Oh hello!

Wow, it’s been a while!

Well, I’m no longer in residency but I am still floating around. I finished chief year last year and started a new position in a new city (still in the US, still on the east coast). I’m in a non-ACGME fellowship which means I’m always confusing people if I’m a trainee or an attending (I myself am confused). This position has had lots of ups and downs, but with the semi-spring brewing outside, lately it has felt like more ups. It has given me a chance to travel to and work in a part of the States that I had never experienced before (the Great Plains) and maybe I’ll write about that a little here some day.

Part of the ups and downs of my new position (still new? I started it 10 months ago) is how different my schedule is. Residency was a non-stop blur where I was either working or sleeping. Chief year gave me weekends back (mostly) and more normal working hours, which was appreciated. Fellowship, at least this fellowship, has been a mix of intense balls to wall clinical work for a few weeks at a time, interspersed with days of unstructured time to work on “projects”. It’s like a strange mash-up of grad school and crazy clinic days.

They say that stress levels increase even when people go on vacation because it’s the change in pace that gets us internally riled up. I think that the unstructured time, after a few days, has riled up my anxieties because of how easy it makes it to procrastinate which leads to feeling unproductive which leads to those annoying existential crisis moments of what am I doing why am I doing this why am I even here?!

This is an expensive city and settling into a wooden chair in a coffee shop with a $4 drink that I could make at home for cents doesn’t make sense all the time but the alternative of staying cloistered at home seems to make everything described in the above paragraph worse. It kind of makes sense now why I’ve restarted this blog, hmm? (There is the third alternative of your lovely local public library, which I have recently discovered and praise everything that they allow drinks!)

Anyhoo, I’m glad this blog is still around to plop in a few words sometimes. Hope to keep writing more. If not, see you again in 4 years!  : )

Halfway through sub-i

Well I’m halfway. Last week I worked every day of the week. A patient coded while myself and my co subi were alone on the floor. Backup came, of course, but it was terrifying nonetheless. Next time we’ll know what we can do, instead of just auscultating while the patient is struggling to breathe.

I’m getting into the flow of things. Said bye to some patients I’ve grown fond of. One patient has her adult daughter by her side almost every moment day and night. Her daughter feeds her, changes her diaper, and keeps her company all through the night. I felt happy and sad to see them go. Will I get to ever know what happens to them? That’s goodbye for real?

I feel like a job is done when patients leave, but really its just that my part is done. They are rarely completely healed, just stable and safe to go home.
It feels good to feel myself becoming more efficient, less afraid, growing. But I also feel myself hardening a bit. Like things don’t affect me as much. It partly comes with experience I guess but mostly just helps to work faster. There are limitations to hospital care and as much as I love the pace and intense patient care, and I love the interdisciplinary work, but I also feel sometimes like just a pit stop or a bandaid. Are the changes I make going to impact their health down the road? Will their primary care doctor make any changes? Will they follow up? Are they any more healthy?

Two Mondays to go.

Family medicine

Family docs are the nicest! Specializing is overrated.

Psych tidbit

Interesting thing I learned from my psych rotation: both when people sink into depression, and when people come out of depression, the person is the last person to feel the change in their mood.

I have a patient who is a 100% example of this. I really like working with him. He has gone from total catatonic to talking and expressing his feelings, his worries and even sometimes thinking he might be getting better. Today we did a crossword puzzle about fruits together. He laughed for the first time in months ( not while doing the crossword, but later when I was testing his memory and asked him to repeat something I had told him a while earlier. Because he knew he wouldn’t be able to do it) I feel really fondly toward this patient, really rooting for him. I feel sad that I will be finishing my rotation soon and won’t see him again most likely. I hope the next med student treats him well.

End of life

Yesterday I teared up on rounds as we were discussing end-of-life care.

We were talking about the end of life and how the caring for the person at that point changes when you are balancing quality and quantity of life. More specifically, we were discussing people who are imminently dying and whether or not they feel thirsty or hungry, and whether feeding them and providing fluids for them was doing more harm than good. My attending was telling us that feeling thirst at the end of life isn’t correlated with the amount of fluid the person needs, and that the thirst can often be alleviated by swabbing the person’s lips and mouth with a moist sponge. Over time, people tend to stop feeling thirsty or hungry at all. She described a common scenario where the family of the dying patient are alarmed that their loved one isn’t being fed or given fluids anymore, even if the family understands that the patient is imminently terminal. There’s an instinctive cross-cultural urge to continue feeding the loved one, thinking that it’s needed to be kept comfortable and alive. I was trying to focus on her point which was that when it comes to people who are that far gone, feeding them can lead to more discomfort with increased salivation and GI secretions that can predispose them to choking, infections, increased interventions and potentially a more drawn-out and painful death.

But I was just picturing my grandma in the hospital bed asking over and over for hot water. But she was NPO because they were worried she’d aspirate. I finally wet a gauze and put it in her mouth. She sucked on it and didn’t ask for water any more. A few days later she died, they said it was because of aspiration pneumonia. I cried because I thought I had contributed to that since I had given her a bit of water when she was thirsty. Even though people told me the small bit of moisture in her mouth couldn’t have caused her aspiration, that she already had food remnants in her esophagus before coming to the hospital, and even after hearing from my attending on rounds that providing a swab of water helps relieve the thirsty suffering without risking them aspirating, I still felt sad and teared up.

Funny experience, standing on the ward floor in our white coats and steths around our necks, discussing studies and evidence for this or that medicine or treatment or intervention, while feeling such dramatic emotions inside. We talk about these things without talking about how it makes us feel. It’s ok to bring up previous experiences with patients, but we don’t bring up personal experiences with our own family or friends. Even though I think one of the most important things is to be able to feel what you’re talking about, to be emotional, to empathize, I still struggled hard to dissociate any feelings from what we were talking about, and to look at it as just facts.

No right answer for things.

Today, a daughter and mother had to decide whether to give the unresponsive elderly father a feeding tube through his abdomen into his stomach or whether to bring him to hospice care. Before coming to the hospital he had advanced dementia but would sing songs to his family. When he came to the hospital he has been sleeping and has minimal brain activity. The mom, elderly, only speaks Italian and during the family meeting today we weren’t sure if she didn’t understand the situation or if she wasn’t absorbing it. The daughter, who is the health care proxy, was at one point made it very clear that he was full code. But today, crying, she thought perhaps keeping him alive for as long as possible no matter what may not be the best decision. I remember the first time I saw the patient in the emergency room. His elderly wife next to him, so little small and seated in the plastic chair, waiting for her firey daughter to finish reprimanding the medical team for not keeping her in the loop at the start so that her daughter could translate everything that was going on to her. When everything had been smoothed out with the attending and the daughter, the attending asked if the daughter or mom had any other concerns. The mother reminded the daughter of something and the daughter translated that the mother was concerned because her husband, hypoglycemic and unresponsive, still hadn’t had his flu shot. I felt so sad that moment.

asbestos and what’s fair

Asbestos is a known killer. Exposure to it increases the risk of lung cancer in both smokers and non-smokers. If you’re a smoker, your chances of getting lung cancer go up 1000x. It also increases risk of mesothelioma, which pretty much only happens to people exposed to asbestos.

The problem with asbestos is that it’s made of tiny fibers, which lodge in the lungs. The body isn’t good at dealing with foreign substances – can’t kill it like it would kill a bacteria, can’t break it down because of it’s synthetic make up – so it just engulfs it then stores it away. It builds up, and the reaction surrounding cells have to it can cause major (i.e. fatal) problems down the road.

Asbestos doesn’t just affect people exposed to it directly at work. It also increases cancer risks in the families of people who have been exposed to asbestos, even if the family members themselves weren’t directly exposed. It’s because asbestos fibers stay on the clothes of the exposed people, and they in turn go home and expose their families to it, along with anyone else who has a lot of contact with them.

Asbestos used to be used in developed countries, like Canada, as an insulator. Once the detrimental health effects became obvious, asbestos was banned from being used anymore. Many institutions have tried to replace asbestos in buildings, but in many cases it’s just left alone because disturbing it would put the people removing it at risk.

Asbestos is a major export from Canada, particularly from the city in Quebec called … Asbestos. Exports go to developing countries that have not banned it’s use, like India and China. While people who work with Asbestos in Canada are wearing full body suits, workers in India and China are equipped with just bandanas. Unfair? Or their fault?

It’s been tough times for everyone, especially small towns without diverse industries to rely on. Asbestos is a small town in Quebec which took a big hit when its asbestos mine was shut down earlier this year. But now that it’s reopening, thanks to this government grant.

Check out this quick-read article  written by a Canadian senator on what the dealio is on the thing called asbestos, a town called Asbestos, developing countries, and what’s good for Canada versus what’s right.

the link: http://www.montrealgazette.com/business/Asbestos+gets+lease+death/6895798/story.html#ixzz21Yh1tVKV

Yuri Kochiyama

I feel every Asian-American, Asian-Canadian, Asian, person should know about:

http://en.wikipedia.org/wiki/Yuri_Kochiyama

 

Finished Year 2

Whelp, that’s that.

Finished the Pharm exam, headed to Charter for a slide show and champagne. Then a jump off the cliff behind the library.

Now my mom and brother are coming to visit, landing in just a few hours! Frond’s parents are coming in too – on the same flight. Yowzas.

Leah and I went up to visit another roommate from first year before heading home, and as we exited the elevator, on the other side was the Pathophys prof and a tutor! The tutor with the bump on his head, the tutor who i felt was giving me such a hard time, and at the time it shook my confidence up. I thought it was because I was the only girl in my small group. It was the start of a term that wasn’t as academically challenging as last term, but somehow it was one of the more challenging, emotionally, mentally. I had moments where I felt so full of anxiety and stretched-too-thin, that I felt something in my chest was going to burst. There were moments I felt so jaded about this career path, asking: why do I care?

Now it’s finished and there’s a new feeling settling in. Something about reaching the end. Days can seem so similar, and trudging along, it’s hard to see where things are going. But moments like these are a chance to breathe and soak it in. It’s a turning point, people!

When I saw the tutor during Pathophys quizzes, he always gave me a smile, which I thought at first was a smirk. But the more sessions I had with him, the more I saw he was really teaching me something new I hadn’t learned yet in school. Out to get me? I think he was out to push me to be a better student, clinician, and better me. He lit up when he saw us leaving the elevator and asked us how the last exam went. Good! we told him. Best of luck on the step and in your careers! he told us, genuinely.

 

Psych! week

It’s Psychiatry week in Pathophysiology.

In honour of this week of self-analysis and labeling everyone you know with a psychiatric condition, here is nice gem from my prof:

It’s SPEAK.  It’s what he counsels his patients with depression to do.

S – Schedule daily (this is important)

P – Pleasant activities (we really don’t get enough)

E – Exercise (get that blood flowin’!)

A – Assertiveness (express those emotions and feelings!)

K – Kind thoughts (kindness starts with being kind to yourself).

He said that med students especially need to look after themselves.  I’m not sure about especially, but looking around at students, there is a definite tend to letting yourself go – physically, emotionally, creatively, and socially (myself included).  On the one hand I feel one-dimensional if I spend my days only studying.  On the other hand if I don’t spend all my time studying I feel behind and like I am not living up to my potential.

In the end, it’s this: we are living now, not just working and preparing for the future – future career, future location, future life.  We keep ourselves going by focusing on our goals but it’s still worth living a good life now.  Besides, it’s only going to get harder to figure this balance out; may as well figure it out now.

 

P.S.  I’m cyclothymic.