camera]), but normally doing hernia repairs. It was a great feeling to have the attending tell the scrub nurse (who gives us the tools in the OR) to pass me the knife to make the first incision, and I realize that though I am learning I am going to be doin most of the operation, which I do. Just recently I had to take a cancerous mole (melanoma) from a patient's cheek, and I didn't think I'd be doing that incision, but the attending passed me the knife and said becareful around the eye. AH! Oh, and I did get to amputate a toe. That little piggy ain't going NOWHERE! I do love operating. It may get repetitive, but that's how you learn. This isn't easy stuff. That's why training is 5 years just for general surgery plus a fellowship to specialize... and even then you're not gonna be at your peak. And each human body is different. Each case is different. And then, when you think you have nothing else to do, you can always be at a teaching hospital and train students and other residents. Plus, we're not only doing stuff in the operating room. On my second week, I put in a chest tube to help decompress a patients lung. And guess what, it worked beautifully. http://s1.e-monsite.com/2009/01/19/10/40556091pneumothorax-gif.gif (This is an example, notice how there are no lung markings on the left, it's completely dark... that's a collapsed lung). Also on my second night, I get consulted as I'm covering urology to put in foleys (the small tubes that go into the urethra to help you pee) for patients because older medical residents are uncomfortable. I literally strolled up to one of them and said: "I talked to the urologist and he said there shouldn't be a problem putting in a foley, he's not at risk for bleeding, so you can do it." "No, I'm not comfortable, but he really needs one, he's very distended" "Alright, fine. I'll do it." And on the 3rd day, GP said, LET THERE BE PEE! True factoid. The patient was so distended and had to urinate so bad that he could not lay still. He was calling out for help and writhing around. The moment the foley went in and about a liter of urine poured out, the patient passed out. But I'm not putting in foleys into pensis all day, all night! Sometimes, I'll find myself in the ER or some hospital room cutting into peoples abscess to let the pus drain out. That's what we do as surgeons, we take care of bizniz. We can take care of our patients operatively and nonoperatively. We can prescribe the medications and all that, but when it comes down to it, we can do all these procedures as well. But unfortunately, compared to more senior residents, I won't be operating as much. I'll get to a decent amount, but I'm an intern. I have to learn how to cover the floor, manage the patients, and answer the pager...... The.... Pager.... The source of all my anger. The pager is not so bad. It helps nurses get in contact with us when they need an order. I was terrified my first morning to get my first page. Why? Not because I wouldn't know what order to put in or how to answer a question. I knew that was gonna happen regardless. I was nervous for the page that would be like "Doctor (Stop calling me that!) your patient is coding!" which is code for dying... NOW! The heart rhythm is all out of wack, their breathing might be gone, they may not have a pulse. It calls for CPR, fast medications, and even defibrillating them like you see on TV.... CLEAR! BZZZ! My first page like that.... I was on night float. My pager went off a few times in a row which is common at night. I can literally sit at a phone for an hour just answering pages because as the intern, we are covering all the other surgical patients which I would say is close to a 100. That can get extremely overwhelming and frustrating, especially when you already have a tone of other work to follow up on from the day team, new consults to see, and emergencies to take care of. But anyway.... my pager goes off a few times, but I'm in the middle of seeing a patient so I dont rush to answer it. When I look at my pager I see ithe callback number is from a room. I start to dial back when I panic... the overhead system says "Doctor Vidal (Whose playing this joke on me?!), please call 8 Tower!" WTF IS HAPPENING? They answer my call on the other side. "Is this Doctor Vidal?!" "Yes" "Your patient in room 69 is bleeding out, come here quick!" I start running. I'm not even sure the fastest way to that building because as hospitals grow they tend to build buildings into complicated mazes with hallways that don't line up, and floors that are not in alignment. But I'm running and thinking to myself what the hell am I gonna do. Luckily, my senior calls me at that very moment while I have the phone in my hand to call her. I tell her about the patient. By the time I get there, thankfully she was closer, she had already applied pressure to the wound to help stop the bleeding. There was blood all over the patient, the floor, and somehow the door about 20 feet away. It was an arterial bleed and so it was gushing like... almost kind of like in the movies when they fake chop off someone's arm. In the end, everything turned out ok. But... that's what I was most afraid of when holding the pager. I still am. More so when I'm on Nights because the whole team is not there. My first time taking call like that was working Fourth of July. I know I know things. I did graduate school. But being new and not understanding protocols and how things work is frustrating. It felt like I was boxed in, but in an open box, yet I was afraid to step out of it. That holiday, there was a patient who was very distended because he could not urinate. He needed a foley, but the nurse had asked if I should straight cath him (just stick in the foley for a second, drain the urine and pull it out, rather than leaving it in) or just put in the foley. I couldn't decide. I kept thinking, would my senior get mad if I make the decision without her? Would I make the wrong one? When exactly do you choose one or the other? Why am I getting so nervous about this? Neither decision will kill my patient, and that's my one goal: Don't kill patient. They tend to frown upon that. The nurse had to stop me and tell me to put the foley in. She said, he needs it just do it. It will be okay.I'm grateful for that. She told me she understood because I don't have confidence at all. I'm pretty sure I had so little confidence I probably owed some back to the general pool of confidence. Ze Lago de Confidencia. All the nurses int he station and I had a good laugh about it, and they all agreed that it comes with time and they understand. I think that gave me a little more confidence to realize that if I know a decision won't kill a patient then it's not the worst thing if I handle it myself. The days and nights have gone better. I feel myself becoming more comfortable at the hospital, but I'm still nervous. I play it off cause I'm awesome, but sometimes I just feel like a glorified student. I'm not ready to feel like a doctor. I know that will come with time. That's why I'm training for a long time. But regardless of all that, this is all about the patients. They are the ones who have to get better. They are the ones in a bed sick, suffering, dying. The crap I go through is nothing to what they experience. I haven't undergone major surgery. I don't have tubes and drains and IVs sticking out of every arm and part of my body. I'm not confined to a bed and room that's not mine. I don't have deep-seated fear that maybe I'll never make it back home. I can suck up being tired, being hungry, and being yelled at... I gotta learn my lesson, turn around, and just keep swimming. (FINDING NEMO IN 3D COMING SOON!) And I do love talking with the patients. Most of them are great, and most of them are very appreciative. You can see it in their faces when they are getting better, when they are ready to leave. We once had a patient say, "Alright guys. I really appreciate you coming in to see me, but it's 5 oclcok so you guys should get out of here and go to happy hour!" Awesome. And so yes, I'm working a lot... 80 hours a week. I'm there 6 days a week. The hopsital doesn't shut down, because the patients don't shut down.... well, not all of them. It's always there. My mind is now 20% always there. I am at a baseline of tiredness... I get hungry often but that's cause I love food... I have to sacrifice a good chunk of a social life to do what I have to do, because it is a responsibility that I took upon myself. And so I will.... and recently I think it has been sinking in more. And I have to say I'm more glad now that I had great early 20 years to look back fondly on, but it is hard not to miss not seeing all my friends, especially now that it is summer. Maybe facebook exacerbates that. I don't know what other things I will have to give up. Somethin happened last week that made me thinkin about all this and is it worth it. And I hope so, I enjoy it now and I'm not going to stop. But it's tough. But I'm not the first person to do this. There have been many a surgeons who have gone on to have families (or had families in residency, had other careers, etc), have great friends, travel the world, etc. They just need the support of people who love them, and are patient, and dedicated. Who are understanding.... that hey, maybe I can't see you every week. But I don't think any of this would be possible without having worked so far with great residents cause I'm no superman. We have a lot of laughs. Pulled off a few prank calls to nurses and other interns. Joke around about things. Everyone loves it when my phone goes off and it's Your Love by the Outfield. It's so far been a great experience and I'm having fun.But I have to be honest... I would like to sleep a little more.... see my friends a little more... dance a little more... http://www.youtube.com/watch?v=bhh7qzurMZY

I Belong to You

I Belong to You 4/2/12 I stare at the moon to believe Your touch is the breeze on my face. Miles apart, our bodies grieve But your soul I can lightly trace. Our dreams bring love to light A place to feel a warm touch, kiss Where this distance is slight And we no longer need to miss. The rising dawn begins the day Bringing new beauty to my life Filled with hope for a way To embrace you as my wife. For our bond began long ago When our eyes met, and smiles grew. One soul in us, it began to show And I knew it was always you. So with my eyes skyward, I hear The music made by a hearts dove That brings those apart close and near Just as it does you to me, beloved.

My Grandma (Mi Mama Aurita)

Last week, my grandmother passed away.

And it's difficult to explain the type of sadness I feel. I cried when I found out she passed that morning, and repeatedly had to hold back tears throughout that day. However and perhaps it's strange to admit, there seems to lack a certain level of grief. I almost feel guilty for not feeling sad enough. And this is something I feel I have to attribute to the distance that existed between us. I love her dearly and will always have many fond memories of her and be grateful for what she has done for me and my family, especially in my younger years, but, other than a few brief moments that I saw her on Skype a few months back, our interactions had been extremely limited over the past 6 years. I'd say hello to her every few months whenever I was home and my mom was on the phone with family, but the last time I spent any significant time with her was when I was in Colombia during the winter break of my sophomore year in college.

This distance isn't to say that I loved her any less for all she has done for me, or even for being my grandma, but I think it perhaps cushioned the blow a lot more. She wasn't directly in my life for a long time, and so there is that disconnect that does not really allow me to miss her more than I normally do, but of course, now when I do think of her, I am saddened by the fact that I know she is no longer around, even if it is for a quick hello.

I perhaps have also been prepared for the fact that she will pass because we knew her time was coming from the cancer she had. My grandmother was a fighter. She always denied any symptoms and downplayed the severity of anything she had. Just days after an operation, she would be trying to walk around, clean, and cook back home. She was tough, but cancer is one of those things that will break down the strongest of spirits. It did, however, happen, very suddenly which was shocking. I think everyone thought they'd get a chance to say goodbye, at least I know my mom did. Again, perhaps because of that distance, it's that I felt more at ease to understand that her time was coming, and she would eventually pass, and find peace and comfort. I also don't know how much to attribute my reactions to having been in the hospital and seeing patients die. Sometimes it'd happen overnight, so when I would come in the next morning; the resident would tell me my patient had passed away. Again, something I knew was bound to happen for whatever reason, but even for that man who I'd only known for a few days, and even if it was for a short moment, there was just an emptiness in the world. There was a need for me to take a moment and acknowledge the fact that this man didn't just walk out of the hospital to continue with his life, he came here, and it ended... right where I last saw him.

The first time I had to see a patient pronounced dead, the resident and I walked into the room, closed the door behind us, and examined the patient. It felt surreal. It felt fake and staged, and out of this world. It was only the two of us and the deceased, and it was as if I was looking at a model. It was a tiny, elderly woman, with frail wrinkled skin, and wisps of gray hair. But, there was no color--no life--in her skin. The eyes were vacant, the lips pale. It felt completely unnatural to not hear heart sounds, to not hear her breathing. To touch the skin, looking for a pulse, but knowing I would not find one, and to know there was no one there to feel my fingers. To hear my voice. It was like looking at an empty vessel, and it made me uncomfortable. It made me empty.

I think its extremely hard to know how to voice comfort and understanding in the face of death. On one hand, words never seem enough. I held my mother after we found out as she cried, as she told me she didn't get to make it back to Colombia to say goodbye. That her mom didn't wait for her. And I had no words. The clichés seemed cheesy and scripted. "She's in a better place. She left fast enough so she didn't feel pain. She didn't suffer. It was for the best. You'll get to say your goodbye tomorrow." Perhaps we say them because they need to be said. Perhaps they are clichés because they are the best we can do. No one has thought of better words, at least not when you're in the spur of things. There is truth to them. She, as we believe, is now in heaven in a much better place because as I heard, you get to bounce on clouds. She left us suddenly--12 hours prior, she had been video chatting with my older brother. She didn't suffer, because the pain from cancer can sometimes be unbearable. And the funeral services were stalled for an extra day so my mom could be there in time. So perhaps the clichés are the best we can do to help bring comfort. But of course I feel it's always more important to be there for the people, listen to them, absorb their tears, and even distract them, make them laugh.

And how to explain death? How do you make someone believe something you do? Especially in the light of losing someone? I believe in a heaven, and I believe that we are both soul and spirit-- the soul being our essence, and the spirit a gift from the Big Guy upstairs. I believe the spirit returns to God where it belongs, and the soul.... I'm not sure. I believe the soul is everything that we are, and I believe that we share it with everyone. It is how we live through others, how we live on through our children, through the ones we love, through the actions we do, and the things we create. It is enriched by our lives, by love and laughter. Perhaps it is the part that we say never leaves this world, and perhaps it goes to being one with all of us. But, this is what I believe. It is what brings me understanding and comfort in the face of death. But it is what I believe on no basis of scientific truth--only faith. Is my answer enough to bring anyone some understanding when they cannot understand the finality of death? We can't force our beliefs on them. I just think of when I will have to deal with talking to patients and their families about death. I just hope to be a source of comfort and empathy. I can't say I would know what more to give, but I guess it depends on every individual person. What they believe in, their religion. I mean, we have religion to explain death... and in turn, provide meaning to life. In order to be rewarded in the afterlife, we have to behave in such ways while we are alive.

But what if we don't have faith in religion? Or in anything? I'd have to admit, I believe I have to question the existence of God in the face of death. Or at least, in the face of my grandmother's death and my mother's suffering. I think it's something all reasonable people should do. And I don't feel it necessarily has to break your faith in anything, but it can only lead to a deeper understanding of what your faith is. I, personally, find it foolish to say things like "God does good things" when good things happen, and say "God works in mysterious ways" when bad things happen and believe it blindly. To just comfort yourself with "God has a plan" when things are down. Not to say any of that is untrue, but I think truly believing in something involves understanding it, which is why leads in religious institutions pray often, meditate, and read their scriptures frequently. Questioning intangible things like this leads you to examine your own life in light of what you believe is important, and it gives you a better understanding of your own ideals.

And I say this, because in light of my mother's suffering, I have to wonder what God’s ultimate plan is for her. I have seen her sacrifice and endure hardships all her life, and as I have stood mostly powerless to change the situation, I have to wonder when she will catch a break. It broke my heart to tell her that her mom only had at most a week to live (sadly, it turned out to be less than 12 hours). She cried and cried and she knew it would be for the best, but would not accept the loss of her mother. She would also not forgive herself for mistakes long in the past. But she also talked about the death of an older brother I had who died shortly after birth 30 years ago. And even though my parents decided to pull life support because it was the best decision, she never accepted his death.

In all honestly, most of my tears were for my mother. I cried when I heard my aunt’s voice through the speakerphone telling me of my grandmothers passing, of her last moments. But it was nothing compared to the pain I saw in my mother. How vulnerable she looked. How she shook. Even the next day, how scared and nervous she was to get on the flight and have this nightmare become reality. And so I wonder... what benevolent being would allow so much trouble for a woman who has given her life to her sons, who works day in and day out to get by, who never denies anyone, and rarely asks? Who finds herself with more bills than friends? With more headaches that joys? As I look into my own future in the coming months, I must still be grateful to that enigma in the sky that the rest of my family and friends are healthy, with food on the table, and a roof on their head. And for now I am happy she is with the rest of her family and she does not have to grieve alone. She can spend a few weeks with loved ones, sharing stories, and celebrating grandma's life.

I, for one, remember..
- the soup (sancocho) she would always make for lunch... even when I go to Colombian cafe's here, she's who I think of.
- the way she never seemed to age... for the life of me, I always thought she was like 80, ever since I was 5 up until now that I'm 25.
- the way she always looked tiny and her skin looked fragile
- the way she'd scoff and storm off when my mom and her started to get at each other.
- the way she could just sit on a chair and knit for hours.. and for someone who was 80 for a long time, her dexterity was impressive.
- the stories I would hear as she would parade me around the city when i was a baby cause I had beautiful gray eyes (now they're boringly brown).
- her glasses hanging from her neck whenever she would look up from reading her little books
- the way she'd say my name and grab my face to say hello
- how she'd turn away from the camera because she hated how she looked in photos (like mother like daughter)
- the way she comforted me after my father passed away... how she calmed me down from the rage that was building inside.. and brought me tea.
- the way she took care of my father as he was dying from cancer.
- the little birdie she hid in her carry-on which she had to fly back to Colombia after a visit.
- the bed of hers which I now sleep on when I stay at my moms.

One could say I'm lucky that as much as I loved her, her death didn't...break me, I guess as much as say my mom or my cousins who live with her, but I think I would've been luckier if it did, because that would have meant she was a much more important part of my life, and I'd have more recent memories of her rather than just those from when I was young.

La bendicion Mama Aurita. Cuidanos desde el cielo con papi y christian y carlos.