the end of residency

over and over, i'm breathing out thankfulness.

i made it.

3 years ago, i was assigned five patients.
i didn't know how to enter orders in the computer.
my white coat was still white.
i thought i would only do this for a year.
instead, i fell in love with taking care of patients and decided to stay.

i couldn't leave the place of listening to human stories in exchange for shaping global health policy. i know policy touches communities, but i needed to touch the person in front of me. at the time, it seemed like a huge decision to give up hopkins for a general hospital in a post-industrial city. but i knew i had to stay.

being healthly intern  year was grace; without that year of health, i would have left clinical medicine and entered the world of public health.

it has been anything but easy. four hospital admissions. countless infections. monthly infusions. my sister over and over reminded me "just keep swimming."

so i kept swimming, upstream like the salmon, and i've ended up at beautiful over and over: working in alaska for a month. watching a friend get married in india. listening and being humbled by the patients who trust me with their stories.

and the same prayer i have breathed out countless times over the past three years, whispered under my breath in airplanes taking off over delhi and sitka, to cries from hospital beds when planes left without me:

blessed are you, o lord, who has kept us alive and sustained us,

who has brought us whole to this moment.

residency in iPhone photos

This is where I have spent the last 3 years:

The views from the hospital aren't that bad:

I spent most my time trying to figure out which pager was beeping and waiting on people to return my pages:

I survived off of cafeteria food and graham crackers stolen from nurse's stations:

I looked at way too many of these:

I rarely saw the call room (note the unused bed):

 

I made sure the important orders got in first:

Only once did I ever see the emergency room empty:

There were early morning signouts, greasy post-call breakfasts, and rare chances to sit in the resident lounge:

I had lots of opportunites to wear Indian clothes:

 

I tried my hardest to avoid being a patient: 

And got to I spend a month working in Alaska:

It's been an amazing, exhausting, humbling, tiring, but beautiful 3 years.

Now I'm turning in my pager and my badge because I'm done!

 

a million thanks and then some to my family and friends

for all the love that has carried me through these past 3 years.



 





i'm going to alaska!

i'll be posting from here for the next month!

 

in memory of her

i knew when i met her she didn't have long to live. it was a sad story, a few months of nausea that was mostly ignored, actually a rare cancer that had spread throughout her belly. 

 

they decided to start chemo. she was optimistic; she told me she was gonna fight this thing. we talked about how her hair would fall out, and what head scarves she was gonna buy. how she wanted to go to the beach this summer but was scared to be away from her doctors. about how cute her granddaughter was.  

 

her family was always in the room. her mom drove her crazy, with the fluffing of pillows and the force-feedings of sherbet and ensure. her sisters told stories of what an amazing person she was. her pregnant daughter brought in ultrasound pictures of her soon-to-be baby girl. her three-year old granddaughter ran through the room, making everyone nervous. they made me feel like family.

 

the chemo was hard on her, but she managed to get discharged, only to come back a couple days later, dehydrated and weak. this time, when her family had left the room, she told me, i know this is gonna kill me. i'm not ready to go.

 

she kept getting sicker, and her story changed: i know this is gonna kill me, but i'm ready. her mom pulled me in the hall and started crying: i know she doesn't have long. what do you think? i couldn't argue.

 

there was something about her, her mix of sadness and hope, resilience and resignation, her honesty, and her willingness to just let me sit with her that kept drawing me back to her room long after i had rotated off her team. maybe because i could carry the grief of my own sickness there and sit with it as she sat with hers. she heard my voice weakening as bronchitis set it, saw my mask when i was at risk for infection, but never asked more than how i was feeling that day. so we would both sit there and separately hold our losses, hers greater than mine, and talk about small things. sometimes she would cry. i would bring rita's and cupcakes that she would inevitably throw up.

 

i knew she was dying fast, but i didn't think it would be only two days after she left the hospital that second time, only six weeks after the cancer was detected, still four months before her second granddaughter takes a breath. 

 

i went to the viewing, not to say goodbye to her, but so i could hug her daughter and her mom and her sisters, because she made me want to hug my mom and my sisters, because life is just too short sometimes.

 

second year end, third year begin.

i started this year with deep breaths of thankfulness. i had survived what was supposedly the worst of the medical training process: intern year. the year ended with a week exploring the pacific northwest with a friend - eating our way through pike place market, kayaking around san juan island, biking and hiking in vancouver. i felt full of life.

 

second year started with continued triumphs: the color run. kayaking all summer long. a friend's wedding in india. loving work.

then things spiraled down: the death of a friend. recurrent hospitalizations. work and life becoming far too exhausting.

now this year comes to a close with another week of sickness, a chest rattling with cough, and a body heavy with fatigue.

like last year, i know life comes with both things difficult and things beautiful. and like last year, i am finding i am stronger than i imagined.
 
so i take a deep breath in and let this last year of residency begin.

telling secrets

i've only told three patients that i have lupus. 
normally, i don't tell.
because my experience of illness is not their experience of illness.
because the things that have given me hope aren't necessarily what will give them hope.
because my trajectory is not their trajectory.
because my journey cannot be extrapolated to their journey.

but sometimes, you need to know you are not alone.
sometimes you need someone else to say "me too."
so on three occasions, i have shared that understanding.

~~~

she thought it was just an ulcer, the nausea she'd been experiencing. it was metastatic cancer. she started her chemo in the hospital. what she wanted to know: when will my hair fall out?

she brought it up a few days later, looking sad. i'm waiting for my hair to start falling out. i could tell she wanted to not be upset. when you are diagnosed with metastatic cancer, it seems petty to care about cosmetics. except that it matters. it is a loss to grieve. it changes the way the world sees you, because now they can your sickness. the disease that was visible only to microscopes and CT scanners is now on display for everyone. i lost half my hair seven years ago when i got sick, i told her. don't downplay your grief. it is real. 

~~~

apparently he usually refused to see med students, but i guess that day he lost his fight, so i picked up his chart and went in.

his recent medical course had been tenuous. recurrent infections and hospitalizations, despite how adherent he had been to his HIV medicines. he now was contemplating taking a leave of absence from work. his worries about this were endless: that his co-workers would find out his diagnosis; that he would lose his job; that he would never be well enough to go back. he started to cry.

i took a deep breath. i had to take a year off of school because of sickness. i wasn't sure i would get better either or that i would be able to go back. it was a long hard year. i don't know what it will be like for you if you take time off or if you will get better or what will happen with your job. but i know life won't be over for you and that you'll come through.

~~~

his thin frame was covered up to his chin with stiff hospital blankets.

they tell me i have lupus, he said. i looked it up online. there are two kinds. i have the systemic kind. that's the bad kind. what happens to me from here? then his eyes filled with tears.

only my eyes were visible above the mask covering my face; they too filled with tears. i have lupus too, i confessed.

he seemed stunned. he commented on how i seemed so functional.

i've been really sick before, i get really sick sometimes. then sometimes i'm better and i cram life into those days and weeks and months. i don't know what this illness will be like for you, but i do know that it isn't a death sentence and that your life isn't over. the waiting and hoping to feel well and the uncertainty of it all is hard, but you are strong. you will come through this.

he is.

 

intern year, end. second year, begin.

during our intern orientation last june, one of the chief residents said, "if this year isn't the worst year of your life, you've had a pretty horrible life." this past year was definitely not the worst year of my life (and i have not had a horrible life). this past year was hard, but i've had harder. this past year was hard, but there was grace.

there are things that have been difficult: a three-day hospitalization for pneumonia. turning down a residency position at hopkins because something in my heart told me i need to be here in pittsburgh for now. keeping people alive who should have been allowed to die in peace. letting people die who i wished could have lived.  

but there are also things that have been beautiful: finding out i really like seeing patients. being healthy enough to see patients. only needing to take five sick days all year (compare with at least thirty the year prior). giant chocolate chip cookies from the hospital cafeteria. being able to meet my parents for dinner after living away the past nine years.  making new friends. escaping to mexico and the pacific northwest with old friends. finding i am stronger than i imagined.  

so i take a deep breath in and let a new year begin. 

what death looks like here

"Public health is the art and science of deciding who dies,

when, and with what degree of misery." - Bill Bicknell

Swaziland, December 2005
she'd been sick for a while, sent home from the government hospital because they had nothing left to offer her. HIV and t.b. combined forces to drain the life from her body. she spent her final days at her homestead, with her momma, sister, and baby boy at her side. her last night on earth was spent singing and praying. she offered up prayers of forgiveness - for the one who gave her the virus that took her life and the life of their firstborn child. my friend tells me she was at peace and that was why she could die that day. she was 27.

United States, May 2011
he'd been sick for a while. cancer and age and recurrent infections numbered his days. he spent his final days at a long-term care facility, his life sustained by machines. his heart stopped on three occasion during his last night on earth. two of those times it was forced to beat again with the help of electricity and chest compressions and chemicals pumped into his veins; ultimately, his 80-year-old heart refused to beat any longer. 

one of these deaths was inevitable. one was preventable. one called on every bit of science and technology available; the other called out to the heavens. one was alone in an ICU bed, with doctors violently attempting to bring him back to life. the other was surrounded by friends and filled with peace and acceptance. 

i know that you can't put a cost on a human life. i know we don't get to decide who lives and who dies. but i struggle with how we can spend millions of dollars to extend a life by months while not spending the hundreds of dollars that would extend a life for decades. i hate how being born on the wrong side of the equator with the wrong color skin means your life might be thirty years too short. i hate the days i go to work and order tests and medicines that will only sustain a person with a terminal condition for a few extra days. i hate that my inbox fills with messages from swazi friends who can't get to doctors or can't afford medicines for things that are treatable. i hate living between these two worlds, of seeing the injustice and disparity. i hate the powerlessness - both in futily treating terminal conditions in order to honor a patient's wishes and in being unable to treat curable conditions in those without choices or options.

learning to breathe

"Let us not underestimate how hard it is to be compassionate.

Compassion is hard because it requires the inner disposition
 to go with others to the place where they are weak,
vulnerable, lonely, and broken." - Henri Nouwen

there is a tibetian practice, called tonglen apparently. a way to face the suffering around you, the darkness in this world. it is simple - when you encounter the suffering of another, you take a deep breath: breathe in suffering, breathe out compassion.

mostly, i don't do this. instead i rush from room to room, prying into people's places of pain, poking the areas that hurt the most, then leaving them alone again. mostly, i'm simply trying to survive myself. i can't handle thinking that hard about the suffering of those around me. but sometimes, there are moments where i pause. where i breathe and offer grace.

sixteen, overdosed on her mom's pills. a mix of pain meds and tranquilizers, she slips in and out of consciousness. everytime we bring her back she wakes up screaming curses and begging for cigarettes. there is sadness, for the life she's given up on. i breathe in her sorrow, and it touches my sixteen year-old self that also ached to find reasons for hope. i breathe out compassion: may she find a reason to live.

five months pregnant, found unconscious. cocaine and methadone running through her blood. a tiny heart flickers on the ultrasound screen. deep breath in, a prayer exhaled out: may this baby be whole.

a birthday celebrated in the hospital, a strange milestone in her 250 day hospital stay. i leave a cupcake on her bedside table that i know she won't eat. i inhale the futility that hangs in her room, the futulity of the machines and medicines that sustain her but cannot offer healing. i breath out an aching cry: may her suffering end quickly, and may she have happiness until then.

back for the third time, now with a breathing tube in his throat. two months ago, his predicted mortality was 100%, yet he still fights. i talk with his wife in the waiting room, telling her if she didn't call when she did, he wouldn't have survived. she bursts into tears in my arms.i pull in air and her tears, and breathe out a prayer: may she not find herself a widow. may she continue to find strength.

and every day the stories keep coming, and i keep learning to breathe.

remembering

it's been six months.
six months of long days and nights working in the hospital. six months of my pager beeping as soon as i get food or sit down or fall asleep. six months of asking people why they came to the hospital. six months of being called doctor (and often nurse) yet still having no idea what i'm doing. six months of survival. six months of health. six months of being near family, of living with a sister who leaves chocolate and reminders to "just keep swimming." six months of grace.

it's been one year.
one year since the dark days of sickness that left me unable to move without oxygen wrapped across my face. one year since the endless days of fever and gasping for breath and tears and enough daytime tv to last a lifetime. one year since i've needed a chest x-ray or any new medicines. one year of survival, of fighting to get enough sleep, of swallowing handfuls of pills to stay well, of taking each day as it comes. one year of grace.  

it's been five years.
five years since i walked through customs back into the united states. five years since i've used my passport. five years of speaking (mostly) english. five years where my shoes aren't stained with red african soil. five years where my heart is on the other side of the world. five years of waiting and praying and wanting to return. five years of sickness and schooling that have kept me from a tiny african kingdom. five years that i struggle to call grace because it's hard to be away. it's hard to feel powerless in the face of overwhelming need. to read the news stories of famine yet not be able to offer rice and beans to a hungry neighbor. to know their are thousands of kids without parents but not be able to hold at least one of them. to have friends who grieve the losses of aids but not be there to grieve with them. it's five years of weak prayers uttered to the heavens, of letters and packages with airmail stamps, of sporadic updates. five years of telling stories that keep my heart remembering the love of my beautiful swazi friends. five years of grace.

   

one of those days

"i think part of the struggle just of everyday life is

remembering that the love is there...to wake up in
the morning and realize that love is there in the world -

if i can do that, that's half the battle." - kathleen norris

i was grumpy. and exhausted. and sick.  and i had an out. 

but i was also stubborn and trying to prove i wasn't that weak, and i said i would go see patients in clinic that afternoon anyway.  then take a sick day tomorrow. 

i regretted that decision as soon as i walked into the building.  it hit me how very tired i was. how i could be home napping instead. but it was too late now.  oh well.

the first chart i grabbed wasn't that heavy. i figured it would be an easy patient. until i realized that this was chart volume 2.  i scanned the face sheet: hiv. bone disease causing 2 hip fractures. cancer. depression. chronic pain. neuropathy. 

as i was heading down the hall, the nurse practitioner gave me a heads up: he just got a new electric wheelchair. and he cut his hair.

i walked in the room, expecting someone grumpy and bitter and sick.  instead, he was smiling. 

how are you, i asked. honestly, i think this is the best i have been in my life, he said. 

how is the pain? it's there. but i have this new wheelchair and it's totally opened up the world for me. i can go places now, i don't have to sit in my apartment. i may try to take a computer class at the senior center soon. they offer them sometimes.    

i hear you cut your hair?  yeah, i donated it to locks of love. i wanted to give back. i smiled inside, wondering what kind of wig would be made from middle-age, graying, ex-hippie hair.

the attending physician came in. we talked some more, sorted out some medicines, set up follow-up visits.  at the end, the attending prayed with him: god, we thank you for the blessings you have brought in this man's life, for his health, for your grace.

i cringed inside.  blessing? very little of his story felt like blessing.  but he took those small moments - leaving his house without the pain of walking and giving away his hair - as gifts.  and i was humbled...because i know there is sickness in my body too. there are limits and exhaustion and fevers and feeling like i am missing out on life and worry that these little symptoms now could be harbingers of a coming disaster. but there are moments of grace too - people that notice when i need a day off, sunflowers blooming on my walk home, sisters who don't care if you use their popcorn maker, dinners with friends, and patients who remind me to name the good in my life.

heart cries

"God is within her, she will not fall;
God will help her at the break of day." -Psalm 46:5

lots of deep breaths.

i look at the schedule for the month, and i'm not sure i can make it.

i'm okay at the moment.  four carefree weeks of quenching wanderlust and catching up with friends and sleeping late has seemed to silence the disease that hides within me.

but what about the coming days?

the easy prayer is to beg over and over that i would be well. it becomes compulsive, enslaving, demanding.  the hard prayer is to ask to be sustained, for grace to survive whatever comes - whether sickness or wellness or a chronic state of unwell, for eyes to see the love around me, for a heart of compassion for those in my care. 

and so i wait, and pray, and hope for health, knowing that may not come, and step forward into this new place anyway.