Spiritual chemotherapy

Many of the things we do to patients are painful and toxic. All medications have side effects. Some medications can wreak havoc on the body, such as chemotherapy agents. So why do we do it? It seems obvious, right? To cure the disease. A patient is diagnosed with cancer and is told, "Okay you can take these medications and they will make you sick as snot, but it's the only way to get rid of the cancer." Well most people would agree to start treatment. Do they realize how painful it's going to be? Maybe, maybe not. I only know from observing the children I take care of. They are poked and prodded with needles on a regular basis. They undergo surgeries to have central lines placed. Those lines can become infected and cause life-threatening illness. They come in for chemotherapy, which can make them feel very tired and sick. They lose their appetites, lose weight, some become very fragile. They lose their hair. They can develop very painful mouth and stomach ulcers. They can become very withdrawn and depressed. And perhaps through all of this, they might even wonder why they are going through it all. Maybe they should stop. But it's the only way to cure the disease.

I wonder if that's how God uses trials in our lives. He allows us to go through painful, devastating experiences because He knows it's the only way to cure our diseased hearts. He finds something wrong in our lives, maybe sometimes it's even a fatal diagnosis. If we keep going untreated, we could very well die. So God allows us to go through "spiritual chemotherapy". He knows it will be painful, and it hurts Him to see us go through that (just as it hurts me to see my patients suffering from toxic medications). But He knows that there is a greater good, and He encourages us to stay strong through the trials. There are days we might want to give up, when the burden seems too heavy to bear. All those side effects seem to be taking a toll. We grow restless, weary, and hopeless. When is it going to be over? We start comparing ourselves to other people, wondering why they got to be so lucky and healthy? We resent the trial that God has allowed us to go through.

But that's when you have to remind yourself of God's promises. He has declared, "For I know the plans I have for you... plans to prosper you and not to harm you, plans to give you hope and a future" (Jeremiah 29:11). He has also instructed us to "consider it pure joy... when you face trials of many kinds" and reminds us that trials help us to develop perseverance, which will strengthen our faith (James 1:2-4). Sometimes it's hard to keep holding on. Families can crumble to pieces when faced with life-changing diagnoses. But those that rely on the Lord and encourage each other can grow so much stronger and closer as a result. It doesn't make the process any less painful to endure, but it gets them through it. I know a family whose daughter was diagnosed with leukemia several years ago. She had a very difficult course with several hospitalizations and set-backs along the way. It affected the entire family, and you could see the pain and exhaustion on their faces. But they stuck with it and leaned on God, and this sweet girl is now in remission. She and her family just recently went on a wonderful Christmas vacation and enjoyed the simple things that most of us take for granted, like staying in a nice hotel and walking around the city. I saw them in clinic for follow-up and there was so much joy in their faces; joy and relief that they had made it through the storm. It really inspired me.

Whatever trial it is that we are faced with, we have to remember: 1) God is going to use it for good, 2) The pain we endure during the trial is for a purpose (it has healing power; it's "spiritual chemo"), and 3) We will come out stronger if we lean on God the whole way.

The agony of the unknown

Many times in medicine, a diagnosis may not be clear from the beginning. Some things are obvious. A kid who has wheezing and hyperinflated lung fields on X-ray, probably an asthma attack. Tympanic membranes that are red and bulging with pus behind the ear drum, otitis media. But then there are the mysteries. The ones where you get a few clues here and there. Or maybe you had no idea that something was brewing all along. You thought you had the whole picture, but it turns out there were things you missed. Were there clues all along? Should you have suspected the diagnosis? So then you begin to gather evidence. You ask the parents questions about the child. This is called taking a history, and it's something you learn early in medical school. We learned a technique called OPQRST: Onset, Precipitating/Provoking factors, Quality, Radiation, Severity, and Timing. You try to fully describe the symptom and get a clear history from the person who has the complaints (or their parents). You get a family history, too. You ask questions about the family members - have THEY ever had these symptoms? Then you do a thorough physical exam, trying to focus on the things you think might be going wrong. Is it stemming from the brain? So you do a thorough neurologic exam - cranial nerves, gross motor, cerebellar function, reflexes, gait. Is it the heart? You listen for a murmur, feel the precordium, check pulses, capillary refill. You do an abdominal exam, looking for enlargement of the liver or spleen. And then you run tests. Blood tests, urine tests, maybe even check the cerebrospinal fluid. You put the patient through all kinds of painful tests, some of them including invasive procedures like liver biopsies and bone marrow biopsies. You order X-rays to look for evidence of what's causing the problem. Plain films first, then CT scans, maybe even MRI's or nuclear medicine studies. And sometimes, even after ALL of this... you STILL don't know what's going on. What is the problem and how are we going to fix it? That's the agony of the unknown. It's horrible for the person who's suffering AND for the person who's looking for answers. How do we find the answer? Will God reveal it?

You know, often I think this same logic can be applied to problems in life. Something comes up, a symptom arises to cause someone to question something they didn't know was wrong. So we seek to gather more information. We ask lots of questions, look for more evidence, run some tests, spend exorbitant amounts of time and energy trying to figure things out. It is emotionally and physically draining. In the end, we just want the answer. But God doesn't always paint the answer in the sky. Sometimes it takes faith. And that can be kind of scary. Stepping out on that ledge and trusting that God will not let you fall. And to make matters even tricker, there's an Enemy who throws obstacles in our way. This happens in medicine, too. We call it "red herrings". Sometimes we get information that makes us think it might be one diagnosis. And we may even lock on to that diagnosis. But then we realize we were totally led astray by the red herring. That's what Satan does in our lives. He throws red herrings our way. He makes us think perhaps we're not doing what God wants. He is the master manipulator, the greatest liar ever. And he hates to see God's people glorifying Him. So he will do whatever it takes to fool us. So how do we find the truth in all of this? When we've collected all the evidence, listened to everyone's opinions, considered whether some "facts" are actually red herrings... how do we come to a conclusion? The only answer I can think of is to pray. Pray, pray, and pray some more. Pray that God will reveal the truth, and He will not lead us astray. And lean on the one truth we are sure of - Christ Jesus.

That's why your mom always told you...

No running with pencils!!

We had a patient come into the PICU who had a pencil stuck in her eye.  This isn't a picture of her, but it's probably what she looked like in the ER before she went to the operating room.  She apparently was running with a pencil, tripped and fell, and rammed the pencil through her eye socket.  Amazingly enough (and miraculously for her!) the pencil just missed her globe and went right next to it through her orbital canal and into the front part of her brain, missing all of her critical eye structures.  She didn't lose any vision, her muscles weren't injured, and there was no brain bleed.  In the OR they removed the pencil and cleaned out the wound, and she was brought to the PICU with a bandage over her eye.  I think she's still on the ward for antibiotics, but overall she was an extremely lucky girl!!  When I told her she was lucky, she replied, "Yeah, I know.  And I'm even luckier because I get to go to Sea World."  Uh, managing not to lose an eye vs. Sea World??  I'd rather have my eye.  Crazy kid.

Happy stories!

It's not all sadness in the PICU, thankfully!  There are some happy stories.  I'd like to share a few.

JS was a teenage boy who had just gotten a new motorcycle and went out for a joy ride.  He was wearing a helmet, but unfortunately the front piece was not attached... and JS ran into a pole.  Yikes!!  He lost consciousness, and basically his face took the majority of the trauma.  He had multiple facial fractures, including his eye socket, jaw, and skull.  He had massive bleeding in his head, mostly in the frontal lobe (the area of your brain responsible for executive function, making decisions, social inhibition, and long-term memory).  He was aggressive at the scene, requiring sedation and intubation.  He had a number of invasive surgeries and was on the vent for a week.  We weren't sure if he would wake up when we took away the sedatives, and if he did wake up we weren't sure if he'd be the same person.  Well, a week after he came in, we turned off the sedative drips.  Within hours, JS woke up and was looking at his family and squeezing his sister's hand.  Now he's making huge leaps in recovery, already up and walking.  Amazing!

DG was another teenage boy who was hanging out with his cousin, who was cleaning his gun... which was loaded, by the way.  Next thing you know, his cousin accidentally fired the gun and shot DG in the head.  He lost consciousness and had severe intracranial bleeding.  The CT of his head looked crazy - almost his entire right side was destroyed by the bullet.  He went to the OR on his first day of hospitalization to get a decompressive craniectomy.  Basically what they did was take out part of his skull to give his brain room to swell.  He was on heavy duty meds and was on the vent for a week before he was ready to extubate.  We lightened the sedation in anticipation of pulling his breathing tube, and guess what - he woke up!  He opened his eyes, gave a thumbs up, held his dad's hand... incredible!!  He is still in the PICU, but making significant progress.  Praise God!

Finally, DE was yet another teenage boy (these crazy teenagers!!) who was out at the river having fun with his friends.  Like any fun-loving high school guy, he decided it would be fun to jump off a tree branch into the river.  The problem was, as he was getting ready to jump, the branch broke... and he fell into the river at an awkward angle, landing on his neck.  He injured his spinal cord, fracturing his C5-C7 vertebrae.  He didn't lose consciousness, but on impact had loss of sensation from the waist down.  He came into the PICU and was started on a protocol for medical management of spinal injuries.  He got IV steroids and a vasoactive medicine to keep his blood pressure high (with the idea of increasing blood flow to his spinal cord).  There was nothing surgical that could be done.  He has now been in the PICU for over a week, and is starting to have a tingling sensation in his legs.  And this morning, I swear he could tell which foot I was touching.  I'm not sure how much function he'll re-gain, but I am extremely hopeful and I've been praying for him.  The happy part in his case is that he's still here!  He could've died from that injury.  He's such a sweet kid, too.  He is taking it all in stride.

So, there are a few happy stories from the PICU after all the sadness.  Yay!

The sad part about Pediatrics

I'm working in the PICU this month.  It's at a trauma center, so we see quite a few serious injuries.  Mostly from car accidents.  But almost as frequently (or so it seems) we see children come in with injuries due to child abuse.  Last week a 12-month old baby boy came in unresponsive.  The parents reported he had been "out of it" and vomiting for a day.  They couldn't recall him falling or hitting his head, and there were no signs of trauma on exam.  There was no history of toxin ingestion.  The CT of his head showed intracranial bleeds and a very swollen brain.  What was the cause?  We weren't sure but we had our suspicions.  The next day, the eye doctor did an exam and found severe retinal hemorrhages - almost pathognomonic for child abuse.  This little boy had been shaken badly by someone, so much so that it caused bleeding in his brain and severe swelling.  His intracranial pressures got so high that he had to have emergent surgery to have part of his skull taken off so his brain could expand.

Despite these extreme measures, this patient went on to develop brain death.  His brain became so swollen that the blood flow had almost ceased completely.  Once he was declared brain dead, the parents and medical team decided to take him off life support.  His heart stopped 18 minutes later.

This is the second death I've seen this year.  The first one shook me up so badly that I cried for almost a week.  This time, I didn't shed a tear.  I don't know why.  Maybe because he came in and died so quickly.  I didn't have time to get attached.  Or maybe because I didn't actually code him.  Or maybe because I'm growing calloused?  I don't know.  I tried to say a prayer for him, but my heart wasn't in it.  I think I felt more angry than sad.  I'm not sure who abused him, but I sure hope he/she ends up in jail.  I don't understand how somebody could hurt a little child.  Children are so small and vulnerable.  They are completely dependent on adults.  They are so trusting and most of them just want to be loved.  It makes me SO angry to think of all of the children out there being abused, like my poor patient who died.  He left this world far too soon.

Anyway, that's just one of the reasons I don't think the PICU is my calling.  It can be really depressing!  Also, I don't like to have to think on my feet.  And I like my sleep.  But God bless the people who do choose to go into it.  They are definitely special people, and a blessing to all the sick children they take care of.

Pediatrician AND Ghostbuster

Last week in clinic I had possibly the strangest patient encounter ever.  I looked at my computer and it said, "7 year old with sinus pain".  I thought to myself, "This will be easy.  I'll take a look at her sinuses, maybe get a CT, maybe do antibiotics, and send her on her way."  

Not the case.  This little girl walks into my office with her parents, mom looking very concerned.  I start off by saying, "So, your daughter is here for sinus pain?"  Mom replies by saying, "No, that's not why she's here.  My daughter has been seeing ghosts."

Okay, stop.  Am I a pediatrician or a ghostbuster?

After I got over my initial shock, I began my interview.  I asked the patient to tell me about the ghosts.  She said they are black, white, all different colors; some look like people.  She sees them at home, school, everywhere.  I was a little worried to ask her if she saw them there in my office... I was afraid she'd say, "Yes, in fact there's one right next to you."  Then I asked her if the ghosts talk to her.  "No.  But they scratch me sometimes."  Mom piped in and said, "Yes, I've seen the scratches."  Then mom launched into a story about how she had gotten attacked by a ghost several years ago.  That's when I started to become skeptical.  Was this mom feeding into this child's "visions"?  Was mom psychologically in the state of mind to make medical decisions for this child?  I told her as respectfully as I could, "Ma'am, I'm sorry your daughter is seeing these frightening images, and I wish there were something I could do for you, but I'm really not trained to handle this.  I am here to rule out any MEDICAL causes for her hallucinations."  Oh, that did not go over well.  The little girl's mom started getting very heated up, exclaiming "I know my daughter is seeing ghosts.  There's nothing wrong with her medically.  She is seeing ghosts, like that little boy in The Sixth Sense.  I'm afraid they're going to start hurting her.  You have to do something to help us."  I don't know what she wanted me to do - perform an exorcism???  I calmly told her, "I'm very sorry she is so upset and scared.  I will try to find someone who is trained to help you."  That's when I called the psychiatrist.  He was very helpful and agreed to see my patient the very next week (usually not that fast).  Mom was okay with that, and after 20 minutes discussing ghosts, I said goodbye to this strange family.

It was definitely an interesting appointment, and worth writing about so I can laugh about it later.  But I do hope this girl finds some help.  She was sweet.  And who knows, maybe she IS seeing ghosts.  Yikes!!

Attitude adjustment

Lately I've been so negative.  If not out loud, then definitely in my thoughts.  I need to change my attitude.  Below are two ways I can think about my work week, negative vs. positive.

Negative:

I have been SO tired lately!  This rotation is kicking my butt.  We have to do all these stupid assignments and the cardiologists are making me drive all over the city to follow them around.  Monday I had to drive 3 HOURS each way to Ft. Hood and tomorrow I have to go to two hospitals to sit and listen to an EKG talk that I've already heard, ugh!  I have no energy, I'm tired of this rotation, and I'm tired of residency.  Maybe I shouldn't have been a doctor.

Positive:

Wow, I have really been working hard this rotation!  But I've been learning a LOT, and it will help me in the long run.  It's a tough rotation for sure, with all these tests and assignments.  But I've passed everything so far and it's a learning process, even if it is painful at times.  What a privilege that I get to work with these cardiologists, who are renowned in their field.  I get one-on-one teaching with them and I see some great cases by going to all these hospitals.  And even though I've heard the EKG talk before, I am certainly not an expert so I'm sure I'll learn something tomorrow.  Residency is tiring - I knew that going into it.  But I trust that this is where I'm meant to be, and God will give me rest and the strength I need to do this.

If only I could think positively all the time.  But it feels so unnatural and phony.  I suppose if I make a conscious effort to change my thoughts like that, then over time it will happen more and more naturally.  Well that's it for today.  Off to work!  :)

M.D. = Make Decisions

When I was a fourth year med student doing my Emergency Medicine rotation, one of the ER docs told me, "M.D. means Make Decisions."  I've always been pretty wishy-washy.  I have a hard time making decisions about the most trivial things.  Take my iPhone for example.  I spent about an hour in the AT&T store trying to decide if I wanted 8GB or 16GB, black or white (I ended up getting 16GB in black, in case you're wondering... after switching between white and black several times).  But now I'm a doctor and I'm supposed to make decisions everyday - sometimes tough or tricky decisions.  This is one of the key components of being a good doctor, and I've observed this in some of my favorite attendings.  The ability to make a decision and commit to it.

It doesn't come naturally to me (obviously, since I spend hours deciding on things like phone colors).  But every time a decision is placed in front of me as a doctor, I consciously remind myself, "Make a decision, Linda, and stick to it."

Yesterday I sent two kids to the PICU.  The first one was a 12 month old girl who had pneumonia and was working hard to breathe.  I did my assessment and decided I wasn't quite comfortable with her staying on the floor.  She's doing fine and her labs were reassuring... but she ended up on continuous nebs which is a reason to go to the PICU.  So maybe I made the right decision by chance.  Then in the middle of the night I got called for a 2 year old boy who was having difficulty breathing after being extubated (he was under general anesthesia for a small procedure).  When I got there he looked bad.  He was sucking his chest down to his spine and had a barking cough.  I told the Anesthesia guys, "Yes, he needs to go to the PICU" and together we came up with interventions for this little guy's upper airway problems.  He started looking a lot better and by the time he got to the PICU he looked 100% better.  I felt a little silly bringing a comfortable, crying baby to the PICU, but considering what he looked like when I first saw him, I felt very justified in my decision.  And I committed to it.  It was a good feeling.

I'm in a transition period now where I'm getting towards the end of my second year.  In July I will begin my third and final year of residency.  I will be expected to make decisions all the time.  I will be the senior resident on call and I'll have first and second year residents looking to me for answers.  It's a little scary, but I think I'm ready.  Or at least, I hope so.  We'll see!

Honduras

Wow, I am really bad at this blogging thing.  Good thing I don't have many readers, haha.  It's been over a month since I returned from Honduras.  I've been meaning to blog about it because it was such an amazing experience, but I just haven't gotten around to it until now.

We left on a Thursday at the end of January.  We flew into Tegucigalpa, the second most dangerous place for an airplane to land in the world (so I've heard... not sure what the first most dangerous place is).  The reason is because the runway is super short so the pilots have to time the landing just right.  Ours wasn't too bad at all.  I was surprised at how quickly we got there - it was a short 2 hour flight from Houston.  It was a beautiful sunny day when we landed.  We were greeted by some of the NCO's from JTF Bravo.  They drove us to the base where we met up with the rest of our team.  That night we packed up our supplies and learned how to perform maintenance checks on the HUMVEE's.  We went over the itinerary for the trip, and then rested up for the mission.

The next day we headed to Marcala, where we would conduct our 3-day household survey.  This is a project our residency program has been doing in conjunction with the Honduras Ministry of Health over the last several years.  We collect data on randomly selected children to assess for nutritional deficiencies and anemia.  Marcala is in the La Paz region of Honduras, near the El Salvador border.  It is a rural area where some of the poorest people of Honduras live.  We stayed in a local hotel called La Casona Inn.  The people who worked there were so friendly and down-to-earth, and they cooked the BEST food for us!  The first night there we organized all of our equipment in preparation for our surveys.  My friend Raman and I were assigned as the logistics officers so we spent HOURS going through all of the supplies and organizing them.  We were quite proud of our work.

We woke up EARLY for the surveys.  I woke up around 5:00 to inspect my HUMVEE.  Then we would eat breakfast around 6:00 (my favorite part was the plantains - yummy!!).  After that we'd gather our rucksacks and load them into the vehicles with plenty of water and MRE's.  The Honduran guards joined us around 7:00 and then we headed out!  We divided our group into five teams, Alpha through Echo (I was in team Echo).  Each team got an interpreter, one of the NCO's from JTF Bravo.  Ours was named Joanna, and she was very helpful and laid-back.  Driving to the houses was interesting.  The roads were ROUGH.  Some of them were just barely wide enough for our HUMVEE's, and most of them were rocky and unsteady.  Often we'd have a ditch on one side and a cliff on the other.  It was seriously dangerous!  In fact, I almost died one day (This is another story in itself, but basically I got my HUMVEE stuck in a piece of road that gave out under the tire; it could've flipped over and fallen off the cliff but fortunately the other tire remained on solid road.  We jumped out as soon as we got stuck, and another HUMVEE came and towed our vehicle out.  Craziness!!).  Sometimes we would drive up to 2 hours to get to our rally point.  From there we would hike an additional distance to the randomized households.  Some hikes were short (our first day the houses were literally down the street from the rally point), but some were painfully long.  Once we got to the house, our interpreter would greet the mother of the household, explain what we were doing, and start his/her questionnaire.  Meanwhile the medical personnel got ready to collect the data.  We weighed the kids, measured them using "Shore boards" and measured mid-arm circumferences.  Then we stuck them and gathered a drop of blood to check their hemoglobin level.  If they were anemic we gave them iron.  And we left every house with soap, toothbrushes, and dewormers.  A lot of the kids had round bellies that were probably filled with worms.

The best part about the household surveys was that we were outside.  It gets old being cooped up in the hospital all the time... It was nice to be able to enjoy the sunshine and the fresh air.  And the kids were so cute.  The second day of our surveys, my team met an incredibly nice family.  Not all of the people we surveyed were very receptive to what we were doing there.  But this family was so sweet and appreciative.  There were these two little boys who sat down next to me and started talking to me in Spanish (which unfortunately I don't understand since I took French in high school!).  I made do with body language and the 2 or 3 phrases of Spanish I know and we managed to communicate fairly well.  I showed them how to use my camera and they had a lot of fun with that.  The 2-year old boy we surveyed at that house was hilarious.  He was such a trooper.  He didn't even wince when we stuck him for his hemoglobin check - in fact, he laughed!  It was so funny.

The third day of our surveys was one of the most memorable ones, not necessarily in a good way!  This was the day of our infamous hike to San Francisco, a little town located way down in the valley.  We were told our HUMVEE's could not go past a certain point, so we ended up hiking all the way down into this valley - it took about 2 hours one way, and we were literally going down a 30-40 degree incline.  I thought my knees were going to give out, and when we stopped for a rest my thighs were shaking.  Of course since we were all a bunch of out-of-shape doctors, it was painful and everybody whined about it.  I have to say, though, the view was incredible.  And again, I was just happy to be outside.  The most frustrating part about that day was that when we got to where our household was supposed to be, nobody was home!  We tried to make the most of it and started handing out soap and dewormers to everyone we came across.  The hike back was exhausting.  Needless to say, I slept like a baby that night.

After our household surveys were done, we did a couple days of clinic.  The first day was for follow-ups from the previous mission.  There weren't very many patients that day.  The second day of clinic was our MEDRETE, an all-comers day that we announced to everyone in the local area.  We set up shop at a school, where we used their buildings for three stations - Preventive Medicine, Nutritional Surveys, and Clinic.  The residents worked the clinic.  I think there were over 300 patients there that day.  The clinic was pretty easy - mostly colds and rashes and stuff.  Nothing too crazy.  After our clinic day, we packed up our HUMVEE's and headed out for our hospital tour.  The first tour was at the regional La Paz hospital.  The second tour was at Hospital Escuela, one of the biggest hospitals in Honduras (located in Tegucigalpa).  We stayed at the Clarion hotel in Tegucigalpa our last two nights in Honduras - it was so nice!  Especially after "roughing" it for a week in Marcala and JTF Bravo.  One of our last nights there a bunch of us went out to a local bar.  It was so much fun!  There was a live band and they played all kinds of fun Latin music.  We all had a few drinks and danced it up in front of the stage (and ON the stage, haha).  The pictures from that night are hilarious.  Let's just say I have some good blackmail material for several of my co-workers...

I was sad to leave Honduras.  I loved being in a new country and doing something exciting and meaningful.  And it was nice to be away from the residency program for a little while.  I get tired of all the politics and demands of being a resident.  The trip came at the perfect time and I must say I came back feeling renewed and excited to be a doctor.  I wonder how long that will last... haha.

Now it's back to the grind!  More stories to come.  :)

Time to leave the country

That's right, I'm leaving the U.S.  I'm tired of residency.  I'm quitting.  I'm going to make a run for the border.

No, I'm actually going on a humanitarian medical mission trip.  It's a 10-day trip to Honduras with a group of military medical personnel and I leave this Thursday.  We'll be providing medical care to the local children there, as well as surveying for nutritional deficiencies and visiting regional hospitals.  I'm pretty excited.  I'll be sure to write about it when I get back.

It's actually perfect timing because I've been feeling restless.  It's been a month since my last blog entry and things have gone back to normal.  I've been doing research, which is interesting but can be a bit mundane.  I have my clinic once a week, which can also be pretty routine.  Not only routine, but it can be tiring and frustrating.  Yesterday I had a very disgruntled mom who was extremely rude to me.  I am usually quite patient and will put up with a lot from people.  But for some reason yesterday it really got to me.  I was in a bad mood the rest of the day.

Which is why I'm looking forward to going to a third world country where people have different perspectives.  People aren't so demanding and entitled.  At least, that's how it was in Kenya.  I'm guessing Honduras will be similar.  Whatever the case may be, I'm looking forward to a change in scenery.  A change in MY perspective.  Something to renew my love of medicine and children.  I've gotten somewhat disheartened over the last few weeks.  I've been feeling tired, inept, and unmotivated.  It's funny how residency works that way - it ebbs and flows.  There are times I love it and feel like I am right where I need to be.  Then there are other times I wonder why the heck I ever wanted to be a doctor.

So I guess it's time to make my escape.  Hasta luego!

My first code blue

A week ago I coded a patient for the first time.  (For non-medical people, a code blue or "coding" a patient means essentially that a patient is dying and needs resuscitation.)  And to make things worse, my patient was only 11 years old.

Stephen had come to the hospital in critical condition about 2 weeks prior to the code event.  He had gotten a very serious infection resulting in septic shock.  He was found unconscious and when he came to the hospital he had an oxygen saturation of 35% and a pH of 6.9 (both of these numbers are nearly incompatible with life).  He was resuscitated the first night there in the hospital and miraculously seemed to pull through the initial injury.  He was placed on a ventilator and received all kinds of drugs and blood products to keep him alive.  When I left for Christmas, he was still very ill but relatively stable.

I came back on December 28, a few days after his 11th birthday.  Not only did Stephen spend Christmas hooked up to life support in the Pediatric Intensive Care Unit (PICU), he also spent his birthday there.  When I returned I found him on higher vent settings than when I'd left (not a good sign) and also on dialysis because his kidneys were starting to fail.  At this point the prognosis was becoming more and more grim.  His parents knew, but were holding on to the hope that Stephen might surprise all of us.  He had been a premature baby who had several complications in the NICU and doctors had predicted that he probably wouldn't live very long - Stephen proved them wrong.  He was a rambunctious boy whose little sister adored him.  Although he had a few medical problems stemming from his history of prematurity, he was otherwise a typical boy.

The next morning, December 29, I arrived to the PICU at 6:00 am to start my shift.  Stephen was on even higher vent settings and my colleague reported to me that he had been unable to correct Stephen's acidosis.  His lungs were starting to fail and were unable to exchange carbon dioxide for oxygen, so he was accumulating large amounts of CO2, which gets converted to acid.  He was also not oxygenating his tissues, so his body was using anaerobic metabolism, which also results in acid.  This is very taxing on the body after awhile, especially the heart.  We had maxed out all of his vent settings, as well as his meds.  Around noon on that Monday, Stephen's time came.  I looked at the monitor and noticed his CO2 was now in the 150's (normal is 40), and his oxygen saturation was in the 50's (normal is 100%).  His lungs were failing and his heart was starting to tire out.  Sure enough, about an hour after his O2 sats had dropped his heart rate started to drop as well.  It happened quickly.  When that happens the monitor makes this awful sound - three loud beeps, over and over.  One of the NICU nurses once told me it sounds like it's saying "I am dead, I am dead."  I looked around and saw my own feelings reflected in everyone else's faces: fear, panic, apprehension about what to do.  Thankfully, my PICU attending was there and she immediately took charge.  She began to bark off orders and we all immediately returned to our senses - no time to process emotions, now we just had to act.  One of the nurses wheeled the code cart in, I grabbed the back board and placed it under Stephen's back.  One of the nurses began chest compressions.  Another nurse started opening up code meds and pushing epinephrine.  Still, the monitor kept beeping "I am dead, I am dead".  My attending ordered me to keep an eye on the monitor and read off the numbers, then told the nurse to stop compressions and check for a pulse.  No pulse.  She looked at me and told me I was up next for chest compressions.  I jumped up to the bed, thankful to have a role and to do something useful.  I began going through the motions, just like I'd been trained.  I tried not to pay attention to the sunken appearance of his chest and the bruises all over.

Then I heard a sound I don't think I'll forget for a long time.  Stephen's parents had rushed to the PICU as soon as they were informed he was being coded.  In the middle of my chest compressions I heard a loud, sobbing wail come from the nursing station.  I looked over and saw Stephen's mom clutching her chest, crying uncontrollably, falling to the floor in horror.  It was almost nauseating to witness her pain.  I felt a hard knot in the pit of my stomach, but had to keep doing what I was doing.  It was one of the hardest things I've done yet in residency.

The rest of the code was like a dream - or rather, a nightmare.  Everyone did their job and we managed to pull Stephen through... the first time.  His heart started beating again and we stopped compressions.  But we knew it wouldn't last long.  My attending talked to Stephen's parents and they agreed that if/when it happened again, we would try everything we could for ten minutes but if Stephen still wasn't doing well, we would let him go.  And just as predicted, Stephen began to crash again.  Around 1:30 pm it happened the same way - his oxygen saturation dropped, then his heart rate followed.  Once again we began chest compressions and started pushing meds.  This time it was even worse because Stephen's mother came right up next to him, holding his hand and crying "Please Stephen, please don't go!!  I love you so much!!  Please baby!"  I stood right next to her checking for a pulse in between compressions and I hated having to say in front of her, "No, still no pulse."  After ten minutes, we stopped compressions and I checked again.  No pulse.  I listened with my stethescope - no heartbeat.  The monitor was flatlined.  We stopped.  Stephen's mother wailed again.

The rest of the afternoon was very strange.  I felt like I wasn't really there.  Like I was outside of myself, watching myself go through the administrative tasks of calling the organ donor service and writing a death summary.  After the adrenaline had worn off, I felt extremely exhausted all of a sudden.  And numb.  I saw Stephen's parents walking around in shock and pain, and I felt numb.  I wondered what was wrong with me.  Had I become calloused?  Why wasn't I feeling anything?  I saw nurses crying, but I felt nothing.  Just shocked.

It was on my drive home that it hit me.  I was staring straight ahead, replaying the scene in my head.  I was imagining what it must've looked like for Stephen's mother to walk in and see me standing over her son's chest giving compressions and my attending yelling for code meds to be given.  Then I thought about what it would've been like if it were my little brother on that bed.  Stephen was only a few years younger than my brother Jacob.  I couldn't even bear the thought of seeing Jacob like that... swollen, bruised, eyes falling open, skin turning blue, getting compressions and hearing the monitor beeping "I am dead".  I lost it.  I started crying uncontrollably.  I cried and cried, all the way home.  I had a hard time sleeping that night.  Thankfully I wasn't alone.  My roommate kept me company.  But I got into my bed and cried myself to sleep.

The next few days were strange.  I thought I was okay but then all of a sudden I'd see the image of Stephen dying in my head and I'd be overcome with grief again.  I broke down crying to one of my mentors.  She was gracious and listened to me with deep empathy.  I cried myself to sleep again the second night after Stephen died.

I'm doing better now, but my heart still hurts for Stephen's family.  I pray that God is bringing them comfort and that Stephen is in a better place now.  You know, as difficult as this week was I am thankful that God gave me empathy for my patient.  I wanted to write about it so that I will not forget Stephen and what I learned from his death.  I know I will probably see more children die in my life - unfortunately it comes with the job that I've chosen.  But I don't want to ever forget the pain it causes the family.  I don't want to grow desensitized and lose my empathy.  True, it is something doctors have to deal with all the time so I will need to learn to cope with it and move on.  But for each patient's family, it isn't something that happens all the time.  It is a life-changing, heartbreaking event.  I hope that I can always remember that.

May Stephen rest in peace.

Reviving my blog

It's been a long time since I've written on this blog.  Part of the reason is because I don't have time (now that intern year is over I have a busy social life!) but also because I didn't think anyone really cared to hear my rambling.  However I think I may pick it up again because 1) it's therapeutic for me to write (so it doesn't really matter if anyone reads it), 2) it's a way to document stories from residency (so one day I can look back and laugh), and 3) somebody told me I should keep writing (probably my only reader!).  At any rate, I have a compelling and heartbreaking story to tell, which deserves its own post so I will start from there.

Be Thou My Vision

This morning at church I re-discovered a beautiful hymn called "Be Thou My Vision".  It's been a long time since I heard it and I was pleasantly surprised!  I was at First Baptist Church of San Antonio, inside an old historic building.  The sun was shining through the stained glass windows and the sanctuary looked grand.  The choir and congregation sang it so beautifully and softly.... and for a moment I had a feeling of peace.  It really moved me.  The melody is beautiful but the words also capture my soul.  Here they are:

Be Thou my vision, O Lord of my heart

Naught be all else to me, save that Thou art

Thou my best thought, by day and by night

Waking or sleeping, Thy presence my light

Be Thou my wisdom, and Thou my true Word

I ever with Thee and Thou with me Lord

Thou my great Father, I thy true son

Thou in me dwelling, and I with Thee one

Be Thou my battle shield, sword for the fight

Be Thou my dignity, Thou my delight

Thou my Soul's shelter, Thou my high tower

Raise Thou me heavenward, O power of my power

Riches I heed not, nor man's empty praise

Thou mine inheritance, now and always

Thou and Thou only, first in my heart

High King of heaven, my treasure Thou art

High King of Heaven my victory won

May I reach heaven's joys, O bright heaven's sun!

Heart of my own heart, whatever befall

Still be my vision, O ruler of all

Adult medicine? What's that??

I'm at Ft. Hood in the great little city of Killeen, Texas.  I was here a year ago for my nursery rotation.  This year I am rotating in the ER.  Which means I have to see kids AND adults.  Weird!  I don't remember how to do adult medicine.  I haven't taken care of adults in a long time.  It's all foreign to me.  Fortunately the people I'm working with are really cool and they don't mind letting me see the kids that come in.  No crazy stories just yet.  I had two patients walk out on me, which was kind of funny.  People seem to think the ER is like Burger King - "Have it your way."  Um, sorry to disappoint, but NO.  It just doesn't work like that.  It's so hard to provide compassionate care to people who are so entitled and ungrateful.  Drives me crazy.  But I guess that's what I signed up for.  The good, the bad, AND the annoying.

The calm before the storm

It's a beautiful Saturday morning and I am enjoying a nice warm cup of chai tea, enjoying these last few moments of peace.  In 3 days I will be starting my second year of residency as the senior resident in the NICU.  I'm a little nervous about this new level of responsibility.  It's just so strange... one night you go to bed a clueless intern, the next day you wake up as the all-knowing senior resident.  Yikes!  I'll have three interns to be responsible for.  I will be their direct supervisor, as well as their teacher.  I'm kind of excited about this job, but also somewhat anxious.  I want to do a really good job.  I had excellent second year residents last year.  I have big shoes to fill.

But there's no sense in sitting here worrying about it.  Worrying doesn't add a single hour to the day, as it says in the Bible.  So for now I will enjoy the sunny weekend and get rested before the craziness begins!  :)

17 days and counting...

I'm almost done with my intern year!!!  I can't believe it!  It went by fast.  I'm super excited, and a little nervous too.  I'm not sure if I'm ready to be a second year resident.  But I don't really have a choice because they passed me on all of my rotations this year so apparently somebody important thinks I'm ready.  :)  I still feel like I have SO MUCH to learn.  I think I'm going to be reading a lot more this year.  I feel like intern year was kind of just a time to get my feet wet, to get accustomed to Pediatrics, and to learn the system.  NOW I need to learn the art of medicine.  It's a lot to squeeze into a 3-year residency.  But I know being a doctor will involve lifelong learning.  I'll never be done learning or taking tests.

Top ten memories of intern year:

10. Walking into my first continuity clinic ever and looking at my first patient's chart - former 22 week premie with cerebral palsy, hearing loss, blindness, hypothyroidism, etc., etc., etc.  AHHHH!!!

9. Circumcising a little African-American baby boy who was so large we nicknamed him "Big Dog Duckett".

8. Rounding on patients with the ward team dressed up as the Flintstones on Halloween.

7. Walking with our leukemia patients on the annual Light the Night walk.

6. Telling off a lab tech only to come face-to-face with him several weeks later when I had a needle-stick injury and he had to draw blood from me.  KARMA.

5. Having a ward spelling bee because all the guys on our team were so bad at spelling - taking home the winning ribbon!!

4. Walking into one of the Labor & Delivery rooms with a newborn in his bassinet, giving my discharge instructions and realizing halfway through I'm in the wrong room - receiving blank stares from parents who have not had their child yet.  Oops.

3. Running my first mock code ever on the ward, not just as practice but as the "official" pediatric ward mock code - failing miserably and crying in front of two attendings (including the department chief).

2. Causing a raucous in Fredericksburg during our resident retreat - Sue throwing a bottle of Worcestershire sauce and me dropping and shattering a bottle of beer.

1. Making some great new friends.  :)

There's no place like home

I wish it were as easy as tapping ruby red slippers together and chanting "There's no place like home."  I wish I could be with my family whenever I'm feeling homesick.  Unfortunately it took a very long plane ride and months of planning.  Also money, Air Force leave request, and much preparation.  I spent the last 10 days on the East Coast, and it was wonderful.  I spent the first part of my visit up in Maryland, where I got to see my good friend Kimberly graduate from med school.  I also reunited with some old friends and even went to my old church.  Then I headed to the Outer Banks in North Carolina for some much-needed R&R and girl bonding time with my mom and sister.  Lisa had flown in from Las Vegas.  She is almost 6 months pregnant with a little girl, and definitely has the "glow" of pregnancy.  She has always been beautiful, and is even more so now.  We went to a lesser known area of the Outer Banks called Ocracoke Island.  It's a very small island that is accessible only by ferry, private boat or plane.  It has a population of less than 1000 and has miles and miles of untouched beaches.  Most of the Outer Banks has been built up and commercialized.  But not Ocracoke.  As soon as we drove off the ferry there was a sense of old-town comfort and quiet.  People ride bikes around the small island.  There are no familiar chain restaurants or stores - no Wal-Mart, no CVS, no McDonald's.  Instead there are quaint privately-owned shops, such as "Sweet Tooth" candy store, "The Back Porch" restaurant, and of course the General Store.  We stayed at a lovely B&B called The Cove.  Our deck looked out at the water.  After 3 glorious days at the beach, the girls headed back home to Virginia and I spent the rest of the week catching up with family and preparing for Lisa's baby shower.  We had a mini family reunion for her shower - almost all of the 12 cousins were there.  My last night at home I walked around the farm taking pictures with my new camera, marveling at what a peaceful night it was.  My parents have built their retirement home on a farm and there's a little pond in front that sparkles at night when the sun is setting.  It couldn't be more picturesque.  The next morning was filled with tearful goodbyes - particularly when my sister left.  I almost always cry when we part.  I miss her so much.  And I miss the rest of my family, too.  Coming home from vacation is always hard.  Especially when you've gone home to visit family.  Hence the title of the blog.  Despite the friends I've made here in Texas and the exciting new adventures I've had here, I still feel like a part of my heart is missing because it's with my friends and family in Virginia.  There truly is no place like home.

Constructive vs. destructive criticism

I finished my ward rotation at University Hospital today.  This is the one civilian rotation we have all year.  The purpose is to expose us to another medical system, particularly one like UH that has a lot of pediatric trauma and high-acuity patients.  I was actually pretty excited about it.  A new hospital, new people to meet, interesting patients, and I got to dress like a girl instead of wearing my very unattractive BDU's everyday.  

I'm sorry to say I was somewhat disappointed with the rotation.  Don't get me wrong - I did enjoy the medicine I learned, and I enjoyed getting to know some of the people there.  Unfortunately, my senior resident and I didn't really click.  She's a very serious, smart, efficient resident.  I'm more laid-back, which I think can be perceived as laziness.  I'm not lazy, though.  I work hard.  Granted I have my off days where I'd rather not be there and I probably don't give 100%.  But for the most part, I consider myself to have a very good work ethic.

Unfortunately, this is not what my senior resident thought of me.  I asked for feedback halfway through the rotation and again today at the end of the rotation... and I have to say, it was probably the most negative, unhelpful feedback I've ever gotten.  And I'm not just being defensive when I say I don't agree with it.  I really do think I did a better job than she gave me credit for.  She totally focused on the few things I did wrong and didn't mention any of the things I did right.  It was really quite destructive to my ego, and not constructive in any way.  Apparently this girl did not attend leadership courses like I did in ROTC at good old Virginia Tech.  Hasn't she heard of the "feedback sandwich"?  Positive critique, followed by negative critique with suggestions for improvement, wrapped up with positive critique.  You can give constructive criticism without making someone feel like a piece of crap... which is what she made me feel like.

But I only felt that way for a little while.  Then I decided I'm not going to let her get to me.  I know how hard I worked.  I know the good things I did.  I don't need her recognition to know that.  I'll be honest, I'm still a little frustrated by the whole thing - but I'll get over it.  I'll put a smile on my face and keep trying my hardest.  Only 2 more months of intern year, and then I'm no longer at the bottom of the totem pole.  Yay!!

And I'm BACK!... with a Mac!!

So about a month ago my 5-year old HP laptop decided to die.  It's been a pretty slow inevitable process... little things kept breaking here and there.  Then I got a nasty virus and everything shut down.  I decided it was time to buy a new computer.  My laptop was extremely outdated and worked better as a doorstop than it did as a computer (it weighs about 20 pounds, haha... no seriously, it's ridiculously heavy).  

In the meantime I've been disconnected from the outside world.  No Facebook, no MySpace, no blog, no YouTube.  In other words, I had loads of time to do more productive things.  Like watch American Idol.  Hahah.  But I also spent a great deal of time researching what I would buy to replace my old laptop.  I seriously spent HOURS comparing all the different PC's.  I learned more than I ever want to know about processors, frontside bus (still don't really know what that means), gigabytes, RAM... I had narrowed it down to either a Dell or Sony Vaio.

And then I talked to some friends who made the leap from PC to Mac.  One friend told me, "I will never buy a PC again."  She let me play with her Mac.  It was pretty sweet.  So today - one month after the death of my HP - I bought a Macbook.  It's a pretty big change for me.  I've never been an Apple girl.  Macs always kinda scared me.  And they seem to be for people who are members of some sort of secret elite club.  But so far I'm happy with my purchase.  My Macbook is so pretty and fancy!  I have hours of nerdy enjoyment ahead of me.  And now I'm back in the internet world.  I'll still be watching American Idol, though.  :) 

Back in the NICU

I'm working in the Neonatal Intensive Care Unit (NICU) again this month, so I probably won't be writing on this blog too much. Not that I write much as it is. I have become too busy and too tired to bother writing on here. I cherish my spare time to sleep or attempt to lead a normal life. Last night I actually got away from the hospital and did something fun. I went to see "The Phantom of the Opera" with one of my good friends who was in town. It was the Broadway show - they are on tour here in San Antonio at the Majestic Theater. It was amazing!!! I absolutely loved it. I've been singing songs from the show all day. What a beautiful, tragic love story. I want to see it again.

And now I'm off to bed, hoping to dream of my own Phantom who's madly in love with me. Haha. :)