j.e.h @j-e-h5 - Tumblr Blog

the next step

I open my eyes and lie quietly in bed feeling the gentle cadence of my heart beat, unburdened by the distressing events to come. I share a simple breakfast with my wife Lucy and head off to medical school before the city has rubbed sleep from its eyes. In the middle of this average day, Lucy calls with terrifying news. She is 3 months pregnant and she’s bleeding. The steady cadence in my chest disintegrates, skipping and flipping into a syncopated rhythm of fear as we wait in the obstetrician’s office. Our doctor wheels in the ultrasound machine and places the transducer on Lucy's belly. An incomprehensible snow storm of white and black rages on the screen. After a few moments of disorientation, a rhythmic flicker appears. The pulsation of blood at 150 beats per minute seems like a miracle. My unborn child still has a heart beat; he is still alive. I hold my wife as we cry with joy.

That day I came to know the attachment a parent has to their child’s heart beat. Each day since, I remember that feeling as I talk with patients and their families. They teach me about their struggles and I try to understand their fears. Through this I have learned much about myself and a few things about the heart. Here are the things I know.

The heart is philosophical. It is the metronome that reminds me second by second that life is remarkable. The flat green line of asystole reminds me of the subtlety between the here and the after. Caring for children who can get so sick helps me think deeply about the importance of my work, the human cost of my decisions, and improving the systems in which I practice medicine. I want to deepen my philosophy of medicine, and of life, to better understand the impact our practice has on the families that we care for.

The heart is poetic. Children recognize this in a moment of disbelief when hearing their heart beat for the first time. I find beauty in pathology and physiology that I can see, touch, and hear. I sense the innate significance when teaching a student who is appreciating their first abnormal heart murmur. The magic is borne in the enthusiasm of an attending who asks me to “be the red blood cell,” working my way through an imagined heart to teach me the implications of abnormal circulation in my patient.

The heart is mysterious. It manifests our emotions, our state of health and illness, and can break when we get stressed. The existing body of work exploring the heart provides treatments I can give my patients today that will help them feel better. The multiple ways the heart can go wrong gives me the opportunity and motivation to discover something new, to improve upon the things we already know, and to ask questions that don’t yet have answers.

I love caring for patients with decades of life in the balance and amazing potential for recovery. I’m excited study under the mentors that will help me imagine what the future of medicine can be. I’m looking forward to visits with a child who wears scrapes and bruises as a badge of honor for a repaired heart that lets her run and play. These are the things I carry with me as I prepare for the next step.

#cardiology #fellowship #essay

a-b-c

She was probably dead when she got here.

The medical team pager beeps at my waist. 13 months old, unresponsive, 5 minutes out. I’d just administered a powerful IV medication to stop the repetitive seizures a school-aged boy was having for the past three hours. He was resting quietly now, his breathing calm and settled into the gentle oscillation of life.

Several hours before the seizing boy arrived in the Emergency Department, our team had just completed a training simulation with a plastic patient that jiggled the gurney with a mechanical facsimile of seizure. We practiced the steps of assessment, stabilization, and treatment needed to care for critically ill people. When done right, the resuscitation is a complex but graceful dance, almost effortless to the outside observer. The team flows and ebbs around the sick child, becoming extensions of the team leader conducting the show.

Still early in residency, my job is to be the team leader’s sense of touch, hearing, and vision. I, "Doc Right," stand at the right shoulder of the patient to examine their breathing and heart function. In 15 seconds or less, my interpretation of the most basic life signs will direct the team’s efforts. I report my findings in a format every team member learns on the first day of training: A-B-C. Airway, breathing, circulation.

There are several ways to die in a hospital, and being dead is more complicated than you might think. The definitions change and the ongoing debates are centuries old, steeped in physiology, philosophy, and religion. In short, dead people don’t always look dead and dead people don’t necessarily stay dead, depending on what rules you use. I digress only to cast relief on a common saying that, while morbid, is basically true. You only do CPR on dead people. If it works, they become not dead. If it doesn’t work, well, they were dead anyways when you started. It frames the situation in a way that the rescuer has nothing to lose. Unfortunately, it doesn’t feel that way in real life.

“Chest compressions in progress!” someone near the door announces to the medical team as the ambulance crew rolls into the trauma bay. The paramedics’ monitor shows the flat green line of asystole, or absence of the electricity driving the heart. I stand at the right shoulder of the bed waiting to accept the small, motionless body and begin my steps in the dance. A-B-C.

From the very beginning, there is confusion. Two of the paramedics are talking at the same time. They are flustered and trying to relay vital information about the care given en-route.

“Stop. Clear communication, please. You. Please speak loudly for the whole team to hear.” Our veteran team leader immediately asserts her place in the room and gently resets the team’s metronome. Early chaos averted.

Then, our dance is beautiful. 1, 2, 3. 1, 2, 3. The urgency is palpable, but our team is calm and in step. A-B-C. A-B-C. Medicines are given, blood is tested, well-planned backup routines are executed. Chest compressions continue. My hands are tiring, CPR is a workout. My co-resident watches over my shoulder speaking quietly in my ear.

“Good rate, good pressure. I can feel her pulses. You’re getting tired. I’m here for you. Ready, switch.”

We push on. The precision is impressive; our practice is paying off. But today is not a storybook day. The respiratory therapist has to keep stopping her rescue breathing and suction blood from the airway. That is not a normal thing. The baby’s chest is not bouncing back between compressions anymore. It vaguely resembles a half crumpled aluminum can. 15 minutes of resuscitation will do that. There are no more medicines to try. No more things to do. The mother is on her way and she wants to see her daughter while we continue to work. The dance has been beautiful but the body is not. We push on.

The prognosis is dismal. I signal for the medical student to come take my place. Now is the time he can practice on a real body while we wait for the mother to arrive. I step out of the dance and the team moves on without me. My new role as a watcher changes everything. I’m no longer a technician with a job and a plan. I’m now a father with a son and a wife. My patient becomes a daughter with a wailing mother whose cries burrow deep into me.

“It’s a dream! It’s a dream! It’s only a dream. Oh my god, why won’t you wake me up?” She screams as I become part of her nightmare. I force myself to watch. Her suffering stings my eyes.

If I'm to wake up and do this again tomorrow, I need to protect myself. Our beautiful dance was a failure. She was probably dead when she got here. You only do CPR on dead people. We had nothing to lose, right?

#essay #medicine #residency #pediatrics

It's firefly time.

I-90 East near Opportunity, MT. #ohmeohmyohweredrivingtoohio

#ohmeohmyohweredrivingtoohio

Good morning to you too. #planetcharlie

#planetcharlie

Some have an unbearable lightness of death. They drift into forever. Others are strangled by mortality, last words crucified by fear.

2013-11-14 7:10 PM

#twentyonewords

A Sunday walk with the love of my life @talzy27.

#photography

Baking.

#photography

A pound of flesh? How about 22, removed with wisps of bovie smoke as I cut through flesh like a Jedi.

2013-10-01 1:23 PM

#twentyonewords

my perfect day

Medicine is hard, but the struggle is part of what brought me to it. Every day we use incomplete knowledge to solve complicated problems. It’s a recipe for frustration and failure. Despite these unknowns, I have tightly held ideals that remind me to keep trying. Medicine is driven by the aspirations of thousands of women and men who are working to make things better, to wake up tomorrow in a world that is slightly more perfect. With realistic expectations, I try to imagine my perfect day as an attending pediatrician. It would look something like this:

I open my eyes, slowly becoming aware of the things that make up my personal atmosphere. I turn off my alarm clock moments before it was set to ring, avoiding a jarring entrance into today. The sun is stretching its legs as it gets ready for sunrise, but it has yet to peek above the horizon. Soft morning light fills the crisp new-day air and gently nudges me out of bed.

My coffee maintains a perfect drinking temperature, brewed from freshly roasted beans, warming my belly without burning my tongue. Silence sharpens my senses before the bustle of the morning begins. I share a simple breakfast with my wife. My commute to work happens before the city has rubbed sleep from its eyes, the streets still quiet. I push hard on the pedals. My bike feels alive beneath me, transferring work effortlessly into forward motion. It’s slightly downhill, just enough to speed me through town without feeling like a free ride.

I care for patients with decades of life in the balance, amazing potential for recovery, and feet that aren’t gross. They have bald heads or struggling hearts, but the fire in their eyes fills a fragile body with life and hope. They paint sunny pictures and gift handmade trinkets as an offering in an innocent childhood treaty—I’ll be your friend if you help me feel safe. Getting the diagnosis right is a terrific rush, but I’m familiar with the frustration of treating the unknown, failing to stop the decline. I think about the critically ill child who I will comfort at the bedside today, delivering a daily reminder that I will not leave her to suffer alone. I cherish the sacred moments where I stand with parents in their child’s last days, helping guide them through those moments.

I get to think about important questions with difficult answers. Listening to patients’ stories informs my study, teaching me that “non-compliance” is more often misunderstanding than indifference. Patients and parents are confused by our vocabulary that frequently suffocates the messages we are trying to deliver. I believe that good medicine depends on physicians who speak without jargon and teach in plain language. My research work throughout medical school and residency has resulted in a computer algorithm designed to identify physicians who communicate clearly. I look through the most recent data searching for doctors who live on the right side of the curve so we can bring their methods to others.

Before nightfall I have dinner with my family and read stories to my children. I sneak out to the woods behind my house and watch the shimmer of evening stars break through the fading twilight. The night sky reminds me that I am a small part of a big thing, but my actions are still significant. As my perfect day ends, I ease into bed. The crisp, cool sheets congratulate me for my time well spent.

#essay #medicine #residency

The city lights sparkle brighter now than before. The anxiety of starting in a new place is replaced by guarded curiosity.

2013-09-01 11:42 PM

#twentyonewords