UnleashTheDuff

There is a plexiglass statue of a salmon in Old Tacoma. It’s almost exactly 2.5 miles from the front door of my apartment, by foot. I run past it almost every day – representing the halfway mark of an easy, 5-ish mile run (though the definition of “easy run” transmogrified quickly once I moved to the PNW as it’s next to impossible for me to run any distance without an elevation gain of more than 500 feet). That fish, which I affectionately call “Mr. Tuna,” or “Mr. T,” is decorated with festive outfits every single major holiday. His current festive attire is a red stocking cap, a green garland wreath, and a string of lights wrapped around his body as an obligatory testament to Christmas™. No matter its décor, every single time I pass that fish I stop my run, find the same small scratch in the plexiglass behind his eye, and kiss him (I do not endorse exchanging bodily fluids with public inanimate objects, either personally or professionally).

Hopefully it goes without saying that this isn’t a romantic expression (though it wouldn’t be the first time my sexuality was questioned – most recently suspected of being asexual!). For as long as I can remember, I’ve spent time while running to show appreciation for…well, I don’t even know what. On my sporadic summer runs in high school, I would pick a leaf off the first tree I ran by and throw it in the air, but not before showing my appreciation – with a kiss of course. I imagine at that time it was appreciation for sleeping in, or time off of school, or for sunny days, or some other discrete, objective entity one can point to, to be thankful for. And for some inexplicable reason, without intention, my awareness would gravitate toward gratitude – well before I was fully conscious of it, and way before the word “gratitude” itself infiltrated the popular lexicon from cringey self-help personalities so as to make me nauseous just writing the fucking word.

For the decade(!) now that I’ve been what one would consider a “runner,” I’ve progressively stumbled on more and more abstract, intangible foci in life to be grateful for, and therefore run for (I had a whole post about it years ago). Now 10 years into this nearly quotidian exercise, with tens of thousands of miles under me, the motivations to run have been distilled down to something more axiomatic. Existential. All the above is still true, but I think now that even if all that were stripped away, motivation would still exist. The famed ultrarunner Scott Jurek more concisely summarizes the phenomenon in his book chronicling his FKT of the Appalachian Trail when he repeats this internal mantra during arduous moments of self-doubt:

“This is who I am. This is what I do.”

This meditative exercise, even if stripped of all of its many, many physical/emotional/spiritual/social benefits, continues because it…just. Does.

This sounds like an unhealthy compulsion, I know. And like many in the running community who have recovered from an eating disorder can attest (yes, I’ve written about that too), being mindful of one’s relationship to exercise and the body is of crucial importance. Yet, it remains integral to who I am, nonetheless. And seemingly unshakable (not that I’m trying to). AND, if nothing else, this morning ritual has provided me a constant in a year full of variability, uncertainty, and blistering change.

My initial impression of this year, before I sat down to reflect, was that it was somewhat…stagnant. Static. A sort of rinse and repeat of the year prior, both personally and in my role as a resident. Maybe its because of just how momentous and bewildering it was to experience everything that I did, that I hadn’t paused to reflect in all the ways that I changed and grew (and hopefully didn’t devolve…). Perhaps more than any other year of my life. Which is a remarkable revelation for someone who has been pithily cataloging their life in residency on social media every single day since becoming a resident. Looking back, its hard to imagine how I would have endured any of this year, the good, the hilarious, the tragic, everything, without the breadth of extraordinary humans I consider my family.

I’m not of the “resolutions” persuasion for new years – which I think by this point has been (rightfully) denounced given its proclivity to promote self-shaming and pathological patterns of thinking. But because I’m introspecting fervently right now (this post has taken me hours as I started with absolutely nothing in mind to write about), there is an intentionality of my life that has been lacking. Persistence and routine – those are muscles I’ve hypertrophied to no end. As is my muscle for tangential wandering, both mentally and physically. But being a doctor (adult in general?) requires a bit more…well, it requires more purpose than just, “it’s what I do.” I am highly cautious of purely cynical behavior – actions taken solely as a means to a personal or political end without any intrinsic desire to complete them for the sake of enjoyment. But aimless, inscrutable actions done purely out of impulse or compulsion aren’t exactly congruent with any of my goals in life, either. I think somewhere between neurotic goal-seeking and aimless, though routinized, hedonism, lies adulthood. If this year I find that balance, I’ll owe much thanks to Mr. Tuna.

Much, MUCH love friends – and happy new year! Enjoy the rest of the 2022 collage 🙂

I had watched the evolution of this disease each day for almost two weeks. From admission, to degression over a period of days, and finally after a week of nights when BiPAP and high flow just weren’t cutting it and their saturations peaked in the 80’s despite every possible intervention. One of now countless COVID victims I’ve taken care of since July.  It was my goal to keep them off the vent for just one more night, my last night on nights. An arbitrary goal for sure, as there wasn’t a person taking care of them over the last 2-3 days that didn’t know exactly where this was headed. It was just a matter of time. But I’d hoped it wouldn’t be on my time. Alas, here we were. A senior ICU resident, a respiratory therapist, the patient’s fantastic nurse, and me, a deliriously tired intern, all huddled over a petrified patient. A patient whose last conscious moments would be a team of faceless gowns and masks screaming over the deafening high flow of oxygen that there is a very real possibility that they would die on the ventilator they were about to elect for.

“If it will help me breathe.”

It was unmistakable, though barely audible, and the nurse recounted the words loud enough for a frightened daughter on speakerphone to hear. A daughter whose love and input was so cherished that prolonging the life of this tortured soul was a decision necessitating her input. There was agreement in the decision. We’d give it a shot. A trial of intubation. 10, maybe 14 days, and then we’d see. Just a little more time. One last college try and if it failed to improve their condition, then it would be the time. One last exchange of tearful “I love you’s” between a parent and child, and the call was over.

Now the work began. Immediately the nurse went to grab the sedatives and the respiratory therapist to grab the vent and call the on-call anesthesiologist. The ICU resident quizzed me on what I wanted for pain management, sedation, and vent settings. I blurted out some basic vent settings and guessed 4 times on the answer for sedation before being educated on the right choice. I carefully discarded my gown and mask and left the room. I dispensed two jets of hand sanitizer and scrubbed them dry before reaching into my pocket to answer mundane cross-cover pages. Yes, I can order Tylenol for Mrs. A. No, no morning labs for Mr. H. Sorry, Mrs. K is probably a surgery patient. Try paging them. I put my pager, that wretched bane of my existence and sleep, back in my pocket. Now in front of me was the anesthesiologist donning a gown and mask. “Is there anything I can do to help you?” I sheepishly asked as I hurriedly threw on PPE again. There was not. But this was still my patient, and I would be there for the intubation, which went off without a hitch. The anesthesiologist conveyed an enviable collectedness, even through her mask, a posture adopted only by someone who has done this 1000’s of times before. I went back to the workroom to put in orders and write the transfer note to the ICU. I managed to bungle that order set handedly (I haven’t done my ICU rotation yet) but received indispensable education by my astute senior shortly after. At least I remembered the chest x-ray.

It was close to midnight, and I needed to follow-up on some urine outputs and labs for one of the 30 or so patients I was covering. A far-cry from the 60 just a few days before. No electrolyte repletion for GI bleeder. Only 100mL out for heart failure dude – I’ll order a slug of Lasix. Ah yes, it’s time for that abdominal exam for Mr. bowel ileus. I floated up the elevators to introduce myself for the 2^nd time that night to a man with an abdomen the size of a small tire. Passing gas, making stool, and no change from previous exam. “Good,” I thought. “I have no desire to drop an NG tube tonight.” I made my way back down to the ICU to check on our freshly intubated friend. The ICU resident appeared out of the workroom and without hesitation asked, “Want to put in a central line?” Without any knowledge of who or what for, I said “Hell yes,” and we walked back to our mutual COVID patient. Once more into their isolation room that, at this point, I’d been in at least a dozen times. More gowns, masks, and this time the addition of a surgical gown and gloves to prepare for a procedure. A procedure that involves jamming a catheter the thickness of a pencil into someone’s neck until it rests just outside the heart. I took the ultrasound probe to find the jugular vein, talking aloud the anatomical landmarks to my senior resident. Because of the ventilator, the screen vacillated between an absolutely perfect view of the large vein directly in the middle of the screen followed by immediate distortion of the image and me losing my 3-dimensional awareness completely. I cleaned and anesthetized the site. Taking the needle, I pressed it gently against the skin at the site of the probe to see exactly where I was, fighting the ventilator as I stabilized my right hand firmly on this patient’s face. After some readjustment I found my best opportunity to penetrate the vein and went for it. I pushed – quick and hard – and slowly my syringe gathered that dark red humor essential for life.

Success.

I exchanged the syringe for a guide wire, then the needle for a dilator. My senior handed me the scalpel and I used the mortally sharp blade to incise the skin just enough to advance the dilator. A rather violent push and turn motion, necessary for the procedure, extruded yet more blood such that a thin film of coagulating blood painted my fingertips. All to be expected. The final exchange of the dilator for the catheter, followed by removal of the guidewire concluded my participation. I left to put in more orders and my senior finished the sutures (I was always terrible at throwing stitches). Slowly I’m learning. Each day I’m practicing. And nearly every interaction with patients is a suspension of reality and the gravity of what it means to practice medicine. At least I remembered to order the chest xray (again).

I wrote something somewhat similar to this around this time last year. Medical journals have these submissions that aren’t research or case reports, but reflections on medicine that involve personal experiences of doctors and lessons learned treating patients. I wrote about an experience I’d had as a 4^th year med student and submitted to a few journals without success. Suffice to say my writing style is…verbose compared to other submissions, and besides being melodramatic in prose (but a completely accurate description of events) it was probably just poor writing. But I’ve included it below:

I was midway through a shift in the emergency department during my ultrasound rotation, two weeks away from a much-needed winter break. I waited for my patient suffering from back pain to return from a CT scan so I could perform a bedside echocardiogram. In the interim I refreshed my cardiac anatomy, but my attention strayed to the open electronic health record tab of our most recent patient. COVID-19 positive, worsening shortness of breath, and chest x-ray demonstrating diffuse, bilateral opacities. I scanned their problem list, developing a gestalt of their health and mentally checked off each comorbidity portending poor outcomes for a virus now resurging. My seasoned 3^rd year emergency medicine resident prognosticated a succinct yet ominous disposition.

“They’re not going to make it out of this hospital.” I followed her gaze to the room behind me and saw a tortured soul fighting for air as the respiratory therapist increased the oxygen via high flow nasal canula. I stared blankly for a moment, yet quickly my attention was averted. I caught a glimpse of my patient returning from CT. My resident was busy finishing notes, but our attending physician also noticed their return. He looked at me while pointing to the ultrasound machine.

“Ready?” He barely finished the word before darting toward the patient’s room. I’d quickly realized this was the only pace at which emergency medicine physicians worked. I eagerly rose from my chair and responded. “Let’s do it!”

My attending provided guidance as I felt the prominent rib contours through the ultrasound probe pressed against my patient’s frail frame. A textbook view of the heart appeared on screen, just as my attending was urgently called out of the room. I continued the procedure, awed by my patient’s abnormally large heart, with such poor contractility it bordered on asystole. As I finished up, I thanked my patient for the learning opportunity yet fumbled briefly having forgotten their name. This rare uncouth moment represented a sharp deviation from what is normally my penchant for quickly building authentic rapport with patients. Leaving the room, I recalled past evaluations by residents and staff that corroborated my intrinsic investment into patients’ lives. But immediately after closing the door, a cacophony of different colored scrubs in another patient’s room broke my internal reassurance. An all too familiar scene of organized chaos I recognized as a code.

Two medics, whom I’d worked with before medical school as an EMT, arrived with a patient in cardiac arrest. COVID-19 precautions barred students from assisting in these, so I watched from afar and reminisced with my former co-workers. Moments later, a nurse scurried from a small opening in the sliding door to hand the crew their LUCAS device. We exchanged farewells and as they departed, I heard the echoes of alarm tones emanating from their radios, followed by their dispatcher’s voice. She begrudgingly addressed the crew, provided them a street address, and gave them their next call: “Code 3 – cardiac arrest.”

My focus shifted back to the resuscitation. A fellow classmate and I talked as we gazed helplessly at the ongoing entropy beyond the plexiglass. We discussed potential etiologies of this patient’s stopped heart, as well as prudent investigations and treatments. When our view inside the room was obscured, our conversation detoured to life updates, postponed holiday plans, and the fraction of anatomy current first-year medical students had learned compared to our class. “They didn’t learn any of the pterygoid fossa?!” I exclaimed in disbelief.

“Can we get another amp of bicarb?” Another nurse exclaimed from behind a small opening in the door. I peered through this fleeting aperture to get a closer view of the turbulent exercise of restarting a heart I’d participated in countless times before.

The resuscitation was momentarily successful – a thready, tenuous, slowed heartbeat restored. My attending remained outside the room to console the family over the phone, tenderly informing them of the situation and the grim prognosis. Silence followed, then muted sobs from the other line. They’d made the decision to act in accordance with the patient’s newly discovered “Do Not Resuscitate” order. Barred from the hospital given COVID-19 precautions, the family listened over speakerphone while the hospital chaplain gave the patient’s last rites. A final ventricular depolarization flashed on the monitor before deafening stillness. There would be no compressions this time.

I was getting hungry as we neared shift change, and anxious to get home. I refreshed my patient’s chart from earlier and opened their CT scan images. I challenged myself to read the imaging before the radiologist’s report. But the pathology was clear even to my novice eyes. The vertebrae in my patient’s spine were peppered with a half dozen or so small, lucent circles representing erosion of bone. As if pierced maliciously by a hole puncher. The etiology of their back pain was clear. I reviewed the rest of their chart.

“Mets,” I said quietly, to no one. Metastatic cancer.

“I called medicine and palliative care,” my resident exclaimed to our attending as they discussed my patient before sign-out. I admired her astonishing efficiency, having already finished her note from the code. This patient, too, was likely not going to leave the hospital.

My stomach growled.

The oncoming night resident appeared at the workstation to relieve us, and I practiced delivering sign-out on my sole patient. I approached a nurse who’d helped me earlier in the shift with placing IVs to say thank you before heading home. My walk back to the workstation led me past our patient suffering COVID-19 pneumonia. Their battle for oxygen grew more intense as the respiratory therapist traded the nasal canula for BiPAP.

Another growl from my belly. I found my resident and expressed gratitude for her teaching, solicited feedback, and we parted ways. I hazily remembered the mental map back to my car as midnight passed. I drove straight home – immediately falling asleep and forgetting to eat altogether. I was awoken peacefully by a late-rising December sun hours later. Feeling refreshed with sleep, coffee, and finally a meal, I began a process I’d routinized since starting clinical rotations that proved crucial to sustaining my humanity in medicine: Writing, reflecting, and learning from the previous shift.

As I began typing, however, the gravity of each encounter began weighing on my conscience. My refreshed energy quickly abated, supplanted by a gnawing grief as I recapitulated the suffering I’d borne witness to. My seeming indifference to this pain, then necessary to focus on my learning and catalyzed by hunger and fatigue, gave way to overwhelming guilt. I recoiled from the keyboard. My eyes closed. My thoughts quieted. I opened up space – to feel. A space to focus on that painful, yet necessary, expression of sorrow unconsciously triaged until now. I surrendered to those emotions, shedding tears concordant with suffering heretofore left unattended. The suffering of three patients and families whose mortality was now palpable. Undeniable. Eventually, my catharsis and tears rescinded, having rehydrated the clearly desiccated but still fertile soil that sprouts the compassion and empathy from which my motivation to practice medicine harbors its roots. I finished my reflections, sobered and revitalized, ready to carry my replenished soul to my next shift.

Now, over halfway through intern year, I’m reminded again that the practice of medicine involves ignoring, or even making light of entirely, solemnity. I recently made a friendly challenge with one of my clinic patients. They doubted their ability to live much longer, so I wagered if I kept them alive from their metastatic cancer long enough to graduate residency that we’d share homemade chocolate cake at our last clinic appointment – we both smiled. I sang Pavarotti with one patient to increase the negative pressure in their chest so I could safely remove a central line in their neck, to the amusement of my nurse and med student. Just two of countless examples of the necessary diminution of morbidity and mortality in medicine, obfuscating the gravity physicians and patients face. But that gravity exists, always, no matter how much it’s shuttered, ignored, repressed. Perhaps each clinician’s scales are calibrated to measure that gravity with more or less weight, but I believe it pulls on each of us, nonetheless. I’m intensely melodramatic so my scale is acutely sensitive. But I think that gives me an opportunity to be uninhibited in my connection with patients and families. Certainly, humanity is tabled when learning or performing procedures is the objective at that moment. Compartmentalization is a necessary component in this field. But my natural predilection is for empathy, not callousness. To be as willing to hold the hand of the grieving and dying as I am to hold a catheter or a breathing tube. To be equally proficient in lines, vents, procedures, and patient management as well as being earnest in my investment in patient well-being. To be unmatched in that part of medicine that’s practiced at the bedside, emulating the physician you’d want to have if it were you about to make what’s likely the last decision of your life. That’s my practice. That’s how I intend to practice.

But as a budding pulm/crit doc, I do really, really love procedures, too.

All-in-all, I still can’t believe they let me do this shit. I fucking love it. 🙂

‘Til next time my friends – much love!

This should be an interesting post. Not because of the content, but mostly because of the fact that it’s coming to you from the inner bowels of the hospital at around midnight, which means I’m halfway through a 14 hour night shift. I’m surprisingly…hmmm, I’m reticent to say energized, but certainly I’m bewildered at how much energy I do have. The quality of writing within this post might be a useful, objective(ish) barometer of how deteriorated my mental faculties are – and how unaware I am of that decline here in the present moment. Humans were not meant to operate at night nor with sleep deprivation. And yet medicine often demands both. Thank God for nurses that literally just tell me what to order for the 30 patients I cover overnight whom I have barely any idea what’s wrong with them, let alone what they need. But in those rare cases so far where I do have time to think, or where the nursing staff doesn’t have the answer immediately, I gain some satisfaction (as one does in an egomaniacal profession like mine) when I can, with some confidence, use the 1000’s of hours of education and training to make an informed decision and place orders on how best to proceed when I’ve been entrusted to do so. Even if, in the end, it’s a big nothing burger.

So here I am. An actual doctor, into the frying pan fresh into my second week as an intern. Don’t worry, I have another licensing exam to be a fully licensed doctor and 3 more years until I am board certified so I get to be a trainee F O R E V E R. I have resigned myself to using the title “Dr. Duff,” for expediency and ease. Though it’s just as nauseating and cringe as I envisioned it would be before I was bestowed the title. It’s slowly becoming tolerable though. Mostly because I ‘ve said/heard it so much since starting nights that I don’t have the time or the energy to recoil every time that ridiculous alliteration violates my ears. Perhaps it really will stick though. Perhaps my tolerance will evolve into acceptance. Maybe, even, a likening. That’s to say nothing of how undeserved of the actual title I’ll still feel well after the grating aesthetic wears off. Who knows how/if/when that feeling will subside, but I’m not holding my breath.

I’m told that’s kind of normal. At least for a while. I have doubts that it will abate as well as my co-intern however. I’m generally immune to entertaining self-esteeming thoughts at baseline. And to think I’ll bridge the chasm between a markedly low self-esteem before becoming a doctor to that expected of a medical resident anytime soon is a pipedream. But hopefully it’s not even required. Hopefully I can procure the clinical and medical knowledge required of my profession, and the confidence to implement it, that an arbitrary need to fill personally validated or self-assured of my “accomplishments” is tangential to the abilities of being a good doctor. I’m halfway through my first week of nights and so far (granted, with an insanely low work volume and acuity) I’ve managed not to fuck anything up. So I’m hesitatingly reassured of my abilities to do my job without actually feeling I completely belong here. Now, that’s not at all to say I regret my decision to do this job. On the contrary, I love medicine. I love thinking. I love working with my hands. I love the autonomy, and yes I love having the decision making capacity and authority to really change outcomes in other human beings. I love most of all just peoples’ stories. But it is a field that attracts and seemingly demands a particular constellation of attributes that I do not possess. The great majority of these folks are extremely detail oriented. I could (and have) got lost in my apartment building. I have gone to school nearly 23 consecutive years and to this day have not learned how to take notes. I am guaranteed to forget at least 20% of pertinent interview questions during basic patient interviews cause I’m somehow incapable of following a simple format for each one. I absolutely despise writing H&P’s and progress notes because it evinces my unintentional disregard for about a million different pertinent details. These people are also wicked intelligent. I (honestly, objectively) am really not special. I took an IQ test about 2 years ago and think I scored at or slightly above average. I cannot remember names or places or directions well at all. I constantly put my foot in my mouth, my thought process is scattered at best, and usually I can say in 100 words what an intelligent person could say in 10. My fellow doctors seem to carry themselves gracefully, and act with a sober mind and spirit. I am preternaturally clumsy, loud, emotionally volatile, and every 1/4 mile I walk I seem to either trip on something or walk into something or someone. Perhaps my biggest departure in my character from that of medicine’s is my absolute disdain for being uncomfortable. I am writing this post wearing my tie-dye crocs, my XL scrub pants (I LOVE baggy scrubs) and a maroon scrub cap I bought from the U before I left. Oh – and I’m going commando. In essence, unconventional attire. I show-up to work wearing torn sweatpants, flip-flops, and a black tank top because I like to be comfortable – always. I like to be candid with patients, and I will cuss, all. The. Time. Because that lexicon is where I’m comfortable.

Not exactly fitting the bill of an MD. And it’s a consternation I feel daily. And one I’ve felt even since well before getting into medical school when I learned how I divergent I was form the status quo represented by my peers. I enjoyed learning science college for essentially for the first time given my complete rejection of formalized teaching up until then, but I realized I loved working with people and working with my hands and moving like a madman trying to keep up with orders working in food service perhaps even more. In an overwhelmingly white-collar profession, I derive much more satisfaction with the minority of the more blue-collar work that is still necessary for its functioning: doing procedures, examining patients, giving orders, etc. Those were my most fun moments as an EMT: Throwing in IV’S and IO’s, helping with intubations, wrapping wounds, etc. And that is evident in just about all facets of my personality. I like to do far more than I like to think (and I do a lot of thinking – even if mostly nonsensical drivel like you’re reading). I like interacting with people and using my hands more than my head (even if I’m mostly terrible at both). It’s antithetical to my nature to be neurotic over tiny details and approach patients with an intense scrupulousness that almost obfuscates our connection as fellow humans and analytically dissects patients into a set of boxes, lab values, diet orders, I’s and O’s, insulin regiments to the point of near insanity…I digress.

So far, residency has been pretty damn good. I enjoy putting in orders that aren’t co-signed by another doctor. My actions are no longer redundant, and the fear and trepidation over the gravity of that is abating dramatically. Especially on nights. I’m far from having the clinical knowledge necessary to perform anything advanced at this point (obviously), but I’m already feeling a groove in making decisions within my purview. And par for the course of my blue-collar nature, I enjoy actually working again. I enjoy working with co-workers, being needed, doing something that contributes to a goal of some kind. Fortunately, in medicine that goal is worthwhile – albeit our means of achieving it in Western medicine are profoundly limited. And if nothing else, work is providing me a reprieve from life, at the moment. I envisioned a certain level of loneliness moving across the country to a place without a single friend, which would have been difficult enough, but I hadn’t envisioned also having my heart broken and, for the time being, losing my strongest emotional confidant in the process. A double whammy emotionally that is therapized by the deluge of work known as intern year. And the work is good – and made better by the incredible co-interns, residents, and staff I’ve interacted with since starting here. I couldn’t ask for a better support system. I couldn’t ask for a better job, even if I’m convinced I’m not the best person for it. It reminds me of a quote from one of my all-time favorite movies called Cinderella Man, where a depression era boxer named Jim (Russel Crowe) makes a comeback to from poverty and injury. In one of the fights his trainer Joe (Paul Giamatti) is encouraging his beleaguered pugilist in the corner between rounds, and he asks him: “Is there any other place you’d rather be?” Jim shakes his head.

“Good!” Joe says. “Now what are you gonna do about it?”

So even though I’m tired, and probably don’t actually belong here, there’s nowhere else I’d rather be and I’m making the best of it. That’s as much as I can muster here at 4am. Toodles my friends! Much love (and sleep) to you all!