“Your next patient is in Room Four,” the doctor quickly said to me as he darted into another room. I grabbed my computer and scanned the name and age of the patient. “Fifty-eight years old… this shouldn’t be too bad,” I thought as I opened the door. I had a number of complicated patients that morning, and I was looking forward to an easier encounter.

I laid my eyes on my patient; she looked significantly older than fifty-eight. She was hunched over with her sweater wrapped tightly around her. Her thin legs dangled from the bench, and she had a grimace on her face. I was surprised by her fragility, but I smiled anyways and introduced myself as I opened up her chart on the computer: “Hi Catherine! So what brings you in today?” It was my routine opening line.

“I’m here for a follow-up,” she whispered to me. This was the routine answer I expected to my routine question, and I prepared myself to discuss lab results and dietary counseling. But then my eyes stumbled upon the words on my screen that seemed to be staring back at me: ‘Lung cancer, metastatic to the bone.’ I caught my breath. Before I had a chance to respond, Catherine quickly thrust a piece of folded paper into my hands: “I got an MRI last week of my brain; here are the results.” Still shocked by the discovery of my patient’s history, I slowly opened the paper. Nothing could have prepared me for what I was to find.

“Metastatic lesions to brain,” my voice trailed off as I realized what I was saying. This can’t be happening, my mind quickly raced. Sure, we had so many workshops and sessions over the past three years all meant to prepare us to deliver bad news but, somehow, all failed to prepare me for Catherine. I fumbled, and Catherine started to cry.

“What do you do when you get your results, and you find out you have BRAIN CANCER?” she sputtered out through her tears. I felt the wetness of my own.

I felt my feet take me to my patient’s side; my arms enveloped her. “It’s going to be okay,” I found myself saying even though I wasn’t sure if I believed that myself. I felt lightheaded as I continued to ask her about her support system – her daughter who worked nights and slept during the day – and how she was feeling – unbearable bone and nerve pain and excruciating migraines. As we continued to talk, she answered my questions less and confided in me more. She had just finished her second round of chemotherapy. She had lost ten pounds in the span of a month since her last visit.

“They told me to start drinking Ensure,” she said. Our eyes locked and she seemed to shrink once again. “I went to the store to look for it, and it was too expensive. I am on government aid, so I couldn’t afford it,” her voice wavered. I felt a pit hit the bottom of my stomach. I thought about the sandwich I had consumed just an hour prior, shoveled in to quiet my hunger without a thought.

My mind raced without going anywhere as we sat in silence. Suddenly, an image flashed into my head of the clinic’s physician assistant, her hands full of Ensure. My mind started to race again, this time going somewhere. The words began to spill out of my mouth: “I got it! I think we might just have some samples of Ensure in the back, and I’ll go pull up some coupons and print them!” As my words sprinted into her ears, her face brightened and the corners of her mouth began to suggest a smile.

“Really? You really mean it? That would be … I don’t even know…”

I charged out the door on a mission, turning to her and telling her I would be right back. I ran to the hall where I found the PA.

“Question! I saw you with Ensure this morning, do we have more?”

As soon as she confirmed, I ran to the sample closet and saw the Ensure bottles, glistening in a row like trophies. I swept the whole collection into my bags. To my delight, I saw a stack of Ensure coupons lying on the counter. I grabbed a handful and stashed them with the rest of the loot. My attending walked in as I struggled to loop my arms through the straps and carry the precious prize to my patient’s room. I froze. We stared at each other, and he asked me slowly, “What are you doing?” I was silent for a moment, then suddenly words spilled out: “My patient has cancer and is dying and can’t afford Ensure and I didn’t know what-”

He raised his hand to stop me and directed me to put the bags down. As I slowly set them down, he could sense my disappointment. “We will still give them to her; I just need to figure out what’s happening,” he explained. He then escorted me back to the patient room.

We sat with Catherine, and I could see his mind motor whirring as I relayed everything. As Catherine sat and listened, her bodily nutrition on the line, he turned to me and said, “Go get the bags. And go get all of the coupons.” My heart swelled up with joy as I skipped out of the room to grab the sacks. When I returned, her eyes welled up with joy as I showered her with all of the different flavors of Ensure – strawberry, caramel, chocolate.  She whispered to me that she had just run out of food stamps and that this was a blessing. The rest of the visit was a blur – my attending was able to register Catherine for free, delivered Medicaid meals among other resources.

As she left, I held the Ensure and asked her if she needed help carrying it out. She declined any more assistance from me and gave a toothy grin as we embraced: “I have cancer, but I’m not done yet.” For the first time that visit, I could hear newfound strength in her voice. I watched her grab the bags and walk out the door.

As I leaned back on the wall, memories of late library nights and long lectures washed over me. I thought about the times I had awakened only to find myself sleeping in a sea of books and lecture notes; I thought about the early mornings that I left my apartment and the street lights were still on. I reflected on the tears I had shed and the times that I felt I had no more to give. Catherine had reminded me of why I had started this journey in the first place. A feeling of purpose surged through my heart as I finally understood what it meant to treat the patient, not just the illness. My cheeks ached from smiling and, as I watched her through the window, I heard my attending call out to me, “Your next patient is ready for you in Room Four.”

Image credit: 4” (CC BY-NC 2.0) by Gerard Stolk ( vers l’ascension )

The post Patient In Room Four appeared first on in-Training.

An anticipatory aura weaves through the calm moments in an otherwise crazy and chaotic place; there is a sense of impending excitement. A pulse remains palpable, but not at the known pinnacle. Like an early Sunday morning in New York City or a football stadium the night before a game, it is a hospital on a holiday weekend.

This is my first experience of how quickly peace can burst into bedlam in medicine.

Finishing my morning tasks, an infamous call rings overhead: “Code Blue!” Another team drops their work and sprints out of the room. Stunned, I look to my senior resident for clarification. He senses my confusion and explains that the team is on-call and thus responsible for attending the code. I feel an urge to go despite not being technically responsible. As I navigate the hospital halls, I recognize the juxtaposition: my colleagues race to the room, unable to get there fast enough, whereas I am walking slowly towards a literal life-or-death situation. I wonder, Should I pick up the pace?

As I approach the cardiac intensive care unit, I can appreciate a growing intensity. Rounding the corner, there is a mass of people standing outside the patient’s room where the coordinated chaos unfolds. I maneuver my way into the front row as if at a concert and watch helplessly and curiously with my fellow medical students while the seasoned team carries out the code.

Someone calls for help with compressions. Removing my white coat and rolling up my sleeves, I ready myself to get my hands dirty, metaphorically, while I frantically rehearse my training: the pace of “Stayin’ Alive,” pushing hard enough to crack ribs, the proper technique and placement of my hands. “Pulse check!” The resident previously performing compressions exhaustedly jumps off the bed, sweat running down his face.

“No pulse. Continue compressions!” It is my turn. I jump next to the patient’s side and begin my first compressions not on a manikin. Struggling to stay focused despite having only one job, I concentrate on the task beneath my hands. Keep going, bud; do not let this patient die, I think. My gaze slips towards the patient’s head. His eyes are open and lock with mine. I think he blinks. It is working; he is going to make it!

“Come on, Matt,” yells the resident leading the code. I leave his eyes and focus on his heart. Another pulse check is called and is negative; I stumble back into the forming line of medical students waiting for their chance to audition for the role of doctor.

Tired and sweating, it is then that the gravity of the situation sincerely dawns on me like a new sunrise that this man may never see. I overhear nurses outside of the room ask if the family is aware of the situation and on their way to the hospital. I feel myself choking up but commotion causes me to swallow my thoughts away.

This cycle runs for 45 minutes with each successive round stealing and suppressing our hope. Heads weighed down by exhaustion, the senior members glance at each other out of the corner of their eyes. Do we call the code? No one wants to be the first to break. The attending physician finally whispers to a resident. Code Blue is officially over, with the following silence pierced only by sweaty gloves ripped off defeated hands.

Out of breath and out of hope, I languish out of the room to retrieve my white coat. I make eye contact with a terrified family member of a patient in an adjacent room. How horrifying must that experience be for the friends and family of patients in that unit: they just witnessed umpteen clinicians battle for the better part of an hour to save an individual who was in a similar state of health to their loved one. His wide eyes look on as we gather ourselves and disperse, defeated by the same disease his loved one is fighting.

Other students return to their teams to round, the residents discuss how they will break the news to the family and the support staff begins to clean. I am struck by this abrupt return to routine and feel myself lagging behind, trying to process my thoughts. A life just left this world, but the world does not wait. Time moves forward.

A couple weeks later I experienced my second Code Blue. Running to the room this time, I immediately took off my white coat and tie, put on a pair of gloves and positioned myself at the bedside. The room seemed more composed than my previous experience — or perhaps I was more composed, more confident in my role. I knew the drill. A pulse check was called, and I readied myself for compressions.

But the patient had a pulse! Suspicious and reluctant to leave, I remained ready by the patient’s side. Eventually she stabilized, and people began to scatter back to their morning tasks. I followed the crowd, selfishly disappointed with my minimal participation but with both my breath and my hope intact. I picked up my white coat and tie. After this code, it was I who was hastily returning to rounds with my team.

This is medicine, and this is a space in which we grow comfortable. A routine day can quickly convert to life-saving measures. Sometimes we succeed; oftentimes we fail (specifically in regard to cardiopulmonary resuscitation). Regardless, we must collect and compose ourselves and return to our duty; we must be prepared for the next Code Blue.

This is not to say that we should not take time to reflect and learn, especially in the moments akin to a sleepy Sunday morning after a rowdy Saturday night. But we must always continue to push forward with the hands of the clock. Our current and future patients depend on it.

The post Code Blue appeared first on in-Training.

Asking someone if they want to kill themselves becomes easier every time. The appalling part is how quickly this and other taboo personal questions became a normal part of my routine. How would they do it? What drugs do they use? Do they hear things that no one else can? Gathering this information is a critical part of my job and necessary for taking care of patients, but sometimes I feel like an emotional trespasser.

As a medical student on my first clinical rotation in psychiatry, I am repeatedly surprised by the calm acceptance and honesty with which my questions are usually answered. I’m still getting accustomed to this new position and the privileges that come with it. When one of my patients, a man fifteen years older than me, respectfully answered all of my intrusive questions with “yes ma’am” or “no ma’am,” I couldn’t help but think how I still address my friends’ parents as “Mr.” and “Mrs.”

I feel even more uncomfortable behind the locked doors of the inpatient unit, where the discrepancy in knowledge and autonomy between patients and providers is more striking. Most of the patients have little insight into the reason for their hospitalization, let alone how their drugs work or why they are taking them. This is not distinct from other areas of medicine, but many psychiatric patients’ distorted perceptions of reality make this gap more pronounced. Our limited capacity to help them understand what is happening with their bodies is frustrating and makes me feel aloof and paternalistic.

This chasm between us sometimes results in providers discussing patients as if they lack intelligence or autonomy and inhabiting different versions of ourselves in front of patients and behind closed doors. It is not the manic patient following the security guard around within three inches that makes me sad; it is the sense that she is somehow the only one left out of the joke that makes me feel guilty.

A middle-aged schizophrenic man quickly became my favorite inpatient. Despite his extraordinary doses of anti-psychotic medications, he continued to experience hallucinations commanding him to punch walls. He would greet me with a smile and tell me he was okay each time we passed, even when his bandaged hands and trembling jaw said otherwise. I would see a glimmer of the person he used to be and somehow feel better. If his upbeat and friendly personality was still recognizable underneath his mental illness, it seemed possible that he could recover to live a happy and less tortured life.

My second day was the first time I was yelled at by a patient. She exercised control in one of the only forms she had left: refusing to allow me into the room. I was disappointed, but didn’t fault her. It is hard enough to have an audience sit in on your doctor’s appointment, even without feeling paranoid and trapped by involuntary commitment. I waited patiently outside, back against the wall, and tried to look busy in order to avoid questions from patients that I would not know how to answer. I realized this was the first time I avoided talking to my patients and feel ashamed I put my comfort above theirs.

When I left the unit at the end of that day, I sheepishly scanned over my shoulder for patients that might try to leave with me. I’m not sure if I was more afraid of being rushed from behind or looking foolish, but both thoughts embarrassed me as I returned to the comfortable student housing across the street.

Sitting on the roof of our building one evening, I video chatted a close friend and showed him the scenic view of the nearby harbor and beaches. I recognized a handful of psychiatric patients in the courtyard as I panned across in the other direction and wondered if they could see the sunset over the high fences that enclosed them. I tried not to think about it, but decided they probably could not.

The most jarring aspect of my first clerkship has not been the onslaught of pathologies, unfamiliar brand names or new EHR; it is the constant confrontation with vulnerable patients that challenge the way I see myself in this new role. I am exhilarated to finally be involved in real care, yet simultaneously terrified to be viewed by patients as a powerful authority figure when I am so acutely aware of my own shortcomings. Until now, students were rarely presumed to have answers; the warm security of being accountable only to oneself has been stripped away, and I am fearful I will not be up to the task. My hesitancy to speak with patients in the hallway that day makes me worry that my desire to be comfortable outweighs my desire to jump in and help.

After being kicked out of an interview today, I went for a walk with another patient experiencing delusions. I was nervous the entire time, but recognized that she was too. There was help for both of us right around the corner whenever we needed it.

The post Jumping In appeared first on in-Training.

During the third year of medical school, you collect many new numbers and contacts, and your phone’s contact list becomes filled with labels like “Bridgit OB resident,” “Bill RED medicine” and “Med Clinic Downtown.” The list grows day after day as you collect the phone numbers of clinics, social workers, residents, schedulers and physicians. You hoard these numbers in case you need them. 

Each number carries with it memories and, inevitably, some of them hold more meaning than others. Though sometimes you feel like just another face in the long line of medical students that residents and attendings see every year, you sometimes feel genuinely useful or like you connected with these people. Either way, each of these people shaped who you will become as a doctor. They are memories and experiences that made your third year what it was: learning, facing mortality and growing up.

As cliché as it may sound, the small moments usually affect us more in the long run than the grand gestures or feelings of intense consternation. For me, one such moment occurred during my surgery clerkship. I had been invited to the General Surgery Journal Club. In the sweltering heat of a southern summer, I dressed as crisply as possible because I had no idea what to expect. While I embraced this opportunity, I had only been invited because another medical student had fallen ill.

I arrived an hour early, afraid to be late for the meeting. Two other male medical students arrived shortly after. They were both sons of different surgeons in the community and seemed to know everyone at the meeting. The residents and attending physicians slowly trickled in, and the other two students greeted them accordingly as I stood there attempting introductions. 

Being the daughter of a railroad conductor and actuary, I felt so out of place. Everyone sat down to order, and a female intern sat down next to me at the large banquet table. I was poring over the menu, which was filled with items I had never heard of before. The two other medical students were on my opposite side. Even though they were my colleagues, I felt too embarrassed to ask them what prosciutto was. In hindsight, I had heard of it, so I shouldn’t have been so nervous. However, I was frozen with anxiety in the moment. I didn’t want to order something and then not eat most of it. What kind of impression would that have made?

I noticed that the server was beginning to make her way around the table to take orders. I must have looked petrified as I frantically wondered what to do. 

After a few moments, I bashfully asked the female resident next to me, “What is prosciutto?” 

She leaned over and whispered, “It’s fancy bacon; you’ll like it.” 

After all of these years, I still remember this moment and still look up to that person. The rest of the night was much less memorable. I eventually asked her how intern year was, and she said that it wasn’t as terrible as everyone said it would be. She showed me pictures of her dog, baked goods and cool surgeries. Although it was arguably a tiny moment in the course of a life or even an evening, it put me at ease and convinced me that maybe I did belong at that table. After all, she was the kind of doctor I want to be.

While there are phone numbers for people you wish to emulate, there are also numbers for  attendings and residents whom you don’t want to be. You might eventually delete these numbers because they remind you of frustrating, demoralizing or even appalling times. However, I sometimes keep these numbers as a reminder of what I don’t want to be. I don’t want to tell horror stories here; that is not my goal. I prefer to recount the beautiful moments of the hospital today: the girl who went home three days after her heart transplant, the candy off the secretary’s desk, the long stories with patients, the laughs shared with classmates and residents. 

Many small, almost insignificant moments, during medical school led me to surgery, and many of these moments were brief pockets of joy in the sometimes overwhelming drawl of medical school. I think of the third-year medical student who took the time during my first year to show me how to scrub. She gave me her number and told me to text her if I ever had questions about the surgery clerkship or medical school in general. I think of the surgeon who — instead of yelling at me — taught me as we discussed our favorite Adele songs in the operating room.

These moments have stuck with me, serving as reminders of what I want my future to be. I want to laugh with others. I want to support others. I want to be the kind of doctor who tells the clearly distressed student what prosciutto is.

The post Prosciutto appeared first on in-Training.

During third year, I was not looking forward to my infectious disease rotation in the HIV clinic. I was worried I would only see sick, suffering patients with a complicated and chronic disease who could not be helped. And I decided to become a doctor because I wanted to help. I also wondered what made an HIV clinic different from any other clinic. The disease and treatment options are set… the patients just take hard-to-pronounce antiretroviral medicines and get Pneumocystis pneumonia, right?

Wrong. The HIV clinic was one of my favorite rotations in all of third year. It was often emotional for me. Many uninsured, low-income patients came to the clinic not only for their HIV treatment, but also for comprehensive primary care thanks to the Ryan White program. I performed a Pap test on a patient who was at higher risk of cervical dysplasia due to her HIV infection; she likely would never have gotten a routine Pap test elsewhere due to her socioeconomic status and lack of insurance.

One of my most memorable patient encounters came in the form of a young mother newly diagnosed with HIV. She came to the clinic with her daughter after a screening test and a confirmatory test came back positive for HIV infection. She had been feeling fine with no symptoms, so she was taken aback by the diagnosis. She asked us if we had ever heard of the test being wrong.

She told us that she did not use intravenous drugs or engage in risky sexual behavior–surely, this was a false positive. Just recently, she had moved back in with her mom to escape a bad relationship with her daughter’s father. As she began to believe the tests, she spent a portion of our visit speculating that her exposure must have come from this relationship. I sat and listened to her speculate about her previous partner’s lies about his negative STI screening while her daughter happily played with my stethoscope.

My preceptor eventually and tactfully stepped in to ease some of the stress our patient was feeling. She reminded the patient that our primary goal was not to find out exactly how or when she was exposed in the past, but rather to treat the current infection and keep her healthy going forward. We explained how far HIV therapy has come in recent years: treatment now exists in the form of a single, once-daily pill, and if she takes this pill consistently, there will be no decrease in life expectancy.

Next, we talked about safety and transmissibility. I reassured her that her new HIV diagnosis did not mean she could not kiss and love her daughter the same way she always had. With that allowance, I could see the patient relaxing and preparing herself to conquer this diagnosis. We also confronted her concerns. For instance, she was not thrilled about the size of the pill she had to take for the rest of her life (understandably), so we reinforced the increased risk of opportunistic infections and anti-viral resistance and thus, the need for compliance.

Then, she had a question that neither my preceptor nor I knew how to answer. She described how she usually chewed some of her daughter’s food for her to help her eat and was worried about transmitting the virus this way. A true mother bird. My preceptor and I told her we would look into it while the nurses drew up some labs. After wading through an abundance of literature, I found case reports that showed transmission of HIV attributed to premastication of food. It was likely through a sore or cut in the oral mucosa and the risk was extremely low, but it had happened at least once. I felt defeated as we returned to tell her what we found: the risk was small but real, and we did not recommend she continue to chew up food for her daughter.

For some reason, I found delivering this small piece of news almost as difficult as telling her she had HIV. Our advice affected her maternalism. I realized that I wanted this patient to only have to deal with one bout of bad news that day. I wanted so badly for the rest of the appointment to be filled with reassurance and wins. Fortunately, our patient took it in stride, rubbing her daughter’s head and telling her it was time to be a big girl and eat by herself now. She told her daughter she would be just fine. Or maybe she was telling herself.

It was a long appointment full of ups and downs. Not only did I learn more about HIV than I had ever known, but I also experienced how to deliver news and talk through difficult subjects. Something that sustains me when giving bad news is the thought that, in a way, we are also giving patients the chance to hunker down under the weight of it and show off their strength. Doctors are highly trained bearers of news–good and bad. Even as a medical student, I feel the strain after a long day of telling patients things neither of us wants to hear.

It is truly a wonder that doctors are able to continue practicing for years despite the burden of compassion fatigue. Still, we dedicate many years of our lives to train in the art of medicine and communication. Just as we learn medicine, we also learn how to educate and impart information in the safest way possible while remaining empathetic to our patients. Though my time in the HIV clinic impacted me deeply, it did not necessarily alter the trajectory of my own life. After all, I will never know exactly what my patient felt when receiving the news of her HIV diagnosis, but I will always know how I felt when delivering it.

That visit continues to serve as a pertinent reminder that every time I deliver a biopsy result, listen for fetal heart tones, or check an A1C, I have the potential to change a life. It is not only my job but my duty to accurately and professionally deliver news to patients and to help share the weight of that until they gather the strength to go forth and bear it themselves.

The post A Physician’s Most Powerful Tool appeared first on in-Training.

I studied abroad in Paris for a summer when I was in college. I had taken French classes for many years and was well versed in listing vocabulary, conjugating verbs and participating in skits with classmates in which we pretended to rent an apartment, order coffee or give someone directions. I knew that the transition to immersion in a language that was not my own would be challenging, but I imagined that I would be strolling through the city having witty conversations with the Bouquinistes who sell their wares out of the green booths that line the Seine in no time.

When I arrived, though, I realized I had a few barriers to overcome before my idyllic dream could become a reality. First, I had only had conversations in the structured setting of my classroom, where I already knew the topic before I even started listening — household chores one day, leisure activities the next. Second, I had only been speaking French to my peers, people around whom I was comfortable sounding like I had no idea what I was talking about.

Suddenly, the stakes felt much higher as I entered into conversations with my host family, taxi drivers and shop owners which felt anything but predictable and comfortable. I struggled with performing simple tasks like ordering pain au chocolat at the patisserie near my homestay. My mouth felt full of cotton and my face turned beet red, prompting the person taking my order to switch into flawless English out of compassion and, if the sly smile was any hint, a touch of superiority.

I never expected to have such a similar experience of being immersed in a new language while remaining in the US exactly five years after my summer in France. But the hospital is truly a world of its own, complete with its own vocabulary — rounds, differentials, curbsides, admits. Despite two years of learning the foundations of health and disease in the classroom, discussing topics with classmates in labs and discussion groups and performing exams on standardized patients, it felt like it was once again my first day of medical school when I started my rotations in the middle of May.

This time, the chilly interior of the hospital was my destination for the summer’s adventure. Everything moved so quickly, and it felt like no matter how closely I reviewed a chart or listened in rounds, there were very big glaring details that everyone else had picked up on except for me. After my first day on the rotation, I did not know how I would be able to make it through the rest of my medical training if it required going back to the hospital again. I felt that there was no way I would ever feel comfortable enough in the hospital to understand what was going on and provide any degree of patient care.

Partway through my first week, I was watching a respiratory therapist draw an ABG when he asked me to “please pass a two-by-two.” I froze, wracking my brain for what that word could mean. Based on its place in the sentence, I knew it must be a noun. I followed his line of sight to the cabinet sitting next to me. My heart was racing, but I figured I would know a two-by-two when I saw it, so I started opening drawers, progressing quickly but methodically from top to bottom while keeping one eye on the respiratory therapist in order to gauge his body language as I tried to deduce what I was looking for.

While I thought I was being quite nonchalant about my search, the nurse clearly caught on to my cluelessness quickly. “There, on the left,” he pointed to a small stack of square gauze, two inches long by two inches wide.

That feeling of my brain racing to take in a situation and use context clues to interpret an incomprehensible phrase felt oddly familiar. Suddenly, I was back in my homestay, and my host mother was giving me instructions as I headed out to meet some friends. “N’oublie pas à fermer la porte à clé,” she said as I walked towards the door. I paused. Like in the hospital, I knew most of the sentence. Almost all of it, in fact. “Don’t forget to close the door…” But then what. I did not understand the last word, and I had the sneaking suspicion that it was the most important one. I looked at my host mother. I looked at the door. Still hoping to make a good impression, and optimistic that my host family still had not caught on to the fact that I only understood about 50% of the words they used, I nodded and continued on my way out, fingers crossed that the last word would click into place once I was safely on the other side.

My host mother, however, could see right through my façade and followed me into the hallway. She took my keys from my hand, stuck them in the door, and twisted. “Voilà, c’est fermer à clé,”she smiled, handing them back as I realized that I did know the word clé, or key, and that she had been asking me to lock the door behind me.

Thankfully, that moment with the respiratory therapist came early on, because the sheer shock of not knowing a word in this environment for which I had spent the prior two years training helped me to realize that I truly was learning a new language, one that I was finally being immersed in. And, slowly, things felt a little more familiar each day. I gradually began to understand what was being discussed on rounds and became able to present on my patients without stuttering over every word.

Towards the end of my summer in Paris, I stopped at an outdoor marché to ask a vendor about the scarves he was selling. We chatted for a few minutes, and as I was about to leave, he asked me if I was Canadian. I took this as a huge compliment after spending the entire summer being easily pegged as a language-learning American; I had a different accent, sure, but he thought that I had been speaking the language from a young age. Even more importantly, the satisfaction I got from finally being able to express myself in the language that I had dedicated so much time to was indescribable.

Similarly, at the end of my final week on the wards, I stopped in to see a patient I had been following for a few days. Her family, who had not been present during rounds, had a question about the plan for the day. During the preceding months, I had always deferred to my default answer of “let me go check in with the team and come right back to let you know.” This was only partially because I did not always know the answer; even when I did, I was hesitant to explain things because I was unsure if I would be able to say it correctly.

This time, before I even realized what I was doing, I found myself clarifying a few points about the patient’s treatment and explaining what that would mean for her when she returned home. I had not initially realized that medicine was a foreign language, but the process of immersion is proving effective once again.

The post Two Summers Abroad appeared first on in-Training.

“Time of death: 12:26 p.m.”

Hearing those words on the first day of my Intensive Care Unit (ICU) rotation was surreal when just a few hours ago we were discussing the patient’s status during rounds.

That morning, my attending informed the ICU team that we should be preparing for the worst for this patient, as Do Not Resuscitate (DNR) status was established per the family’s recommendation. I hadn’t realized it would be this soon.

Being in medicine, I am frequently numb to the idea of death, and my emotions are walled off from my professional identity. To me, feelings are often overpowered by the volume of work that requires attention. As I passed by that patient’s room, I noticed that it was dark inside and the curtain was closed, with the soft sound of sniffles heard just beyond the barrier. My brain had no time to fully interpret that information before my resident beckoned me to see our newest patient. 

John Doe: unknown male, unknown age, coming in from the field due to a possible overdose, coded once in the emergency department and transferred to the ICU. We tried to work as fast as possible – drugs, oxygen and a plethora of maintenance. When he seemed fine enough, I was whisked off to another task on another patient. After all, my resident and I had seven ICU patients to take care of; there was no time to fixate on any one. I was so frazzled by the endless avalanche of items to check off the list that I was relieved when it was finally time for the medical student lectures — even though it was only day one of my rotation.

When I returned to the ICU after lectures, things seemed to have settled down. All the patients were tucked in, all appropriate workups were completed, and the resident was enjoying her few minutes of restful peace. Lost in my thoughts, my eyes passed over the telemetry monitors. The monitors tracking the heart rate are always beeping; the patient in bed 10 was bradycardic, and another in bed 22 had some a-fib. Once again, I found myself indifferent to these sounds that signify life. A moment later, a red blaring word caught my eye — “asystole.”

Often, nurses remind us that patients constantly knock off their leads so that their rhythms cannot be properly read. So, thinking this was misread, I casually approached bed 14. I peeped inside to see a frail man lying still, sleeping. He was peaceful, almost as if in a trance. I glanced over at the monitor which confirmed the flat line. Alarmed, I informed the nurse and we both entered to check if there was a need to replace leads. To our surprise, the leads were in place. The nurse instinctively checked for a pulse.

Pulseless. How long? Why did no one know? The nurse yelled to call a code and immediately began chest compressions. Some nurses did not bat an eye while some seemed surprised we were even calling for a code. I reiterated to call a cardiac arrest (Code 99), and soon over the announcement system, the entire hospital was booming with the announcement of what we had found: “Code 99, fourth floor ICU. Code 99, fourth floor ICU.”

My adrenaline began pumping almost as if to make up for his non-pumping heart, and I was invigorated to be of use in this patient’s revival. I started a round of chest compressions as the code team arrived. A beautiful display of collaboration was in play during the code — the entire team of doctors, nurses, pharmacists and respiratory therapists choreographed to resuscitate the patient. Each team member was rapidly falling into their roles like the pieces of a puzzle, communicating and displaying their strengths while utilizing their skills to the maximum. 

Ten minutes into the code, I heard the announcement system again, shouting, “Code 99, fourth floor ICU.” It struck me as odd that the announcement was repeated so late, given we all heard it at the beginning of the code. A nurse ran to our room asking for help at bed 17. My heart dropped. The code team quickly realized that there was another simultaneous Code 99, this time being my John Doe.

At that point, we split in half; one code team properly trained to focus on one Code 99 was spread thin across two patients simultaneously. Without the strength of a complete team, chaos ensued. I continued helping on the first code. Shortly thereafter, I enjoyed a sigh of gratitude because my current patient’s pulse returned. 

Without taking another breath alongside the resuscitated patient, we all rushed over to John Doe to assist. The code team was reunited. Unlike our older patient in bed 14, we had no information on John Doe. So, we started by going through the ACLS protocols to identify the cause of his cardiac arrest. Not more than 15 minutes into assisting with John Doe, a nurse asked for the team to immediately return to our old man in bed 14, whom we had just stabilized not ten minutes earlier. Overhead confirmed yet another Code 99, and the code team split again.

At this point, those assisting in chest compressions were drenched in sweat, flushed bright red and physically drained. Our minds were fatigued and split between two rooms, precluding us from working at our best. John Doe thankfully regained a pulse 38 minutes into his code. But it seemed that both patients were teetering on their last breath, as were we. Bed 14 continued to crash with all resuscitation efforts temporarily successful only for his weak heart to fail just a few minutes later. John Doe ended up on the maximum dose of vasopressors, and without any family or friends to contact, we were clueless as to what his wishes would be.

The disarray endured while the team was rapidly trying to make a final — and I mean truly final — decision on John Doe. The code team worked on the two beds for two hours until, at 4:24 p.m., John Doe was pronounced dead. 23 minutes later, tears of sorrow and loss emanated from bed 14 as we pronounce the old man’s time of death at 4:47 p.m.

A classmate also working in the ICU and I left a bit jittery and exhausted from the day’s events. Throwing a few jokes at each other, we tried to communicate: “If one more thing goes wrong, like if someone honks at me or cuts me off, I’m just going to lose it!” My mind was unable to focus on anything related to medicine; it seemed as though the mental exhaustion was manifesting itself in a pounding headache to match my sore muscles.

We parted ways with partial smiles. My normally pleasant nature was working as hard as I had during the day to cover up something. I struggled to shake off the feeling of something dark growing in me. As soon as I exited the hospital doors, the darkness imploded and I broke down. Bawling, I rushed over to the train to quickly get home to my safe space. But the despair was so great that I needed to veer off to a deserted street to simply cry it out.

I was sad for my three patients. I was heartbroken that John Doe, who should have been a resilient young man, passed so early without saying goodbye to anyone. I was devastated that the families lost their loved ones. I was furious at myself for not being able to do more for my patients. I was resentful that even a large team of medical “professionals” could not save these patients. I felt hopeless that my position as a future physician seemed to have no meaning in the care of these men. I was disappointed that I was not excited to return to the ICU the next day.

After collecting myself and my thoughts, I sought counsel from the only one who could slap some sense into me: my best friend. She gave me permission to grieve for my patients. She reminded me that this grief demonstrates that I care about those that I take care of, and that they are not just a collection of symptoms or diagnoses that I am trying to fix. She reiterated that being vulnerable is not a sign of weakness, but rather a sign of strength, especially in the medical profession. She encouraged me to let out my emotions; this is the best way to confront the strife that we go through. She told me to keep working hard and that I am doing my best — that is all my patients could have asked for.

—–

Grief is a profound response to loss that we experience on the wards as medical students, but we rarely discuss the hardships. We can be stricken with imposter syndrome, feeling so insignificant in the course of a patient’s care that we believe we had no impact on their lives. And when faced with a patient’s death, we often don’t feel warranted to grieve. We sometimes detach ourselves and treat these humans beings like just another patient vignette on a never-ending test.

But we are significant players in our patient’s care. As medical students, we connect with our patients when our residents do not have time to. We learn about their histories, their concerns, their beliefs, and their desires; we learn about who they truly are beyond the hospital room. When our patients die, it is understandable that we feel grief.

Finding ways to support ourselves physically and mentally is the key to our stability. We are physicians-in-training, but we are also humans with a very real set of emotions. So, as medical students and simply as people, we need to normalize the grief that comes with our work. After all, grief on the wards is inevitable.

The Silver Lining

From the outside, medicine is a grand profession — physicians and trainees work together to help those that are in need while saving lives. However, every day we are faced with darkness that does not get shown to outsiders. How we deal with these obstacles truly shapes our experiences within this profession, often leading to physician burnout. This column will focus on some of Rohan’s personal experiences facing the dark sides of medicine, while shedding light on how one can overcome these challenges. After all, there is always a silver lining through the darkness.

The post Grief on the Wards appeared first on in-Training.

The operating room (OR) can be a tense place.  There are times in the OR when only a few words will be spoken for what seems like an eternity. This is a list of words you will not find in First Aid, Dr. Pestana’s Surgery Notes or the NBME Surgery Shelf exam.  Knowing what those words mean and their context will help your situational awareness and learning experience in the OR during your surgery rotation.

4×4 (“Four-by-Four”)

What the layperson might think: a vehicle with the ability to send torque power to four different wheels.
What it means in the OR: a four inch x four inch piece of gauze.

Airplane

What the layperson might think: a flying machine. 
What it means in the OR: tilting the bed (and patient) in the roll axis to expose a lateral portion or change the patient’s hemodynamics.

Army Navy

What the layperson might think: the branches of the military that protect the land and sea, respectively.
What it means in the OR: a retractor with heads on both ends, one wider than the other. I surmise that the “Army side” is the bigger side since the Army has more personnel, has produced more U.S. Presidents, and even has more boats than the Navy. There is no clear consensus on the history of the name.

Bair Hugger

What the layperson might think: someone who hugs bears and spells incorrectly.
What it means in the OR: a plastic sheath/blanket that has a constant supply of warm air piped in to help the patient maintain body temperature in the normally chilly (66-68F) OR.

Bipolar

What the layperson might think: a psychiatric condition that has manic and depressive features.
What it means in the OR: a piece of equipment shaped like tweezers… I mean, forceps! The bipolar is used for cauterization. It provides more precision and decreases the chance of unwanted tissue damage than the traditional cauterization tool, the “Bovie.”

Bovie

What the layperson might think: someone butchering Jon Bon Jovi’s name? A slang term for bovine?
What it means in the OR: named after Dr. Bovie, this is an instrument that has a “cut” and “cautery” function (you will hear this term a lot in nearly any procedure). Some purists may call it “cautery” because “Bovie” is an eponym for the tool’s inventor, similar to the “Kleenex” versus “tissue” conundrum.

Christmas Tree

What the layperson might think: the place where Santa Claus places gifts on Christmas morning.
What it means in the OR: the thing anesthesiologists use to protect their tubes and cords from becoming tangled or compressed. You will likely be tempted to rest your hand or some weight on the “Christmas tree” during a long procedure, and the anesthesiologist will likely tell you to get off their equipment.

The Count (not of Monte Cristo)

What the layperson might think: a royal person who lives in a castle.
What it means in the OR: the scrub tech/nurse accounts for every surgical instrument, sharp object, sponges, etc that may possibly be left inside the patient. The count occurs before the procedure begins, anytime the scrub tech/nurse switches out, many times throughout the procedure depending on personnel preference and local policy, before closing the fascia, and at the conclusion of the procedure. If the count is not correct, there will be an extensive search for the missing item. If the missing item is not found, the patient may need an x-ray to check for retained items.

Cocaine

What the layperson might think: an alpha-1 agonist traditionally used for illicit recreational purposes.
What it means in the OR: can be used as a vasoconstrictor and local anesthetic for nasal procedures.

Donut

What the layperson might think: a delicious circular pastry.
What it means in the OR: a support for the patient’s head to help keep it in place that usually replaces the patient’s pillow after anesthetic induction.

Drain

What the layperson might think: where water goes after you take a shower or wash your hands.
What it means in the OR: a “Penrose” drain is placed in many operative sites to prevent fluid accumulation. Once a drain has less than 30mL of output in 24 hours, it can usually be removed, a great task for a learning medical student.

Gator

What the layperson might think: a hungry carnivore waiting to chomp anything that gets too close to its swampy home.
What it means in the OR: a surgical tool used to grasp in tight spaces, such as the ears or nose.

Irrigation

What the layperson might think: the technological advancement that contributed to humankind’s advancement from a nomadic hunter/gatherer species into an agrarian based species.
What it means in the OR: a turkey-baster-like piece of equipment filled with normal saline that is used to irrigate (don’t use the term in the definition… facepalm), er, clean the operative site of any blood/debris. You will hear this term a lot in nearly any procedure.

Jump Room

What the layperson might think: a trampoline park called Sky Zone.
What it means in the OR: it means that there is another OR waiting for your surgeon usually staffed with another team (anesthesiologist, scrub tech/nurse, and circulator), so that the surgical team does not have to wait for OR turnover/cleaning.

Pedals

What the layperson might think: the part that connects you feet to your bicycle (or tricycle or unicycle)?
What it means in the OR: there are pedals for many pieces of surgical equipment including the Bovie (cautery), bipolar, coblator, scope cameras, etc. Before starting the operation, help the OR staff make sure the pedals are plugged into the right machines and positioned at the correct spot for the operator.

Snow

What the layperson might think: a fluffy form of water that falls from the sky and provides great skiing.
What it means in the OR: Snow, brand name Surgicel, is a hemostatic agent. When used it is usually placed at the conclusion of procedures.

Sponge

What the layperson might think: Bob Squarepants’ first name? A fungi? What you use to wash dishes?
What it means in the OR: Anything used to absorb blood. Laparotomy sponges may also be called “laps.” They do not look like the other types of aforementioned sponges, but rather look more like rags.

Suction

What the layperson might think of: the rubber circles that stick to windows or the cups that Olympic swimmers use.
What it means in the OR: a way to remove blood and or “irrigation” from the operative site. You will hear this term a lot in nearly any procedure. “Suction” nearly always follows “irrigation.” So, look for the scrub tech/nurse to pass you the suction handle after the attending/resident asks for “irrigation.”

Valsalva

What the layperson might think: how to equalize ear pressure when ascending or descending in flight or in water. 
What it means in the OR: the same maneuver but for a different reason. The Valsalva maneuver decreases preload and builds pressure in the venous system. So, it helps expose venous bleeding that might not be readily apparent.

Good luck out there. Take any advice you get seriously, but don’t take it personally. I hope this information helps make you more comfortable entering the OR!

The post A Beginner’s Guide to Operating Room Terminology appeared first on in-Training.

Superficial to deep, deep to superficial,
90 degrees, in and out,
Not too deep, filled with doubt.

Don’t buttonhole; don’t pull too tight;
There is such a thing as doing it right.
(And I’d show you if it wouldn’t take all night.)

Prolene, vinyl, monocryl…
Stop.
2-0, 4-0, 6-0…
Pop.

Needle driver, critique-survivor,
Running subQ, interrupted
by you.

Pick-ups, slip ups, let down:
Anesthesia’s waiting.
All eyes on me.

Superficial to deep, deep to superficial.
Please don’t falter; please don’t break.
I’d do it if there wasn’t so much at stake.

Poetry Thursdays is an initiative that highlights poems by medical students and physicians. If you are interested in contributing or would like to learn more, please contact our editors.

The post Sutures and Stones appeared first on in-Training.

“Well, what should we do for this patient?”

I started violently, perceiving to my chagrin that I had zoned out on rounds again. My heart knocked against my rib cage before I realized to my relief that the attending was pimping the intern for the answer, and I was not under the interrogation light. I delicately turned my sudden startle into a hair-tuck behind the ear, desperately hoping the look of hunted prey had disappeared from my face and forced myself to pay attention. As we stood, I shifted my weight in my shoes and thought about what I should eat for dinner, then realized that my mind had again wandered from the subject of our huddle. To my horror, I realized not only did I not know what we should do for this patient … I didn’t even know which patient we were referring to.

Glancing across the group, I watched my fellow third-year listening intently, and I wondered why I couldn’t do the same. The desire to impress, to compete, to prove myself to this attending whose admiration I desired and whose respect I hoped to garner by the end of the internal medicine clerkship won over the idle ramblings of my sleep-deprived brain. I squared my shoulders and tilted my head to the side quizzically as if caught in deep and perplexing analysis of the case. I was determined to look the part of the astute student, in the hopes that one day I might wake up and realize that my act was in fact reality. I succeeded for about 30 seconds.

My gaze had wandered across the heads of the team to a man standing by the elevator. He looked to be in his 30s. He had a short build. He was wearing Bermuda shorts and a t-shirt with red and white stripes. And he was crying.

I averted my eyes instinctually. Most of us know what it is like to cry in public. We pray that people will have the decency to ignore the very obvious streaks on our faces, because we think that this is the best approach to helping us forget the cause of our grief or our own unseemly public displays. I tried again to focus, focus please, on the patient the team was discussing, but I again found myself looking at the man. He was slumped against the wall near the elevator, holding a cellphone and talking softly into it. For a moment I thought he was collecting himself — rallying the troops, so to speak — until I saw a fresh wave of tears running along the rivulets left behind by their predecessors. I only saw them for a second before his hand moved quickly to cover his face. He began to pace in small circles, still weeping softly while pressing the phone to his ear.

If you have ever been in a hospital hallway, you know it is not a quiet place. Yet for some reason, this man’s grief was deafening to me. I racked my brain for the reason: Bad news, maybe bad news, maybe cancer? We are on the cancer ward after all. Maybe death! Had someone died? Maybe his mom? His wife? Heaven forbid a child…

My agitation grew as I realized I needed to do something, that I should do something. I was a medical student training to be a doctor after all, right? Wasn’t I supposed to help alleviate the burdens of others? Wasn’t half my job to listen? Yet I stood still. Completely still, my feet cemented into the linoleum just as surely as if I was a wax figure without mind or conscience or will.

My line of questioning had seamlessly taken a different course as I stood frozen, my gaze still fixated on the grieving man. What about the team? It would look so bad if I just wandered off as if I hadn’t been paying attention. Well, I haven’t been paying attention, but then I’d be making it obvious. What kind of impression would that leave? What would the attending say? The four week block is almost up, I don’t even know if he remembers my name, but I don’t want him to remember me badly … What if —

A stir of movement at the group’s edge distracted me from my internal barrage of questions. I watched, speechless, as my colleague — same team, same attending, same subordinate role in the medical hierarchy — stepped away from the huddle and walked towards the man by the elevator. I watched as he stood by the man, clasped his hands together in front of him and asked the man a question. My colleague — we’ll call him Jordan — was tall, almost a full head taller than the man, so he had to stoop his head to hear the response. Jordan then put his arm around the man’s shoulders and said a few words. They could not have been more than one or two sentences; I strained and strained to hear what was said, but in all honesty the content was of little importance. The man nodded, and Jordan lowered his arm after giving him a small pat on the back. Then Jordan seamlessly rejoined the huddle, just as surely as if he had never left.

He had strayed from the group for all of 45 seconds. No one had called the dean of the college of medicine to report his absence. The attending had not spouted a tirade of verbal abuse against Jordan’s decision to walk away from the huddle. None of our patients had suddenly coded prompting a team member to suddenly ask, “Hey, where’s Jordan?” No one stood speechless at this obvious act of insubordination; in short, the world had not ended. The only person who stood speechless and in awe … was me.

We live in a world defined by the axiom that “time stands still for no man.” Our lives are a bustling whirlwind of events taking us from point A to point B and back again, and we think our purpose is realized when we achieve this movement rapidly, efficiently and without distraction. I truly thought that I was accomplishing my goal, my purpose, by ignoring the distraction and performing my task. In reality, the distraction was my task. That man was my task, that man was my purpose, and another more genuine individual recognized it before I did.

To this day I still do not remember the management for the patient being discussed by the team. I do not remember the patient’s diagnosis or even the patient’s name. But I do remember the man by the elevator and I remember Jordan. I remember Jordan … because he did not hesitate to step away from the huddle.

The post But The Laborers Are Few appeared first on in-Training.

I proposed a deal to my fellow student on our surgery rotation. “You can have all the other cases today if I get the laryngectomy.”

“Sure,” he sighed apathetically. “Whatever you want.”

A total laryngectomy involves dissecting through the thyroid gland and small muscles of the neck to expose a person’s airway. Intricate blood vessels and elusive nerve fibers are navigated to obtain a clean view, and then the connection from the patient’s mouth to their windpipe, including their vocal cords, is removed. A new hole is created in the front of the patient’s neck that allows air to reach their lungs. Important nerves that affect a person’s ability to smile, move their tongue, shrug their shoulders, turn their head, and take a deep breath are all at risk. At the end of the case, patients’ are left unable to speak. This surgery is usually performed to treat an aggressive cancer, and it is always high-stakes.

Laryngectomies are rare at my training hospital and I did not want to miss the opportunity to participate. My eager feet bolted down the stairs towards the pre-operative area, galloping in asynchronous parallel with my racing mind. I strained to remember textbook images I had reviewed the night before, knowing the anatomy would be much more disorienting in the flesh than in glossy labeled pages.

I restrained my eagerness as I introduced myself to the patient for the first time. It would be callous and insensitive to show such genuine excitement for a procedure that was about to render her permanently mute. She was more weatherworn than I expected; her withered frame was easily overlooked beneath the stack of impersonal hospital blankets specially engineered to shed fewer fibers. Her raspy greeting was barely audible over the maelstrom of surrounding nurses, patients, and alarming monitors. I wondered if she used as few words as possible out of shyness, physical pain, or if she was already trying to prepare for life after her surgery.

When we finally arrived in the operating room, our patient tightly shut her eyes after one glance at the carefully arranged surgical instruments that would take away her organic voice. A heaviness nestled deep in my diaphragm that made each breath feel more drawn out and deliberate. The permanence of what we were about to inflict on this scared woman was oppressive and inescapable. I felt guilty wondering if the surgery I was so eager to be a part of would feel worthwhile to her in the end.

I took extra care in helping to position the patient on the table and explained every step before touching her. “These wraps will massage your legs and help prevent blood clots. I’m going to put them around your calves now.” She silently nodded, and I wrapped them twice around her child-sized limbs.

“These foam pads will protect your heels from developing sores.” Another nod, smaller this time.
“I’m going to place this belt around your waist to protect you from falling.” This time she opened her eyes with a look that wondered if I was crazy, but she nodded a third time.

Per hospital protocol, the full operating room team reviewed our patient’s information and imminent procedure before the anesthesiologist put her to sleep. Sallow, heavy lids shielded her gaze from the harsh lights above, but tears rolling down her cheek betrayed the otherwise stoic demeanor lying supine on the table. The anesthesiologist dammed her silent weeping with sedative medication and two pieces of tape.

Twenty-five minutes later, my guilt ebbed away as I watched the attending and resident dissect down, plane after plane, identifying anatomy in views I had only seen in pictures. I reveled in the novelty of it all. I was having fun. There was no conscious patient for whom I needed to reign in my excitement; I was in the company of surgeons. Jubilant violins and soulful folk singers warbled over the speakers to soundtrack our work. I felt the internal crescendo of each pulsating artery and elusive nerve safely dissected out of harm’s way. I no longer noticed my own breathing or any other feeling in my body; it was as if I was hovering a few inches off the ground, weightless and unrestrained. I felt personally lighter with every lymph node and tissue section removed from the patient’s throat.

After the incisions surrounding our patient’s delicate new airway were coated with bacitracin, everyone in the room broke away for their respective jobs. The attending took his music and left to call the patient’s far-away family. Over the drone of the room’s ventilation, the resident clacked away on a keyboard in the corner to write the operative note. The nurses were at the back table double-checking their instruments to ensure nothing was left behind, while the anesthesiologist read monitors and titrated medications. For a few moments, I was the only person to just stand and be with our patient. I watched her chest rise and fall in the midst of activity that was entirely about, yet did not involve, her at all.

As she began waking from anesthesia, I instinctively reached down and held her forearms to the bed as her hands started to reach up. Patients regaining consciousness can inadvertently injure their eyes and dislodge breathing tubes and IVs, and I didn’t want anything unexpected to happen on my watch. As I pinned her arms to the bed, fear-filled hazel eyes pleaded with mine as I used increasing force to keep her arms down. “Your surgery is all done. It went really well. You’re still waking up in the operating room. Just rest your arms down!” I commanded her, hoping she would stop fighting me.

Tentatively she tried to speak, but had been rendered completely mute by our scalpel. The only sound she could make was a soft pucker from her parting lips. I fumbled through an attempt at lip reading that frustrated us both. She gave up trying to speak and instead of lifting her arms up, she pushed them out to the side. I decided to let go, but she reached out and took my hand between hers. She smiled at me as I finally understood the word I failed to make out moments before: hand. I had been restraining a defenseless, frightened woman from trying to hold my hand.

In my overzealous effort to protect this woman from herself, I lost sight of what was happening in front of me. A vulnerable person who trusted us felt scared and alone, and she needed to be shown that we would be there for her and she would be alright. I moved so blindly through the motions of doing my job that I failed to recognize the most basic need for human connection.

We inflicted massive, irreversible damage to remove a tumor that might kill her anyway. Did we miss the mark there too in our enthusiasm to do good? This woman was counseled extensively about her treatment options, but it is difficult to ignore even the quietest whispers of guilt and self-doubt. There is often no clear answer for when the most aggressive treatment is the best one, and I worry that my excitement for innovative procedures will obscure what future patients need most. I might not get it right every time, but will try to be worthy of their trust, listen to what they tell me, and help them wake up by holding their hands.

The post Restrained appeared first on in-Training.

The electric doors opened. I walked through the passageway to the post-anesthesia care unit (PACU) with Zo, the other medical student on the service. Even at 12:30 a.m., the hallway was lined with people in purple scrubs: nurses, CNAs, and whoever else was staffed at that time. Chatter filled the usually quiet PACU. No beeping, just the light conversation of night shift.

Any time the electric doors opened, there would be silence. “False alarm!” someone would yell, and the chatter would resume. The electric doors opened again, but this time no one yelled.

A hospital bed rolled in. It was Marvin. His last walk. On rounds we would say, “Twenty-two-year-old with GSW (gunshot wound) to the head. Waiting for organ donation.” In the real world, that meant that Marvin had died by suicide.

He had succeeded, but only partially. He was brought in functionally brain-dead, but we had to wait for his brain to herniate to officially pronounce it. His organ donor status meant that we kept him alive until transplant. Finally, after a week of laying in the critical care unit waiting for organ harvest, he was here in the PACU.

Behind his bed, pushed by a nurse, was his family. Ten people. His mother was beside herself. The child she had raised, for whom she had weaved dreams of a wonderful life and whom she had protected from the world, was leaving her empty-handed. As Marvin’s family followed him to the door, their devastation was on display. No longer could they hide behind the curtain of his room or in the comfort of their home. There was nothing else they could do.

Tears filled the eyes of the bystanders. Empathy flowed freely in an area where nurses and doctors usually remained composed. Once the bed made it to the operating room door, each family member said their final goodbye. Marvin’s grandmother leaned over to kiss him. They were handing him over to the doctors and nurses — the vultures waiting for his organs to save another human life. Somehow, it still didn’t seem fair.

In the cold operating room (OR), I stood quietly hugging myself. The transplant surgeons stood at both sides of Marvin with the anesthesiologist at his head. For the first time since I began my surgery rotation, I knew for certain the patient wouldn’t leave the OR alive. Bryan, the transplant nurse, asked for a pause. The eulogy started. This time, I couldn’t hold my tears back. Suddenly, the 22-year-old with a GSW became a whole human — loving rock-and-roll, playing with his pets, and seemingly happy — rather than fragments on a piece of paper.

Unfortunately, there wasn’t much time to linger on my emotions at the loss of a patient and a human being. All too soon, it was time for the harvest.

Zo and I made our way to the head of the bed where I stood on a stool to get a better view of the operation. I witnessed the longest incision I had ever seen. He was exposed, his chest and abdomen just splayed apart. The medical student in me was in awe. The beating heart trembled in the surgeon’s hands: ventricular fibrillation. Over the next half hour, they continued to work on taking the heart out of his body.

Marvin remained alive. His brain had not been functional for a week now, but its remnants lay well hidden under the dressings over his head. Finally, the nurse introduced the infusion that would arrest Marvin’s heart. His blood pressure plummeted. Marvin was gone, and there was no time to waste or grieve. The heart now belonged to a 42-year-old man a couple states away.

Measurements and packaging of the heart finished quickly, and the cardiology transplant team left. The GI team continued to take out the liver and kidneys. Part of me felt exhilarated to see this miracle of medicine, but another part of me just wanted to pause and grapple with the loss of someone I had never spoken to. Finally, only the OR staff was left. We helped them put Marvin in a body bag for a forensic pathologist to examine; he was empty. I thought about his family; how empty they must feel without him.

At 4:45 a.m., we finally walked out of the OR. Placed on the outside of the door was his high school graduation picture. Both Zo and I stared at it. Marvin seemed so innocent and happy, but who knew the chaos that had stirred inside his soul. Silently, we walked through the halls to the call room. Despite the near 24-hour shift, I didn’t feel exhausted. All I felt was empty.

Marvin was my first patient to die and, in his death, he touched me in an inexplicable way. Maybe it was the loss of a life that could have been, maybe it was that I related to his struggle with mental illness, or maybe it was the inconsolable grief of a family. I’m still not quite sure. However, what I do know is that I will never forget him and that feeling: empty.

The post Emptied appeared first on in-Training.

As Coronavirus Disease-2019, commonly referred to as COVID-19, upends domestic and international hospitals, it is also interrupting medical education. On March 17, 2020, the American Association of Medical Colleges (AAMC) and the Liaison Committee on Medical Education (LCME) jointly issued a statement supporting “medical schools in placing, at minimum, a two-week suspension on their medical students’ participation in any activities that involve patient contact.” The recommendation is unprecedented, as there is no evidence that medical students were pulled from clinical clerkships on a national scale during the H1N1 flu pandemic or recent epidemics such as Ebola, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). The joint recommendation by the AAMC and LCME leaves thousands of third year medical students, who will soon enter into their final year of school, contemplating their role in the face of this evolving pandemic.

What makes COVID-19, caused by the virus SARS-CoV-2, uniquely dangerous enough to temporarily pause clinical medical education?

First, the virus is extremely contagious. Epidemiologists quantify how contagious an infectious disease is with a variable called R naught (R0), which represents the expected number of cases directly generated by a single case. While data is still emerging for COVID-19, early estimates from the World Health Organization suggest the R0 of COVID-19 is between 2 and 2.5, meaning that on average every infected person will spread COVID-19 to at least two other individuals. Comparatively, the seasonal flu R0 is slightly above one.

Becoming infected with the SARS-CoV-2 does not necessarily mean a person will develop clinical symptoms of COVID-19. On the Diamond Princess, a cruise ship with infected passengers, about half of the individuals who tested positive were asymptomatic at the time of specimen collection. Although not all passengers were tested for the virus, using data from this cruise ship and applying statistical modeling, researchers estimate 17.9% of individuals infected with SARS-CoV-2 are asymptomatic carriers. This data is important because asymptomatic carriers can unknowingly spread the virus, fueling the pandemic. As such, social distancing is crucial to slow the spread of the disease.

In addition to being contagious, COVID-19 leads to significant morbidity and mortality. The case fatality rate (CFR), an epidemiological term representing the proportion of people who die from a specified disease among all individuals diagnosed with disease, is between 0.25%-3.0%. This estimated range is broad but still significant; the CFR of the seasonal flu is less than 0.1%.

What is most concerning, however, is the stress COVID-19 will put on our healthcare system. One analysis predicts 20.5 million Americans will require hospitalization, with close to 4.5 million requiring Intensive Care Unit (ICU) level care. If the pandemic is concentrated to six months, this analysis predicts a capacity gap of about 1.4 million inpatient beds and 295,000 ICU beds. It is still early, and hospitals are already thin on resources: the Centers for Disease Control and Prevention (CDC) recommends using homemade masks such as bandanas and scarfs as a last resort, some hospitals are converting operating rooms to ICU beds and others are using one ventilator for two COVID-19 patients.

One would think that a healthcare system teetering on the verge of collapse would require all hands on deck, including physicians-in-training. After all, medical students play an important role in the care team: we coordinate care, speak with consulting services and case managers, explain confusing procedures and tests to patients and have time to spend with them and their families. Often, we are able to spend more personal time with the patient than the residents and attending physician on the service.

However, everyday operations are disrupted in hospitals. The American College of Surgeons recommended postponing all non-high acuity surgeries; medical students on surgical services are not spending time in the operating room, but rather seeing consults, many of whom are in the emergency department. But some emergency departments are limiting student activity due to personal protective equipment (PPE) shortages. Medicine services are overwhelmed with suspected or confirmed COVID-19 patients, and as the AAMC previously stated, “It may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19.”

In my experience on a neurology service, there were three patients awaiting COVID-19 results; it is safe to assume there are many more on internal medicine. For clerkships based in the outpatient setting, patients are no-showing or cancelling their appointments or the physician’s office is rescheduling them altogether. This environment is not conducive to learning, which is the primary objective of medical students rotating on clinical clerkships.

Of course, people are still falling ill with other diseases during the COVID-19 pandemic, and they need our attention just as much as before. Some argue that medical students could assume more responsibility with these patients, allowing residents and attendings to focus their time and energy on COVID-19 patients. This idea is fantastic in principle. However, we must humbly remember that all our clinical work is duplicated. Medical students do play an important role in the care team – but it is not vital. During this pandemic, it is crucial to limit patient contact with providers, as clinicians can serve as unintentional vectors.

There are over 20,000 third year physicians-in-training at more than 150 medical schools in the country. Marc Lipsitch, an epidemiologist at Harvard School of Public Health, predicts at least 20% of the world’s population could become infected. Applying population data to third year medical students suggest that about 4,000 third year medical students will have COVID-19. Of these cases, about 700 would be asymptomatic carriers, potentially spreading the virus to other students, providers and patients. (These analyses do not consider that, as student physicians, medical students are at higher risk of becoming infected.) Importantly, everyone in close contact to a student who tests positive COVID-19 would be required to self-quarantine for two weeks;  students work closely with nurses, residents and attending physicians. The downstream effects of a student testing positive would further stress the healthcare system, and the risks do not outweigh the potential benefit we provide to the clinical team, at least at this time.

If third year medical students cannot help in the clinical arena, then what is our role in the current climate? It is unclear, as information changes every day. Meanwhile, medical students can find creative ways to stay engaged, assist clinicians,and help our society better understand the disease. We can educate our peers and parents about the importance of flattening the curve and that we are not immune to the risks of COVID-19 simply because of our age. We can help collect and enter data and conduct initial analysis for research studies. During the Ebola outbreak, medical students were able to identify gaps in infection prevention in close to 100 facilities in a city in the Democratic Republic of Congo. Blood is now scarce because thousands of blood drives across the country were cancelled; medical students can promote awareness and encourage our peers to donate blood.

More directly, we could assist with triaging patients via telemedicine. Already in progress, across the country, students are coordinating babysitting and grocery shopping for providers on the front lines. There are ample ways we student-physicians can help doctors on the front lines and our society as a whole while not putting patients and others at risk.

This pandemic is a rapidly evolving situation, and there might come a time when the benefit of deploying third year medical students to the front lines outweighs the potential risks. COVID-19 patients will likely overwhelm the system and many providers will become exhausted or stuck in quarantine. This problem is currently unfolding in Italy, where the government is waiving the traditional graduation requirements and allowing thousands of student doctors to enter the workforce eight to nine months early. The National Health System in the United Kingdom is considering the same. Now Governor Andrew Cuomo of New York is calling on qualified medical and nursing students to assist, but their potential role remains unclear.

The COVID-19 pandemic is quickly developing into disaster medicine at hospitals across the United States. During disasters, it is paramount that medical providers do not become victims themselves. Disaster medicine creates challenging ethical situations, but the four basic bioethical principles – respect for autonomy, justice, beneficence and non-maleficence – still hold true.

First, we must do no harm. Having third year medical students continue our core clerkships, where all our clinical work is duplicated, has the potential to do more harm than good. Nonetheless, we can contribute and play an active role in the COVID-19 crisis in unique and non-traditional ways. After the two-week clerkship hiatus concludes on April 1st, third year medical students should not return to our rotations, but rather be utilized in meaningful ways that help providers on the front lines.

Image Credit: “Hospital ….” (CC BY-NC-ND 2.0) by Miquel Lleixà Mora

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It does not grace your ears,

but you can hear it.

It does not touch your skin,

but you feel its pull.

It can’t be seen or read

but nonetheless, it guides you.

Yours is the sound of a hammer hitting a nail,

a dark night’s ring,

a stiff wrist and rigid composure.

And yours, it’s a hallway and rooms,

a group with a goal,

a list of complexities

You’re in charge of them all.

Ours are not the same.

Mine is loud, and has been for a while.

It’s a dark place, just you and me.

A desperate plea,

a mind tangled and elegant.

If you haven’t heard it yet, that’s ok

It is there, growing, and evolving.

Your calling.

Poetry Thursdays is an initiative that highlights poems by medical students and physicians. If you are interested in contributing or would like to learn more, please contact our editors.

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“There’s a great neuro exam in room 5147,” my resident said as I dropped my bag in the call room. “Why don’t you go check it out?”

I clutched my reflex hammer in one hand and googled the components of a neuro exam with the other as I headed towards the stairwell. I was on my internal medicine rotation, early in my third year, and had just barely figured out how to find room 5147, let alone logging on to the EMR. Approaching room 5147, I adjusted the stethoscope draped around my neck, hoping it didn’t look as unnatural as it felt.

As soon as I met Jack, I knew I was about to learn far more than a review of the cranial nerves.  His piercing blue eyes and full head of white hair suggested a richness of experience, yet his face was youthful with a bright complexion to match his gleaming white smile. In meeting his gaze, I realized I hadn’t understood what it meant to “have a twinkle in one’s eye” until that moment.  The man beamed, managing to warm the fluorescence of his hospital room.

“I like to know people,” Jack said with his hands folded gently on his lap, looking curiously at the large medical team that had descended upon his room for rounds later that morning. He insisted that we introduce ourselves one-by-one, telling him where we grew up and our role on the team. I had never seen a patient take command of rounds like this before. Only after some lengthy introductions did he share details with us about himself and what brought him to the hospital. 

Jack had traveled to us from Alabama. An architect by profession, he took Portuguese lessons, and practiced coding in his free time. “Something just isn’t right,” he told us. He described recent difficulty recalling basic vocabulary in Portuguese, unsteadiness in has gait, and a tremor in his hands. With a goofy grin, he joked that if we figured out what was wrong with him he’d design the nicest offices for us that we could imagine.

Off to work we went. Our differential was vast, ranging from simple vitamin deficiencies to devastating neurologic conditions. Each progressive day we spent furiously ruling out infectious, paraneoplastic, and autoimmune causes of Jack’s symptoms while he seemed to dissipate in front of us.  As labs returned and ruled out the simple stuff, my stomach sank. I never could have fathomed hoping to discover a malignancy as the etiology for a patient’s symptoms until participating in Jack’s care. It’s never a good sign when you’re hopeful for cancer. One Friday morning as I placed my stethoscope on his chest, he grasped my wrist and forced out the words “I’m scared.” Me too, Jack. When I returned to his room on Monday morning he no longer knew who I was.

Creutzfeldt-Jakob disease (CJD) is one of those diseases you only know about because you read it in a textbook. Prior to meeting Jack, I could have written everything I knew about CJD on a post-it note: prion disease presenting with rapid onset dementia, personality changes, myoclonus. Associated with 14-3-3 protein in CSF. Incidence low, universally fatal.

Some refer to death as “dust to dust,” but Jack was a shooting star. Composed of dust and rock, sure, but particles leaving a streak of light in their wake as they barrel through the atmosphere. When the light fades from sight just an instant after being spotted above, one can’t help but to pause to acknowledge the vastness of the world around them. And for a moment, everything seems to have just a bit more meaning.

As I moved on to my next rotation, Jack lingered in my mind. Lying in bed one night, exhausted but unable to sleep, I opened my laptop and typed his name into google. I wasn’t certain what I was searching for, but when I scrolled past his obituary I felt compelled to click it. There, in a local paper, was a beautiful description of the vegetarian architect from Alabama who cared ferociously for his community by offering kindness and respect to those around him. I felt an odd sense of relief. Relieved to have confirmation that even though I only knew Jack for a brief blip through difficult moments at the end of his life, he had revealed his true self. I really did know him. 

Editor’s note: All patient information has been changed to protect patient privacy.

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I recently attended an Alcoholics Anonymous (AA) meeting. It was a Monday evening — cold, dark. I was on my psychiatry rotation and such attendance was mandatory as part of the rotation, an effort to better understand the hardships surrounding substance use disorder. Having only seen the meetings on television, I was curious.

In a room hidden behind a rehabilitation center, 40 individuals sat assembled into a circle. I tried to sit on the outside as I was there mainly to observe and learn. The topic of discussion for the day was “rock bottom,” and each participant took turns introducing themselves and describing their experiences. There were speakers of all kinds — some loud and unhinged, others timid and vulnerable. Some exuded positivity; others dwelled on the volatility of their addiction. And finally, almost all described some connection to their loved ones.

They vividly described the lies they had told (stealing wallets and later helping to find them was the most common) and the celebrations they had repeatedly missed with their children or significant others. And then came regret — remorse over who they had been a year, a decade or just even a day ago. It seemed like a vicious cycle of feeling better and succumbing to a trigger the week after. They wanted to be a better daughter, parent, grandparent.

Hearing their stories, I wished for their recovery.

A few days later, I was working with an adolescent patient in the inpatient psychiatry unit. This individual had been admitted to the unit for wanting to kill himself — a teen with feelings so intrusive that he even attempted. The patient described a long history of physical and emotional abuse by his mother’s boyfriends. He recounted tales of constant belittling, slaps and punches that he had suffered at the hands of “alcoholic” boyfriends.

Hearing my patient’s story, I was angry. I despised these boyfriends, and my mind couldn’t separate that they had been called “alcoholic.” That label helped me identify a reason for their behavior. And I was livid at their actions, a sharp contrast from the empathy I had felt while at the AA meeting.

It was easier to see my patient’s story, to blame the “addicts.” But even though this label helped me understand my patient’s trauma, to see all my patients with substance use through this lens would be a mistake. The predominant narrative around addiction can make it difficult for us to see beyond an individual’s “rock bottom” moments, and, unfortunately, as healthcare professionals, this can sometimes translate into the care we give.

Perhaps it’s because the failures are readily apparent and progress is sometimes too slow to be noticed. But seeing the teary-eyed parent wanting to be better for their child at the AA meeting was a reminder of just how much work is done “behind the scenes.”

Our patients deserve to have their battles acknowledged. That means believing your patients when they implore, “I am trying” and appreciating that we may encounter people at different phases of recovery. It means trusting the motivational interview session you are about to begin. And finally, it means referring patients to community resources like AA with conviction — as opposed to a formality when discharging a patient from the hospital.

Image credit: AA Meeting sign – Lynchburg (CC BY-NC-ND 2.0) by Retronaut

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Featured image courtesy of Medical Students for a Sustainable Future.

While Americans grapple with the horrors of the COVID-19 pandemic, many ask how they can support their cherished communities and those risking their lives on the frontlines. Along with organizing PPE drives and providing mutual aid, there is something else we all can do to prevent our communities from facing crises like the one before us: organize to address climate change.  

As medical students, we are embarking on a career to join our mentors and colleagues to protect health. While the toll of this pandemic has rendered it difficult to think about the climate crisis, now, more than ever we are reminded that our planet is sick. On this 50th anniversary of Earth Day, we must reflect on the lessons from COVID-19 and how they can equip us to tackle what the World Health Organization has called “the greatest threat to global health in the 21st century.” Honoring our oath to “first, do no harm,” we must safeguard the health of our planet and communities. We implore Americans to vote for leaders who champion ambitious climate policies.

The Present: Lessons from the COVID-19 Pandemic

Despite warnings of an impending outbreak, we were unprepared for COVID-19, leaving our health system overwhelmed and patients vulnerable. Beyond our hospitals, COVID-19 is exposing unsightly health inequities. Older adults, people with chronic conditions and communities of color suffer from higher rates of mortality from this virus. Our current system of employer-based health insurance leaves those who are unemployed without health insurance. Simultaneously, lack of paid sick leave renders many low-wage essential workers unprotected. The added strain of these systemic inequities is stretching even our modern health system beyond capacity and perpetuating great and avoidable suffering.

The Future: Healing in a Time of Climate Change

Like COVID-19, climate change is a major global threat and health emergency. We have already seen increases in lethal heat waves, massive flooding in the Midwest and raging fires on the West Coast, all of which have harmed patients, health centers and economies. Climate change is already increasing the global burden of disease, including increased hospitalizations for people with COPD, asthma and heart failure, and increased rates of birth defects, cancer and psychiatric disorders. Additionally, due to human activity and climate factors, three out of every four new or emerging infectious diseases, like COVID-19, are zoonotic in origin, meaning they originate in animals and jump to humans.

Like COVID-19, climate change will overwhelm already strained health systems and essential services. Researchers are increasingly worried about how first responders will continue to fight COVID-19 amidst predictions of flooding in 23 states by the end of May, a hyperactive hurricane season this summer and more wildfires in the West. If we do not prepare, these compounding crises will debilitate our workforce, global supply chain and healthcare system. These situations, once unfathomable, feel all too real in the current pandemic.

Like COVID-19, climate change will exacerbate existing socioeconomic inequities. Without equal access to clean water, air, food, housing and health insurance, historically marginalized and vulnerable populations will bear the initial brunt of the health consequences of climate change. Extreme weather events will disrupt healthcare delivery, resulting in increased morbidity and mortality for people with acute and chronic illnesses. Furthermore, 88% of the burden of climate change will fall on children as they are particularly susceptible to compromised environments.

As we build a healthy future, these important consequences must be considered.

Call to Action

The nightmare of the COVID-19 pandemic offers a view of what climate change will impose on our future health system and communities if uncontrolled. As future doctors, on the 50th Anniversary of Earth Day we raise our voices in unison to draw attention to the urgency of the climate crisis.

We are moved by the solidarity of communities as they innovate and collaborate to tackle this pandemic. In the coming weeks and months, our government and society have the opportunity to recalibrate and rebuild for a more equitable, healthy future.

We urgently call on our elected officials to uphold their oath to protect the American people. We need more than adequate pandemic preparedness. We need a systematic transformation with the capacity to respond to the increasing number of health crises before us. Policies like universal health coverage, the Green New Deal and the Paris Agreement will protect our communities and health systems, paving the way for a future of economic prosperity and justice.

In honor of all those risking and adapting their lives during this pandemic, we urge our fellow Americans to vote for candidates who support climate action. We have the tools we need to combat the climate crisis and protect health. Now, we need the political will to use them.

Together, let’s vote to flatten the curve on climate change.

Watch this video!

Sarah Hsu (0 Posts)

Contributing Writer

Warren Alpert Medical School of Brown University

Sarah is a second year medical student at the Warren Alpert Medical School of Brown University in Providence, RI, class of 2022. In 2017, she graduated from Brown University with a Bachelor of Arts in sociology and is currently getting her concurrent Masters in population medicine. She enjoys teaching dance, reading contemporary fiction, and promoting menstrual cups in her free time. After graduating medical school, Sarah would like to pursue a career in Emergency Medicine.

Natasha Sood (0 Posts)

Contributing Writer

Penn State College of Medicine

Natasha is a third year medical student at Penn State College of Medicine in Hershey, Pennsylvania Class of 2022. In 2016, she graduated from the University of Michigan with a Bachelor of Science in environmental science. In 2018, she graduated from Columbia University Mailman School of Public Health with a Master of Public Health in environmental science with a specialization in climate change and health. She enjoys yoga, running, and hanging out with friends & family. In the future, Natasha would like to pursue a career in the intersection of climate and health.

Harleen Marwah (0 Posts)

Contributing Writer

George Washington University School of Medicine and Health Sciences

Harleen is a rising fourth-year medical student at the George Washington University School of Medicine and Health Sciences. Prior to medical school, Harleen earned her M.S. in Global Medicine and B.S. in Health Promotion and Disease Prevention from the University of Southern California. Harleen recognizes the need for clinicians and medical students to drive solutions and advocate for communities. She founded Medical Students for a Sustainable Future in 2019 to bring together medical students for a collaborative effort to act on climate for health.

Ellen Townley (0 Posts)

Contributing Writer

Creighton University School of Medicine

Ellen Townley is a first-year medical student at Creighton University School of Medicine in Omaha, Nebraska. She is the Advocacy Co-chair for Medical Students for a Sustainable Future and is passionate about the intersection of climate change, health, and social justice.

Sarah Schear (0 Posts)

Contributing Writer

University of California, San Francisco School of Medicine

Sarah is a fourth-year medical student at the University of California, San Francisco School of Medicine in the Class of 2021. She is Co-Chair of Advocacy for Medical Students for a Sustainable Future. In 2017, She graduated from the UC Berkeley - UCSF Joint Medical Program with an MS in Health and Medical Sciences. She holds a Bachelor of Arts in anthropology from Amherst College, and before entering medicine, she was a Fulbright-Nehru Research Fellow in India focused on child health and helped run community mental health programs at Project Horseshoe Farm in Alabama. In her free time, she enjoys serenading friends on her guitar, dancing and spending time in nature. Sarah plans to pursue a career in Pediatrics and advocacy for the health of children and our climate!

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Take him to the ICU,
Now.
Trauma, Level 1, coming from just outside of triage.
The bullet went straight through, right above his ear and clean out the other side.

The resident flees from the elevator, with his head in his hands. We need to stabilize him,
Now.
Nurses rush in and out of the ICU room, as blood continues to cascade down his neck.
Close the door! I need a flush! We need blankets! What’s his pulse?
Everybody needs to calm down!

We need more hands. Someone apply pressure to his head,
Now.
My fingers tremble as I press them firmly against his skull, with his head in my hands.
I stare into the young man’s vacant face, as I desperately wish to push hard enough
To return his mind, memories, and thoughts that were encased in his skull just moments ago.

His mother and father want to see their son. We need to get them in here,
Now.
Dad falls to the floor, bawling inconsolably, with his head in his hands.
Why did this happen, what happened to my son?
Mom insists he’s a strong boy, and he’ll get through this, right, Doctor?
She furiously demands to know why he won’t.
You can’t do anything else?! You’re saying this is goodbye?!

Go home, it’s late, you’ve seen a lot.
Now.
Driving home, with the radio drowned out by the still audible
Cries of parents who lost their son tonight.
I pull over, with my head in my hands.

Poetry Thursdays is an initiative that highlights poems by medical students and physicians. If you are interested in contributing or would like to learn more, please contact our editors.

The post Head in Our Hands appeared first on in-Training.

They say to be tough is to have thick skin, but I say to have thick tears.

Skin? It can collect pimples, papercuts, and pus, can be scratched, scraped, and sliced.

Tears? We can barely catch them, not even with a tear cup. I learned in my twenties that not all mothers use one. When I was a kid, tiny paper cups would arrive, rushed over from their home at the bathroom sink, alternating cheek to cheek.

When we fall, skin breaks and bleeds, it rips and reveals our insides.

Then tears fall, come to help heal before skin can cover itself back up.

Our lids stay open to the world, the globe shying away only for a blink of an eye, protected by thin, persistent tears. The blues, greens, hazels, and browns, even touches of greys or yellows, those most beautiful parts about us, are left exposed. Vulnerable, but so often unscathed.

You could say this is the weakest idea you ever heard. I’ll tell you I have thick skin.

Poetry Thursdays is an initiative that highlights poems by medical students and physicians. If you are interested in contributing or would like to learn more, please contact our editors.

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Why is Hahnemann University Hospital standing empty? Amidst a growing pandemic, 496 beds lay empty. As dust gathers across abandoned wards, Philadelphia scrambles to accommodate the 12,868 cases of the novel coronavirus as of April 27, 2020.

As numbers continue to rise and the city treats patients from nearby epicenters New York and New Jersey, the recently-closed hospital could alleviate this bed shortage. Hahnemann historically served as a safety net for the city, providing care for a majority of Medicaid and Medicare patients, until its new owner Joel Freedman filed for Chapter 11 bankruptcy in 2019. Hahnemann had been experiencing 14 straight years of financial losses under its for-profit model, and the hospital was ultimately deemed too expensive to save. Despite efforts by community members and providers at the time, the closure of Hahnemann left behind Philadelphia’s most marginalized and vulnerable populations while Freedman’s wealth was protected. The closure allowed Freedman, an investment banker and CEO of a private equity firm, the opportunity to liquidate the hospital’s assets, including the valuable Center City real estate.

This is neither the first time that Philadelphia has faced a pandemic nor the first time that shuttered hospitals have been required to meet demands. During the Spanish Flu epidemic in 1918, Philadelphia was one of the hardest-hit cities. The Medico-Chirurgical Hospital, which had been closed to make way for construction of the Benjamin Franklin Parkway, was emergently reopened when the City donated the buildings to the American Red Cross. History has come full circle in Philadelphia; patients are once again in desperate need of beds, and the city is aiming to restore institutions once shuttered closed.

This time, the City was faced with an impossible decision: purchase the building from Freedman or lease for close to $1 million a month. Freedman and his group believe they are accommodating the City by asking for a reasonable price. Meanwhile, philanthropy is coming from elsewhere; for example, Temple University has offered the Liacouras Center, with 250 beds, free of charge. While Mayor Jim Kenney denied the City’s need for Hahnemann and stated that negotiations are over, Philadelphia health professionals remain desperate for bed space.

The government just printed 2 trillion dollars to save small businesses. So why do 496 hospital beds lay empty? We believe the City of Philadelphia should seize Hahnemann from Freedman and abolish any private ownership of a hospital in times of crisis. The value of human lives cannot be priced per bed.

Holding Hahnemann Hospital hostage in the context of a global pandemic prioritizes profits over people. At the time of Hahnemann’s closure in 2019, other hospitals in the city wondered how they would absorb the additional patient volume without compromising quality or safety. The scale of this pandemic now makes one thing very clear: there are not enough hospital beds in Philadelphia to provide safe and quality care for everyone who will be infected. The city may not see the peak of the epidemic until June, and it does not currently have the capacity to support its citizens or patients from overburdened NYC and New Jersey hospitals.

This isn’t a problem that only affects Philadelphia; it is one that every city will face. But while we all must live with this virus, we are not affected equally. We are not affected equally when over 10 million people filed for unemployment in March 2020; when healthcare providers are dying because of unsafe conditions without proper PPE; when Americans are reluctant to go to the hospital due to a lack of medical coverage and must choose between potential death or a $10,000 bill. Many of the essential workers we now tout as heroes may not be able to afford coverage, and those that lost their jobs are now at the mercy of an employer-based insurance system. This country must come face to face with our broken healthcare system, of which Hahnemann is a prime example. Operating healthcare as a business model, as CEO Joel Freedman did, is unsustainable. Overall, we call for an America with universal access to healthcare. Right now, that requires hospitals where that healthcare can be administered.

In a society where the government and infrastructure have left us unprepared, we as civilians are all on the frontlines. And all community members have the agency to make decisions that will influence the spread of the pandemic. But, in our current healthcare system, individuals with tremendous wealth like Freedman have a special opportunity to redistribute their resources for the greater good of entire communities. He has passed up on this opportunity. He has made it clear that we cannot rely on philanthropy to provide care for everyone else. This hospital belongs to the city.

Hahnemann’s doors stay closed and our patients are waiting. While Philadelphia has stopped negotiations, we, as students with futures in healthcare, cannot accept this. We demand that Freedman provide free use of Hahnemann for the duration of the pandemic. If he does not comply, we demand that the City of Philadelphia and the State of Pennsylvania invoke any and all emergency powers necessary to seize and reopen the hospital. According to Pennsylvania law, the Governor’s emergency declaration provides the power to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.”

We have 496 beds waiting. We must take control of our own future and secure the hospital as a space to save lives rather than bend to the will of multimillionaires like Freedman. He contributed to a system that works for shareholders and not for patients.

We, the people of Philadelphia, can build a better one.

Image Credt:”Inauguración del Hospital Municipal de” (CC BY 2.0) by Presidencia de la República Mexicana

Kristin Spiegel (1 Posts)

Contributing Writer

Drexel University College of Medicine

Kristin Spiegel is a third-year medical student at Drexel University College of Medicine in Philadelphia, Pennsylvania, Class of 2020. In 2016, she graduated from Johns Hopkins University with a Bachelor of Arts in psychology. She enjoys yoga, hiking, and baking in her limited free time. After graduating DUCOM, she will pursue Child & Adolescent Psychiatry.

Jenny Nguyen (1 Posts)

Contributing Writer

Lewis Katz School of Medicine at Temple University

Jenny is a third-year medical student at the Lewis Katz School of Medicine at Temple University in Philadelphia Class of 2021. In 2016, she graduated from Yale with a Bachelor of Science in molecular biophysics and biochemistry. Her interests include bioethics, health equity, minority health, immunobiology, music, and fitness. She aspires to use her M.D./M.A. Urban Bioethics degrees to pursue a career in primary care, community health, and health policy.

Emma Schanzenbach (1 Posts)

Contributing Writer

Drexel University College of Medicine

I am a third year medical student at Drexel University College of Medicine in Philadelphia class of 2021. In 2016 I graduated from the University of Pittsburgh. My interests include uplifting poor and working-class communities through access to medical care and advocacy work for people who have experienced adverse events in childhood in my free time. I hope to dedicate my career to serving my community and increasing access to affordable healthcare throughout Pennsylvania through a career in Primary Care.

Natalie Marie DiCenzo (1 Posts)

Contributing Writer

Drexel University College of Medicine

Natalie is a fourth-year medical student at Drexel University College of Medicine in Philadelphia, PA class of 2020. In 2016, she graduated from Vassar College with a Bachelor of Arts in neuroscience and behavior. She enjoys running, listening to podcasts, and eating vegan food in her free time. After graduating medical school this spring, she will pursue residency in OBGYN at Rutgers Robert Wood Johnson with a focus on family planning and reproductive justice.

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