nanimov

If You Wait Long Enough, The Heart Will Suffer

These were the words if my attending today. Of course, here he was talking about the literal heart in the context of cardiorenal syndrome (specifically type 4, which is technically more of a renocardiac syndrome), but it kinda hit me hard on a figurative heart level. Recently (but also chronically) I feel like I put off doing things that move me in the direction I want to go with my career, my relationships, and my life in general, often for the sake of more transient things. And over time, that “lost” time weighs on me more and more as the dreams I had for myself become more distant, and that hurts my heart a bit, ya know?

Don’t get me wrong, I’m very happy with my life overall right now. I love the work that I do and I feel lucky to have so many good and fulfilling personal and professional relationships, there’s just a part of me that feels like I could and should be doing more, not sure for myself, but for the people I care about and for my community (locally and globally). But if I keep holding off on working towards the things that I think I have to offer this world, I may well go into acute heart failure which as we know requires some diuresis (of like ideas, as in I need to do the things [or maybe forget about some] so that they don’t just build up inside me).

Just Words

Now that we’re a couple weeks out from it, I wanted so share some of the thoughts I had following the night of the election:

Words can’t fully capture how I feel right now, so these are just words. I’m angry, sad, disheartened, disgusted, appalled, furious.

I’ve been hearing a lot of talk and seeing a lot of posts on social media about people no longer wanting to associate with anyone who voted for him. First of all I want to acknowledge that this is a valid sentiment for any individual who feels this way because yesterday the majority¹ of our country essentially invalidated multiple marginalized and vulnerable populations (and some that have been disregarded regardless of yesterday’s outcome), which includes a lot of people who I hold dear.

Another part of me thinks the solution to the situation we are in cannot be to further isolate into our echo chambers. This is not meant to shame any one who has decided that they no longer want any part of the population that has in invalidated their existence, you have every right to do whatever needs to be done to protect yourself and your wellbeing, and no one should be telling you how to feel or how to act in this moment. For myself, who has the privilege of being a cis-hetero-man, a US citizen, educated, from an upper middle class family with all the opportunities in the world afforded to me by the work put in by my immigrant family (some of whom are supporters of his), I feel like I can’t step away. I owe it to all the people I hold love for — my family members, my patients, and everyone else out there who are going to suffer because of the direction our country may head in these coming four years — to fight the affliction of heart and mind that has seemingly taken hold in so many people.

Despite what the election results show, I (perhaps naively) choose not to believe that all those people are hateful, idiotic, misogynistic, sexist, xenophobic, transphobic individuals. It’s possible that a large number of them may be one or multiple of those, but they are also people with their own priorities who were made promises through cult rhetoric of a better life for themselves and for their loved ones.

Something is missing. I ask myself, How can intelligent people, people who I have at least at one time called my friend, support a man who represents so much hatred and idiocy? There has to be as disconnect. Maybe not… perhaps every single one of those supports are themselves representative all those things. But if so, then where do we go from there? Because based on how this country elects presidents (i.e. the electoral college), leaving both sides fester in their own bubbles will not turn out well for progressive ideals, as we’ve seen. And something tells me that process is not going anywhere soon — call it a hunch.

It’s so easy nowadays to shut off and shut out beliefs and perspectives that differ from out own. Algorithms, socials media, likes, and follows all exacerbate this, if they are not indeed the root cause.² Unlike, unfollow, report; sure it makes us feel better because then we no longer have to see it, but rarely will that stop it from existing, and those who do resonate with that content will find it and come together, free of any dissenting thoughts thus hardening their beliefs, and making it inconceivable that anyone else of sound mind would think differently.

The change we need comes in culture shifts, not in elections in and of themselves. Culture shifts come through changes in believes and values. Those changes can only come when you are challenged by beliefs and values that differ from your own. It comes from not demonizing other people for having a different world view or having different lived experiences. It comes from finding common ground, as difficult as it may be. It comes speaking up, but perhaps more importantly, from listening. It comes from being disruptive for the sake of change, as well as being open to change.

I could have done more, even if it wouldn’t have changed the outcome of this election. I failed to speak up in casuals conversations for fear of embarrassment, retribution, or not being knowledgeable enough to back up my beliefs. I stayed in my comfort zones only engaging in spaces where I knew my ideals would be validated. These are things that need to change, even if they are coming woefully late. I anticipate that 9.5/10 times doing any of this work will leave me frustrated, hopeless, angry, and desperate, but the alternative is equivalent to me personally giving up and choosing to live with my privilege relatively unscathed, which beyond complicity, would be an injustice and waste.

Again all of this is just words. Words that are basically meaningless in light of what is at stake, and in the absence of action.

I know not all the people who read this will share my perspective. If you are one of them I want to hear your thoughts. I can promise to come into the conversation with an open heart and an open mind, and I hope you can do the same.

¹Which might not be quite true anymore, but that doesn’t change the outcome.
²The roots cause is human nature, these technologies just feed off of and augment it.

PGY1D87 – A Good Doctor

It’s been a little over week now that I finished my first block of medicine wards as a PGY1. Med wards thus far is the most similar to what I expected residency to be like. The days were long and the tasks seemingly endless often times, and yet the days also flew by because there was always something to do. Not all of those tasks were “doing medicine” in the way most probably think of it. It’s not like I spent 12+ hours per day prescribing medicine, doing procedures, reviewing blood test results and body scans. Many days the “medicine” seems to be the minority of of the work, with the rest being talking to patients, talking to families, coordinating care, and preparing for next steps. Through all of this, I couldn’t help but feel like this is where I am meant to be.

In my last week, one of the patients, Mr. P, who was on since the start of this block was being discharge to a SNF for rehab. He wasn’t the easiest patient, but not because he wasn’t an agreeable person, in fact he was a lovely person. He just had some difficult and conflicting medical problems. On top of that he mainly spoke Vietnamese, making it difficult to communicate with him at times, even with the use of a translator. I did the best I could to take the time to make sure he understood what was going on and address any questions or concerns that he had. He often took up the most of my time, despite being one of the most medically stable patients on my list at any given time.

On the day of his discharge, I went in to give him the news and say goodbye to Mr. P. After again answering any questions and addressing his final concerns I shook his hand and said goodbye. As I did, he held my hand tightly in his and in his broken English said, “Thank you… You are good doctor.” My gaze went from our hands to his eyes which were welling up with tears.

I wasn’t the one who fixed his broken leg, or the one that delivered his pain medication, or changed his dressing, but I suspect I was one of the few people who came in throughout the day to listen to him and talk to him, not just perform a task. That to me is what the art of medicine is about, and I’ll never forget Mr. P for reminding me of that.

PGY1D43 – Some Time

Hard to believe my last post was over a month ago. Time feels like it has gone by really quickly, but at the same time I feel like I’ve been in residency for months already. I’m writing now because I’m on the night shift in the NICU which is not as busy as it may sound. Similar to nights in the MICU, most of the primary tasks are done during the day and at night we are just responding to calls and questions from the nursing staff, etc. We also go to any deliveries that happen overnight and admit any babies to the unit that need it, but nothing so far.

I keep telling people that ask that NICU while super different from the MICU in so many ways, is also kinda similar. The patients don’t talk to you and you are just kinda managing them without much input from them (of course if the adults are awake and conscious and have capacity they are always involved). There’s a lot of thinking and physiology talk which I like.

What is nice about the NICU is in most cases the patients are able to go home, and of course the babies are (usually) very cute.

There is a lot of optimization that happens here too. We are always looks at and adjusting patients in’s and out’s (I/O’s) which theoretically need to be carefully balanced, especially in the premature ones. We are constantly looking at their nutrition and how many calories babies are getting, how many macronutrients they are getting and how many electrolytes/ micronutrients they need, and assessing/ changing these things on a daily basis. It is interesting stuff, just very different than on the adult side where we do pay attention to this stuff, just not as closely.

As a side note, I had a really rough weekend personally. Still having a tough time, but kinda thankful to have work to distract me. Nothing I feel like elaborating on now because I’m still going/ working through it, just wanted to make a note of it.

PGY1D8 – Weekend Warriors

It’s crazy the difference 2 people make in the workflow of our team. Then again it’s also crazy how easily the rest of the team is able to pick of the slack. Today also was pretty busy because we were down 2 people (it was their day off), but busy is good, it makes the day go by faster and I get to see more interesting stuff. That said there are definitely task that I don’t look forward to, or times when I don’t want to be perceived doing the things I need to do (talking to patient, calling consults) it in almost all cases I have either a senior or someone else right next to me whether they are actively engaged in my conversation or not. Anyways overall, this has been a pretty nice way to transition into this new role in the hospital. I get a lot of model examples of what the work should look like and can easily determine whether or not I am meeting a certain standard, while also being in a safe space for mistakes and stupid questions, because here lots of people have my back.

PGY1D7 – Careful What You Wish For

So I got what I wished for: a busy, hectic day running around between patients and responsibilities. At times it was stressful, but at the same time it felt like I was doing more or less what I was supposed to. I got to field some calls on the VoIP, I had to put in urgent orders, I was interacting with the nursing staff and pharmacy and others like a real member of the team, which feels kinda lame to say, but this is also never something I really experience as a medical student, at least to this level. It always felt like playing as a doctor. It still feels like that sometimes, but when I see my seniors, and the fellows, and the attendings who are really doing the damn thing, it’s pretty cool to watch. So being a part of the team, and being a productive and valuable part of the team makes me feel like I’m getting a little bit closer to that which is nice.

PGY1D6 – Repurposing Imposter Syndrome

Today was especially difficult from an imposter syndrome standpoint. All my patients got transferred or discharged today. Which may be a good thing from a patient health standpoint, but it also made me feel like I wasn’t taking care of complex enough patient, or maybe I am not being trusted with the more complex patients. This makes no sense of course, because this whole time we’ve pretty much been picking our own patients. I took on an relatively straightforward one today with the plan of taking on the first new admit. It never came. Meanwhile, my co-interns are dealing with multiple complex patients, many of whom were moving towards goals of care discussions or required extensive work ups, and working closely with the seniors and talking to families just made me feel a little less like a doctor today. Again this is all my own problem, and I feel guilty about having these selfish feelings because on the other side of this all are real people with real lives. But I think that’s also where some of these feelings come from. I feel like I’m not doing enough. But instead of wallowing in these feelings for too long, I want to use them to push me to be better. Also while I so appreciate my seniors and the fellows and the attendings being so nice and patient, I feel like a little constructive criticism, communicated tactfully, would be similarly appreciated.

Today we talk about hyponatremia — a topic that I’ve learned and been lectured on more times than I could count, and yet still get confused by. Today though our attending went over it in a way that I thought was really helpful, while also using a real world example of one of our patients. Creating frameworks rooted in physiology and in real work examples has always been really helpful for me. I’ll come back and maybe put together my own version of what we talked about to solidify my understanding.

PGY1 – Day 5

There’s so much to be learned in the ICU on a day to day basis that I feel like I don’t do a good enough job solidifying what I learn in my brain. I’ve learned a lot each day about both the process of doctoring and the medicine itself. Since I feel like I’ve been kinda getting repetitive or at least somewhat stale in this posts, I feel like I will try to use this space to help nail down the things I am learning while still having space to put my reflections.

Today we talked about a few things. Pressure-volume loops in individuals with different types of airway obstructions. First there are fixed airway obstructions in which the loop is flattened in both the inspiratory and expiratory phases. Which makes sense; if you have a small opening for air to go in and out and it doesn’t change, the flow will be inhibited in both directions. Then there are variable intrathoracic obstructions and variable extrathoracic obstructions. The terminology was confusing to me at first, I think because I didn’t quite understand that we where talking specifically about airway obstructions and not just any kind of inhibition of flow. Thinking about it now, this actually will help a lot in me thinking about airway obstructions vs restrictions. Anyway, for variable intrathoracic obstructions, there is negative pressure in the intrathoracic space during inhalation so when the person inhales, the soft tissues is able to move out of the airway to allow air to flow unobstructed. During exhalation when that negative intrathoracic pressure is gone, the obstruction is then present, inhibiting flow on exhalation, therefore only the exhalation phases is flattened. On the other hand for a variable extrathoracic obstruction, during inhalation the negative pressure is in the airway lumen causing the obstruction to worsen, and then during exhalation when that negative pressure is gone, the airway can open up again and you get the opposite effect on the pressure-volume loop. From a Med+Peds perspective, this also helps me better understand possible clinical findings related to airway obstruction such as stridor and wheezing (just because these are probably more common findings in the younger hospitalized population), and know when we would expect to hear those abnormal breath sounds. That’s all for now.

PGY1 – Day 4

Even though today was probably more busy for our MICU team as a whole, it was a little slower of a day for me. All my patients were pretty stable with mostly minor interventions. One of them did have some activity toward the end of the day was kind of exciting, but both in a good and a bad way. It’s kinda hard to watch people come out of sedation, at least when they appear to be struggling and fighting, or if they are coming out of it agitated.

On another note, I haven’t had to talk to any family members about their loved one in the hospital which is good, but also having those conversations is part of what I like about the ICU, not in the sense that I like it when people are sick and having to break that news to people. There is just something that feels special about being in this place between life and death, dealing out what hope you can, fighting against death, but at the same time trying to do you best to manage expectations and guide patients and families gracefully to whatever may happen. It feels morbid to put it down in writing, and I am not sure if that is even a good way to think about my time here, but I guess it’s how I feel none the less.

PGY1 – Day 3

I started in the medical ICU today. It felt good to be back in the hospital, and especially starting in a rotation I surprisingly enjoyed a lot during medical school. I definitely still feel behind and honestly still feel like a medical student, but I know that the more time I spend doing it the more comfortable I will become with this new responsibility. I still find myself waiting for approval to do really anything, which I think is probably expected to some extent, but also I feel like if I was more confident in my skills I would definitely trying to take more initiative. That is going to be my motivation going forward to really hone in on my clinical skills, develop my workflow, and expand my knowledge base.

I’m feeling excited right now I just hope I can sustain it.