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Are you there?

A longtime reader (and by longtime reader, I mean my mother) of this blog recently commented to me that I haven’t been writing here very much as of late.

As a blogger, I suppose it is good to know that your absence is missed — even if that absence is noted by your mother.

My last post was published prior to this academic year ending. I was wrapping up my year as a Chief Resident. It truly was a good year. I felt that I learned a lot and developed not only as a clinician but an educator and (dare I say it) administrator too.

Am I still here? Do I still exist? Well the answer is yes, obviously. I have been left in the post residency… afterglow? Is it even appropriate to call it that?

Though I did round as the attending physician during my chief residency, those stints were scattered here and there. Now, however, that is life. I’m no longer involved in the inner workings of residency administration. And that’s ok. It’s time to move on. The new chiefs have taken over that baton beautifully.

But it does sort of force you to redefine your life. Because for so long life has been about training and learning and education and answering to a program director.

Sure, I still have a boss and a department chair. But there is a much more autonomous feel to it now.

I’ve taken up some leadership positions. I’m trying to get involved with our institution in ways I feel I can contribute positively. I’m working with residents and medical students. Overall, though, I feel that the path is now less defined and it’s up to myself to figue out where I’m going to point this ship.

That’s an exciting, scary, and daunting idea.

But this journey goes on.

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The End Is Coming

The end is near.

As I type this we are speeding through the month of June.

On June 30, my year as one of the Internal Medicine Chief Residents will come to a close.

Before this year began, I remember hearing a former chief resident fondly look back on his own time as chief resident years ago. He told me that was the best year of his career.

I don’t know if that nostalgic statement was supposed to be encouraging. It probably was.

Right now I hope that this year will not go down as the best year of my career.

I’ve had fun. I’ve had headaches. I’ve learned a lot — both clinically and in other professional areas as well.

But, like I said above, I sure hope that this year isn’t the best of my career and it’s all down from here!

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Thanks For Nothing, Thanks For Everything

Thanks.

It’s can be a powerful sentiment — as in gratitude for the ultimate gift or a heavy sacrifice.

But it can also be empty — as in a “thanks for nothing.”

I remember taking care of a patient midway through my residency. We had tried many different things, but eventually he succumbed to the disease and passed away in the hospital. I don’t remember what the patient looked like. I don’t remember his name. I don’t remember the disease.

What I do remember was that we tried. We tried to make him better, but in the end we did not meet this goal. As the futility of our efforts became clear to us and to the family, we decided to focus on comfort.

The patient passed away.

The memory that has haunted me to this day is walking into the room and having the patient’s brother walk up to me. As he drew closer he pulled me into an embrace and thanked me. He actually thanked me.

In dealing with death and dying it has not been uncommon for me to hear a thank you from the loved ones of a patient who has passed. But this was the first time I experienced this. And maybe that’s this memory has stuck with me since then.

Thanks. It jarred me to hear that sentiment from this grieving man. In that instance I could not do much more than return his embrace. I had no words but to say, “I’m sorry.”

To me, my words felt empty. They felt inconsequential. But it was all I could muster.

I felt like I was being thanked for nothing. I felt like I was being thanked for failing. Because that’s the lens through which I viewed the situation.

Now, I realize that I should be grateful for their appreciation. I marvel at how some people, in their moments of grief, can still take time to express their gratitude — even if it is “just” for compassion and care instead of the cure for which they had pleaded and prayed.

Medicine is a profession most of us go into because we want to fix problems and make people better. Too often it is easy to view death as a failure of what we set out to do. The danger in allowing us to view death this way is that we may feel that we have provided nothing to our patients and their families.

But sometimes patients and their families don’t need a savior. Sometimes they just need someone to be with them through the journey’s end. And to them, you have given way more than “nothing.” You have given everything.

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About 3 Months Left

There’s about 3 months to go in this academic year.

That means I will be a Chief Resident for only another 3 months. My contract is coming to an end. The incoming Chief Residents have already been chosen and announced.

It some ways I feel like I know what a lame duck president must feel like.

The year has gone by faster than I could have anticipated. It’s been a period of satisfaction, personal & professional growth, and frustration. There have been ups and downs. Joys and disappointments.

My fellow residents who graduated from residency last year — well those who went on to work “real” jobs — have pulled in so much more money than I have this year. I’m sure they are enjoying the dough. Sure it is not has high as those surgical specialties. But it sure is a lot more than what I’ve been paid this year.

Still, I don’t regret it. Knowing what I do now, I would do it again.

There is a fraternity of sorts with former chief residents. And I’m proud to have joined those ranks.

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Attending Status

What’s in a title?

My ID badge now says “Attending Physician.”

I guess that’s my title now.

Last month I worked two hospitalist shifts. A week later I followed it up with 7 MOD shifts.

As a hospitalist I was responsible for my entire set of patients. I did get to work with one resident who was spending the month doing a hospitalist elective.

During the MOD shifts, I was the attending on one of our Internal Medicine teaching teams. I had a senior resident and two interns.

It is definitely a new feeling to have “the last say.” All my previous experiences on inpatient medicine had been as a resident. There were always things that I deferred to the attending. Like discharges home, for example.

As the attending, I had the final say. And it was a very different experience.

Serving as the attending on the teaching service was interesting as well. I remember frequently paging my senior residents to check in and make sure they did certain things. And as I did that, a light in my head turned on. I realized why I used to get several pages from attendings as they wanted to make sure I followed through on certain things.

When you have other people taking care of patients under your license and supervision, you start to pay attention.

Part of my job as a Chief Resident is doing a cetain number of MOD shifts. Seven shifts down. Looking forward this upcoming year. I have a lot to learn about medicine still. I have a lot to learn about teaching residents and students. I also have a lot of fun in store.

Stick around, dear reader. This should be a fun year.

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Chief Residency

It has begun.

On June 30 I officially ended my Internal Medicine Residency. Well, maybe I should say that I completed it.

On July 1 I walked up to my brand new office. As I stood in front of my door, with key in hand, I read the new nameplate on the door. It was awkward.

Residency ended without much fanfare or closure. My program, for whatever reason, does not have a “graduation” ceremony. They did have a “graduation banquet” in May but I was on a pre-planned family vacation during that time. Maybe that’s why I felt like I lacked any real resolution to the residency phase of life.

So far there has been anxiety, confusion, frustration, and fatigue. I’m hopeful that the year will be one of professional and personal growth. I just hope that the growth does not require much pain.

On July 1 I attended the mandatory “new hire” orientation. After completing all required paperwork, I went to HR to pick up my new ID badge. As I already had a picture on file, I just waited in the lobby for them to bring out the new badge. After what seemed like 20 minutes, someone came out to deliver it. Instead of “Resident Physician” under my name, it now said “Attending Physician.”

Looking at my badge, almost 1 month later, it still seems weird to see that.

I don’t know what this year will bring. I’m sure it will be challenging. I’m sure it will push me.

So for those of you who have followed this journey through this blog, I invite you to continue with me.

And for those of you who have just found this blog, well, you’re invited too.

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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.