The Resident Diaries

28yo PGY2 p/w stubborness, idealism, and a big broken heart 

[theresidentdiaries]

In the intensive care unit again. Sometimes I wonder if I am hooked on pathos - how motivating it is to run from code to code, to push my brain to hold 14 patients’ worth of q4 hour lab values, daily CXRs, CT scans, medical histories. To switch gears on a dime after a frenzied morning and sit down with the woman who is finally seeing her husband for the first time after a month-long COVID hospitalization. To sit so still and wait for her questions. To answer questions until she can’t think of anymore. To ride out waves of tears. 

The hospital isn’t so fun any more. The nurses are tired and resentful, appropriately. We’re always short-staffed, even worse than before. Everyone is one edge. At the end of every phone call with a family member, when I ask if they have questions, I wait knowing they’ll ask: “can we switch out family members? Can you extend the visiting hours? Can I sneak my son in, just for a second? She’s dying. You just said, she’s dying. Can’t we come?” I think it’s maybe this moment that curdles me, renders me panicked and lonely and purposeless on my day off. 

[theresidentdiaries]

yesterday i thought: let the record show that I am formally Sick of It. 

[theresidentdiaries]

The days run together. 

Most mornings, I start the day with the death toll. The numbers continue upward, out of proportion to the serenity outside my window. I hear that social distancing is helping. We may not run out of ICU beds after all. 

I sit in on countless meetings. Yesterday we’re tasked with how to best ration vents. It’s odd to sit with my mentors, faculty who taught me as a med student, who joked with me in the PICU - now we discuss how long the trial of ventilation should be, who decides, how we tell the family. It’s a weird sideways world, where the same principles still apply but the hospital is a different place. We are calm and thoughtful. If you mute the mics, we could be all just be discussing a tough ethics consult from the previous month. 

I’m called to clinic, away from my extended isolation-vacation. The schedule looks light. I’m grateful to have something to at least say I’m doing. 

HCWs everywhere are dying. I saw a post about the glorification of those we sent for sacrifice: why we revere the troops. How now the HCWs are becoming revered. Nurses are being paid to go to NY but MDs are volunteering. We are the best fodder for the health industrial complex, because we love to be martyred. 

[theresidentdiaries]

Everything at the hospital is changing. We dissolve our usual teams, promote the interns to residents 3 months early. Vacations disappear. All the usual structures evaporate. The world mobilizes and dissolves. 

[theresidentdiaries]

Yesterday we have people over, for the first time in weeks. A. and C. come by to celebrate C.’s match. And N. joins us too. We sit by the water out in the sun, float on innertubes. Pabu finally dials in his doggie-paddle but is still a bit wary. It’s in the mid-80s and it feels like summer. 

This morning I wake up feeling guilty. I. is at work and I have some presumed work to do at home, but I delay it. The air feels idle. 

[theresidentdiaries]

Trying to write again. It’s hard. Unusued muscles make me stiff and ungainly. I think of A., how he says he only enjoys playing the violin when he’s practicing 1+ hours a day. I loved to write, and got good enough at it, and now what I create is frustrating and inelegant. Perhaps my nostalgia oversells the past, anyway. 

It’s the time of COVID. Here in NC, we are still early in the crush, and in the back of our head we all wonder if we may dodge the rising madness in NY, Chicago. Last week we had 6 sessions of Covid preparedness, masterminded by PGY-2 S., and led by residents. It’s odd, at first, to speak into a microphone while looking out at any empty auditorium. The jokes fall flat, and it’s easier than usual to lose track of one’s thoughts. 

But everyone chimes in via text, and I’m happy to find that videoconferencing is much better than the staticky google hangouts from 5 years ago. It feels special, and I wonder if it is: hierarchy flattening. The pretense evaporating. We speak openly about anxieties and fears. Critiques of healthcare systems are not unwelcome, and our representatives sit at the table when decisions are made. The crisis is so vivid and stark that we are compelled to move. I hope we remember that our system is in crisis for so many of our patients, even without this killer virus. I hope this urgency stays. That we remember how many things can be done differently, that things can change, and very quickly. 

Everyone is staying home. I miss my parents, and A. and C. I miss seeing friends, stopping by Steel String for beers with Torie. Dressing up to go out. Ian and I are fortunate to be captive on our sweet little section of earth. Pabu and I run around in the afternoon, playing tug-of-war and keepaway. Ian builds us garden beds that will fill with expensive soil. The birds are coming out, and we have a pair of red-shouldered hawks that have built their nest in the woods beside our house. There’s a very surreal disconnect between the slides I read at virtual morning report and the familiar shimmer of water on the pond, the gladness that always comes with spring. 

But here we are. I’m deeply grateful for this rest, this limbo. No one can plan. Most things grind to a halt. I still feel the guilt of something-I-should-be-doing, but it’s been a long time since it’s been this mild. The voice of ‘if you’re not busy you’re behind’ gets less insistent. This is probably not because COVID has changed the landscape of ambition in medicine, but because I’m gently reminded that my happiness has nothing to do with it. I used to stay I could have easily been happy with a small job, my time and energy going to home, on projects and pets and children and my partner. My energy has felt different this last year: anxious and ambitious, like Pabu pulling at the end of the leash. Desperate for the thing he can’t reach. When he pulls, Barbara from puppy class just says to change direction. Here is COVID, changing my direction completely. I let the leash go slack and refocus my gaze. 

The world is always changing, but it’s really changed now. We do everything we said, ‘nope, can’t make that work.’ I hope it’s as obvious to everyone else as it is to me: we’re all connected. We need each other. None of us are healed when one of us is suffering. 

Today, the world is good. You can’t tell me otherwise. 

To our president-in-name, to the people stockpiling guns and hoarding groceries, today is not your day. Today is not for you. Today is for healthcare workers getting up and risking their life for yours because they said they would. Because someone has to. Because they’re as scared as you are but they have skills that are desperately needed. Today is for those stocking grocery store shelves, for those preparing take-out meals, for those wiping down rooms and working in the recently-repurposed factories. For everyone trying their best to help us along. Today is for parents trying to figure out how to teach their children, and for teenagers figuring out how to live with their families. For the seniors who still smile at me. For everyone’s pets, who reminds us that we belong at home. For the bees who go on pollinating, and the seeds that germinate quietly in the dark. 

For those who made their philosophy, MINE FIRST, who manipulated others, who peddled the drivel of selfishness, who goaded the fearful into gripping even more tightly on the little that they have - we’re done with you. If you show up in my ICU I will do everything I can to save your life because you deserve that, at least. But I do not have time anymore for your grandstanding. And I am not listening anymore. 

Today I am listening to everyone who showed up with ideas. Who got bored and home and wondered, how can I help?

[theresidentdiaries]

On elective month, I’m non-essential. I sign up for whatever I’m interested in: echocardiography, cath, clinic, or consults. It’s just me and the attending, who teaches me about re-entry tachycardias, how to localize the aberrant pathway in Wolf-Parkinson White, the difference between L- and D- Transposition of the Great Arteries. One day I’ll measure the R-R intervals on a baby in SVT, the next I sit in the warm darkness of the reading room and read the Echo. If I’m late, or if I have a meeting and need to leave early-- it doesn’t matter. The attending will go along seeing the consults and reading the Echos and threading the catheter wire into the femoral artery. I’m superfluous, unimportant. 

It’s such a relief. I love it. I tell N. that for the first time in a long time I learn something and just think: whoa!! That’s so cool! They way I used to in biology class, isolating immunofluorescent protein, that time in lab we combusted magnesium and it glowed as bright as anything I’d ever seen. The satisfying feeling of looking at something many different ways and then finally a *click* of understanding. 

In college I was quickly bored with knowledge-for-knowledge’s sake, but I couldn’t guess at how pragmatism shifts the joy of discovery. I have many aha moments still, but they’re always girded by fear, the worry that I should have known this sooner, the anxiety that I’m already forgetting it. Don’t miss this, is how we learn diagnosis. Don’t forget to screen for this, is how we learn management. There is a real urgency to what I learn. 

I don’t know that I’d trade it to go back to the classroom, diagramming sentences and methodically writing out my lab reports. I never need convincing to get up and go to work. I never have to look far for the consequences of my actions. I’m grateful that there are many to teach me this odd and anxious craft. I understand better than ever the limits of knowledge, the way we are all always trying and falling short. But I’m still beyond-thankful for the days when I show up as an observer, chewing through textbooks for fun, spinning the model of the heart in my hands. Today the valves and ventricles and plaster and not tissue, there is no sleeping baby’s face just a few centimeters above my stethoscope, the model is heavy in my hands but the heart is so, so! light

[theresidentdiaries]

Don’t lose your idealism. You have a lovely way with patients, hold onto it. How many times have I received variants of this feedback? I heard it all the time, especially as a student. 

The first few times I heard it my heart leapt that doctors many years more experienced than me didn’t dismiss idealism as naïveté. It felt validating to hear that my efforts were interpreted not as impractical impossible standards, but that my vision was something honorable, something to be aimed at. 

Later on, in the depths of third year, I’d wonder if there was some dark echo to those words. A dare to accomplish something the resident believed was impossible. You better hold on, grip tightly to something that forces will unceasingly wrest from your grasp. 

And now I’m the one giving feedback. I wonder if I misheard the echo, if it wasn’t cynicism so much as its harmonic, an odd kind of envy. If they recognized that vision because it had once been their own, if their words were as much to themselves as they were to me. Did they recognize themselves, with a sad pang, did they ever want to be back where I was, freshly-started, unbound, unbeholden to an institution, a career path, the fraternity of all of us who have seen endless death, who have called CPS, who have inserted the central line despite the screaming of the demented patient, who have discharged the patient begging not to go? 

[theresidentdiaries]

Last night I found a collection of stories about Bellevue hospital in the workroom. I skim one and its vivid and emotional, the accounts of a med student just at the beginning of her training, a silent observer in the corner of the OR and the exam room. 

I remember the feeling. Like being allowed in some sacred, diabolical theater. The challenge of familiarizing myself with new norms and an entirely new culture, how I loved to find a way in the cracks, befriending my patients, suspicious of my attendings. Every day was filled with stories, moments that I couldn’t escape unless I transcribed them. 

But the writing-voice is gone. Two years into residency and 6 into my medical training, the bizarre customs of the hospital start to become invisible to my eyes. I understand why and how the hospital works, start to inherit that this-is-the-way-it-is mentality, even as I resist it. The most profound ache is the stories, which suddenly all seem futile and desperate and not worth telling. I no longer figure as the quiet determined underdog in the corner, aghast and passionate and determined. 

Here I am, a main player, dictating the treatment plan and the discharge date. Rolling my own eyes. Letting my exhaustion get the better of me in the workroom. Like the residents I worked with, I can fake it even on the worst days. My people-reading, expression-controlling social skills have only gotten better. I don’t think I look like the callous, jaded doctor. But behind my actions I miss the feeling. The sense that these were unique, important stories. By now, there’s nothing fresh or compelling about human pain. 

Who did medicine make me? I wonder, driving home after my 7 or 9th night shift. I was politically radical, determined to be kind, desperate to make somebody else’s life better because mine was arbitrarily so good. My convictions weren’t so dogmatic, just stubbornly held, a belief that we deserved a fair, just world. In medical school I felt right at home, embraced a patient-centered curriculum designed to keep me principled and idealistic. 

Someone in the last two years that center receded. I didn’t stop believing those things with my head so much as my heart. After my 10th or 15th admission for non-accidental trauma (child abuse), after the 20th or 30th time I’ve been yelled at by a patient, all the times we do everything and the patient still dies, every weekend and evening and night shift I work, every time I curse the hospital and the system and the EMR and the administrators like the old doctors I used to roll my eyes at-- something slips away. 

I know that this is probably where I need God, this is the moment begging for true faith, for me to fake it as generously and sincerely as I can. To believe that there is a possibility of the perseverance of love. 

[theresidentdiaries]

I left a message on your voicemail in the middle of the night, told you to call back, my voice just this side of breathless. It was the end of my shift so we never spoke, but when you called back, panicked and fearing the worst, I know what was said. We told you he died in the middle of the night, that we tried for 45 minutes to bring him back, that we couldn’t.

We didn’t tell you that you tried to get up when your heart went into the arrhythmia, confused and not yourself. We didn’t tell you that you were too big up lift up to the bed. We didn’t tell you that your chest tubes got dislodged and when I walked in there was blood all over the floor. We didn’t tell you that we coded him on the floor on our knees, covered in his blood. We didn’t tell you after a few rounds of chest compressions you got a pulse back briefly, fought us, that it took all of us to keep you still.

We didn’t tell you how the blood from your fresh incision kept soaking through the defibrillator pads. How many, many times we shocked you. How there was no one from your primary team in the hospital so I had to call your wife, barely remembering your name. How we worked on your for 45 minutes, pushes dose after dose of epinephrine, of bicarb, of amio. How we knew you were dead but kept going because you were so young. How we cycled in and out, over and over, bringing our whole weight out over your chest, pushing your sternum in.

How they waited until I called you to end the code. How the 45 minutes seemed to pass like seconds. How we felt your body stiffen and cool beneath our gloves. How after time there was no rhythm left to shock. How when we were done the floor was covered in blood and gloves and plastic, empty vials of dispensed meds, sharps all piled to the side. How we wrestled your body in the Hoyer left so you could lie in the bed until they came to bathe your body, to take you downstairs.

How it was an hour from the end of my shift and how we washed the blood off our sweaty bodies and went back to the rest of our patients. How your surgeon showed up 45 minutes later and seemed to imply that we hadn’t done enough. How she walked away from that room, shoulders hunched. How I spent my drive home wondering if that was anything else we could have done.

How I sleep poorly, as expected. How I wake up seeing you, still. How familiar I’ve been come with the cold, dead, naked body. How familiar the way the blood drains from the skin, how it happens before my eyes. How did I become this woman, dreamer and harbinger and dealer in death.