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Too Late — Part 1

She was an elderly woman; I’ll call her Helen1. Her hair was silver. She smiled pleasantly as I walked up to her bed in the emergency department. But her eyes betrayed her. Her eyes were dark and solemn. When I asked Helen how she was doing, she told me she was “alright.”

I picked up her chart and noted that it was her first time here. Fortunately, though, she had brought her records from her previous hospitalizations. We discussed why she had come, what had previously been done for her at the other hospital, and what her goals were now.

She had been recently diagnosed with advanced, metastatic cancer. I learned that her oncologist had wanted her to get a PET scan — a scan that would allow them to see the extent of her metastasis. I also found out that the reason she had come to my hospital (or maybe I should say the hospital I work at) is that she had lost her home in a city over an hour away. With no other options, she had moved in with her younger, widowed sister who lived just down the street. And now, she presented to this emergency department. Because this was the closest, large hospital. I also learned that a big reason for coming into the hospital is that her sister just couldn’t take care of her. The patient needed help. Her sister needed help.

We admitted Helen and over the next few days ordered a few tests and reviewed outside records. We knew she had a fluid collection in her lungs (pleural effusion), but we didn’t feel it necessary to put her through the risk of a procedure as she was breathing well without any oxygen. We got our Oncology service involved and they actually scrapped the idea of doing a PET scan. They said it wasn’t necessary. Reviewing outside records they already knew this was metastatic cancer — a PET scan would no longer change management of therapy at this point.

I remember walking in to see Helen shortly after I was notified by the Oncology resident that they had already spoken to her with her options. The Oncology resident told me that their note was in the chart. Of course, I reviewed it before I went in.

As Helen lay in her bed, I asked her if she had been seen by oncology already and if they had talked to her about what could be done. I knew the answer already, but I often let my patients tell me. Sometimes it’s a good thing as this allows me to get an idea if they actually understand the situation.

In Helen’s case, she understood — for the most part. She told me that there were two options: chemotherapy or no chemotherapy. If she received chemotherapy she would probably live about 1 year and have to go through side effects. If she chose not to have any chemotherapy, she wouuld have about 6 months. What the oncologist had said was that for patients with her scenario, the mean survival was 6 or 12 months depending on therapy vs non-therapy.

I suppose it’s common for patients to hear phrases like “mean survival” and forget that we are talking about averages. They apply it specifically to their own case. It makes sense. I’d probably do the same thing. But there’s a reason most doctors never give out solid predictions. We give ranges on purpose. We understand that patients never read textbooks — and so they present in strange ways or with little variations and surprises.

I stood at her bedside. Silence filled the air. Helen offered up another smile and said, “It’s ok. I’m 88. I’ve had a good life.” All I could do was offer up a smile. She told me she was leaning towards no chemotherapy. She didn’t like the idea of all the side effects. But she would have to talk to her family first. She would call them and give her answer to the oncologist in a week’s time.

I nodded. We had found a nursing facility for her to go to. There was nothing we could offer her at this point other than some pain medication for the pain she had in her chest. I couldn’t help but think that she should have come in sooner. But would it have made a difference? What if she had come in before the cancer had spread anywhere? Would she have chosen chemotherapy then? Would her old, frail body have taken those medications? Would she have been able to afford the treatment?

Too many “what if’s.” Too many “too’s.” Too late. Too old. Too much.

I said goodbye to Helen. She would be discharged the next day and I was going to be off. I wished her the best. I reminded her to follow up with Oncology in a week. Little did I know, I would be seeing her again too soon.

To be continued…

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Night Float

I’m on my Night Float rotation this month. Needless to say, I’m not a big fan of the rotation. There are four interns assigned to Night Float this month. Two interns are on each night. So we each have about 14 or 15 nights during the month. Which is still better than months when there are only 3 interns — they have to do about 21 nights each. On days that I am not scheduled to come in at 7 PM, I am supposed to go into the Ambulatory clinic and see patients there.

I was one of the two lucky interns to start the month on Nights. Just finished Day 2. Or, I should say, night 2. My first stretch is a 4 nigh stretches of nights. The hardest part is those last few hours between 4 and 7 AM. I just get so sleepy.

This morning I came back home after my 2nd night of night float. I got home before 8 AM. Get out of my scrubs and jumped into bed. Ok, maybe I crawled in. The next thing I knew it was 2 PM. Again, not a big fan. It really messes up your schedule and ability to get normal things — even mundane things like errands — done.

Perhaps I should talk to the nocturnist and ask them how they do it.

Well, better try and get a bit more rest before I have to go back tonight!

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I’m Still Here

It’s been so long since I have posted. According to the site, the last post was back in November. I’m still here. And I’m still alive and surviving internship.

I plan to continue blogging. I will just need time to sit down and write. Often, I get home and just want to eat and sleep. But I will need to begin writing again.

There are so many stories and experiences to share.

I will also have to update the header image of this blog. I’m not quite in medical school anymore.

This week I have off. It is my 2nd (of 3) week of vacation. Unfortunately it cannot be a true vacation — I’m trying to use it to study for Step 3 which I am taking in a few weeks. And even when I am not actively studying, my mind is telling me that I SHOULD be studying.

I feel like a student again. But only because I have a Step 3 test to study for.

Well, until next time…

I will continue to write. I will continue to blog. Stay tuned.

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Geriatrics and Palliative Care Medicine

That’s what this month has been all about.

Ok, so I did get a week of vacation at the beginning of the month, but after that I have been dealing with senior citizen patients, quite a few of whom are hospice care patients.

It has been strange — the palliative care side of things, that is. I feel like I have spent the last few years preparing for a career in which I do everything I can in order to help someone get better. And on occasion, we must get out of nature’s way and allow death to happen. However, this month I feel like that model of medicine has been flipped upside down — that my role has now shifted.

I feel like so many of the patients I see are desperate for help. They crave to die with dignity and with peace. And for that, they look to us.

It is different when the family members of patients come looking to you, not for hope in a recovery, but for hope in a peaceful passing.

I have a great deal of respect for physicians who choose to go into palliative medicine. I used to look at the specialty of Oncology/Hematology as the “saddest” of specialties. Yet it seems the field of Palliative Care is grimmer still.

Perhaps I am just not used to it.

But maybe I don’t want to get used to it.

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Month One

The first month of intern year is over. It was definitely a ride. For my first rotation I was assigned to the local county hosptial for a month of in-patient medicine. I have been told that the two hardest rotations of the intern year here are the months at county and the MICU month at the Universtiy Medical Center. Seeing as I’m still alive and breathing, and that I still have a job, I’d say that I survived my month.

The first challenge I encountered was just transitioning from a medical student to intern. I remember being asked things by nurses as a Sub-I (during my 4th year), or any other rotation. I could always fall back on the “I’m sorry, I’m just the student. I’ll let my team know” response. Even if I had an idea of what the answer would be, I couldn’t give any nursing orders.

And so the first challenge was transitioning from the one who could always defer (actually, I had to defer), to the one that now should be able make some calls regarding patient care without always running to the senior resident or attending with a “Can I do such-and-such for so-and-so” type of question.

Another part about transitioning from student to resident is that now I am a “doctor.” Now I have an M.D. after my name. Now my signature has the power to make things happen. Now I wear a long white coat (instead of the short one reserved for medical students). It was pretty trippy the first time I heard someone call me “Doctor.” Sure, I had had patients call me “doc,” or “doctor” as a student. But I always introduced myself as the student. Now, I introduce myself as Dr. W. and the nurses call me Dr. W.

They call me “doctor.” How weird is that? It was a weird thing for me when residency began. Heck, it’s still a weird thing for me if I pause and think about it. But I’m in this for the long haul. I’m not planning a career change anytime in the next decade. I’ll probably be called “doctor” for a long time — likely for the rest of my life. Might as well start getting used to it.

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Dr. W?

I was waiting in the lobby of the building. I had a 9:30 appointment with human resources. I knew they wanted to take a picture for my ID badge. I assumed I would be given some other info as well. I had already previously completed a bunch of new hire “paperwork” online.

As I sat and waited (im)patiently in the lobby I started playing with my phone. Then I heard a male voice call out, “Dr. W?” (And he did a decent job of pronouncing my last name, too!)

I almost laughed out loud. But I stood up and went to meet him, all the while trying so hard not to have a weird grin.

It’s still weird to hear someone seriously call me “doctor.” Better get used to it though. I start on service in about two weeks…

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It’s Over, But Not Really

It is now just over a week since I marched at my Commencement ceremony and received my diploma. Yes, the actual diploma was inside the folder — which is very exciting since all my previous diplomas (college and high school) had to be mailed to me once the financial office had decided that I no longer owed the school any money.

I suppose that this is officially my first post as an MD. I am now a graduate. I now can tack on the suffix M.D. to my name. I remember just one day after graduation I sat staring at my diploma. As I stared at it, I almost could not believe it was in front of me. I looked at the piece of paper — a sheet of paper that has been the most expensive (physically, mentally, spiritually, and emotionally) paper I have ever earned.
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During the days prior to graduation, I remember feeling excited. At the same time, I also felt nervous. Nervous about being done. Nervous about new responsibilities. Nervous about wearing the long white coat I have wanted ever since I looked into the mirror and saw how ridiculous my short white coat looked. I am now waiting for my long coat. Literally. I sent an email to the Graduate Medical Education (GME) office a few weeks ago with my size. I hope I sent in the right size. Again, I am excited. But again, I am nervous about the long white coat and all the responsibility it represents.

I have a few more weeks before residency starts and I step onto the wards as a new intern. During this time I will have to complete some online modules and get certified for Advanced Cardiac Life Support (ACLS). I will also complete my move into a new place. It is a few weeks that I know will go by very quickly. Actually, I feel like the next few years will go quickly, but I don’t really want to think about that at this point.

And so, my medical school career is over. One chapter is completed. But I know that I am far from the end. Medical training continues at the next stage — residency. I know, too, that it will continue long after I leave residency. Medicine, as they have taught me throughout medical school, is about lifelong learning. In the grand scheme of things, I am still at the beginning. I have “leveled up,” but I’m still at a very low level.

I have a long way to go. I know the road ahead will be hard. But it’ll be full of adventure, I’m sure.

I will continue to blog here. For those of you who have been following my journey thus far, I hope you stick around.

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