Ode to my Stethoscope

I lost my stethoscope a little over a week ago. It happened without my even noticing. I know I had it on Saturday morning, when I was post-call, but when I went back to work on Monday it was missing from the bag I carry to work, and missing when I searched my apartment when I got home that evening. I must have lost it somewhere in the hospital on my post-call morning. I’m actually pretty surprised this didn’t happen earlier. The post-call state of being is one that is bursting with the possibility to make careless mistakes. You see the evidence all the time: half-finished cold cups of cafeteria coffee can be found, abandoned by post-call housestaff, on desks in the resident workrooms or unassumingly sitting on the backs of wheeled computers; the post-call resident will make his or her exit after saying goodbye to everyone on the team, only to sheepishly return a few minutes later to grab the coat or scarf or bag left behind. All this is to say that it’s easy to misplace things when you’re post-call, so I wasn’t surprised when it happened. What did surprise me was the intensity of my emotional reaction to the loss.

I’ve written before about how much I hate losing things. It’s a little embarrassing, really, how worked up I get when I lose physical objects. After all, my religion teaches me not to become attached to objects, that they carry no intrinsic value, that they’re all part of the illusion of this physical world. Yet I can’t seem to help myself. I get upset when I lose a water bottle, or a pen, or a sock, and I have enough insight to know that my emotions are out of proportion to the actual significance of the loss. So I tried to apply some rational thinking when I lost my trusty stethoscope, and searched online for a new one to replace it. Time to upgrade, I told myself. Finally buy a pediatric-sized one, or maybe one in a different color. But all I wanted was to find one exactly like the one that got away–a purple Littmann Classic II, outfitted with gray earbuds and gray trim on the bell. I knew that it wouldn’t be hard to buy another stethoscope exactly like my old one, but, I kept telling myself, it wouldn’t be the same. So I abandoned the effort, and opted instead to use rinky-dink disposable ones that I could find in the clean utility room at work–the type we use when patients have contagious illnesses that we don’t want to transmit to other patients. It was a poor substitute, the sound quality dismal compared to the one I had lost, but I needed a placeholder before considering a more permanent replacement.

Over the next several days, I told everyone who would listen about losing my stethoscope. I frequently proclaimed how sad I was to my teammates. I texted my fiance and g-chatted my best friend from med school roughly 2-4 times a day about how much I missed it, capping off most of the digital messages with multiple sad-faces, tears welling in their eyes. I knew I was being a little melodramatic, but I really was that sad. Wearing my rinky-dink Fisher Price-esque black disposable replacement aruond my neck, I felt deflated by its lightweight frame. I missed the gravitas of my old stethoscope, the way it would slip down, chestpiece-side first, leaving the end with the earbuds to jut off my neck at a crazy angle, if I wasn’t careful. I cursed myself for not identifying my all-too-common stethoscope with my name, or a sticker, or a detachable toy the way other pediatricians do. I not-so-casually stared at every purple or purple-appearing stethoscope I saw my nursing colleagues walking around with, wondering if for some reason they had accidentally picked up mine.

Slowly, I began to dissect my emotions and try to figure out why I was feeling what I was feeling. I realized that my stethoscope was the one tool of my profession that I had continually used since the very beginning of my medical training. Unlike the short white coat of medical school, which was unceremoniously abandoned once I graduated to the long white coat of residency, my stethoscope had stuck with me for seven long years. It was a constant presence during my hardest cases, my moments of connection with families, the diamond-bright clarifying moments when I finally understood a medical concept through experiential learning. It was a witness to my growth as a physician. I still remember laying the end of it on my own chest and listening to my heartbeat for the first time, the way my heart began to race when my body recognized itself in a way it never had before. I remember all the times a patient borrowed my stethoscope because he or she wanted to listen too, and how I guided the chestpiece to the right spot on the patient’s chest, and saw little eyes widen in surprise at the sound that sprang forth.

In the past, when I’ve lost things, I’ve sometimes stumbled back upon those things, accidentally tucked away somewhere and forgotten. A small part of me is holding out hope that the same thing will happen with my stethoscope, though it seems unlikely the longer it’s lost. Still, in a vote of confidence of sorts, I haven’t purchased a new one yet. Instead, I’m using my fiance’s old one, which he generously mailed to me. It’s sleek and functional, completely black. I still miss my old purple friend though. Here’s to the inanimate objects that support us in ways they will never be able to know.

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The Age of Worry

This week I started senioring for the first time. It’s a rite of passage for every aspiring physician, and follows one of the themes of medical training: see one, do one, teach one. I went into the week with a healthy dose of anxiety. Sure, I’ve been a doctor for 2 years now, and sure, I’ve already spent several months supervising residents as a metabolism fellow. But the idea of senioring was still daunting, because I feared it would bring me face to face with my own inadequacies. 2 years into being a doctor, I have more experience than the interns on my team, who are 5 months out of medical school. However, since I’m in a combined program with genetics, I don’t have as much pediatric experience as most of my peers. I’ve been on genetics for several months now, and I haven’t thought about general pediatrics for most of that time. Adding to the worry was the fact that I’m senioring in the neonatal ICU, a place that requires calm reactions in emergent situations and proficiency in procedures, both of which are skills that have challenged me.

Here’s what I know I’m good at: going through patient histories with a fine-toothed comb; noticing subtly different facial features that are clues to a diagnosis; thinking methodically through metabolic pathways and treating patients in metabolic crisis. Here’s what I know I’m not very good at: arterial sticks and lumbar punctures; staying focused during rounds, especially when the discussion becomes esoteric and rambling; mustering up the intellectual curiosity it takes to read a scientific paper without getting distracted by something easier to digest (e.g., a listicle on Buzzfeed).

On Monday, I met my interns and sub-intern, three smart, capable, conscientious young women. Over the ensuing days, these chicks succinctly summarized their patients’ problems, deftly formulated plans for their care, and asked me thoughtful questions. I watched with a kind of ashamed alarm as they searched the primary literature to learn about retinopathy of prematurity and read textbooks to understand why premature infants have a higher risk of hypertension. In contrast, I guiltily browsed wedding blogs and had to harness all my powers of attention to read one paper over the course of an afternoon.

In short, I was deeply impressed by the interns and sub-I I was charged with senioring, and wasn’t very sure they needed me there. As far as I was concerned, these girls were performing better than I had been on their level. So it was a shock, (and if I’m being perfectly honest, a bit of a relief) to hear them say over lunch on Thursday that they felt like they were floundering. I told them all the things I remember my seniors telling me as an intern, things I didn’t really believe were true: “You know your patients extremely well.” “You’re performing exactly where you need to be at your level.” “You’re thinking about this the right way.” “Don’t feel bad that you didn’t get that stick; you have no idea how many I’ve missed in the past and still miss now.”

As an intern, I was most surprised whenever people would tell me I knew my patients well. Sure, I knew whether they threw up yesterday or the highlights of their medical history, but I couldn’t remember the most recent antibiotic regimen they had been on, or when exactly their last positive blood culture was, or which specialists they’d need to see after discharge. Whenever people told me they thought I knew my patients well, I felt the full force of impostor syndrome. “I’ve really got the wool pulled over their eyes,” I used to think. “I don’t know these patients well at all.”  It’s only now, in the act of telling my interns how well they’re doing, that I realize that my seniors weren’t just humoring me two years ago. This isn’t to say that I was an extraordinarily skilled intern—I wasn’t. But I really was performing where I should have been at that time.

Roughly two years ago, I wrote a blog post about the struggles of transitioning from medical student to intern. Near the end, I wrote that while intern year was just as hard as I expected it to be, “It feels good to walk home at the end of a long day and feel like I’ve worked hard, and I’ve learned a lot, but eventually the work will get easier, and the learning curve will become less steep.” I felt the same way when I was walking home from work late this week. It still isn’t easy to be a resident; to wake up early and spend far more hours at work than at home; to bear the weight of responsibility that comes with caring for patients; to bear the new responsibility of teaching and mentoring that comes with being a senior resident. But I was right: eventually, the work does get easier; your knowledge base expands and you understand more of what you’re doing and why you’re doing it. There is something singularly satisfying in that experience, in going from scared intern to slightly-less-scared senior, in looking at your nervous interns’ faces and knowing that, two years from now, they’ll have learned more than they can imagine or articulate; that they’ll have seen patients through the hardest times of their lives; that they’ll have made deep friendships; that they’ll have gained more confidence than they ever expected. That arc of growth is nothing short of a gift. So to all of the unsure interns out there, I’m here to tell you, unequivocally, that you are doing better than you think you are. You may be in the age of worry right now, but make friends with what you are. Stated another way: You are intern. Hear yourself roar.

SYTTD: Chandni Chowk edition

Ever since getting engaged, I’ve struggled internally with the whole enterprise of wedding planning. On the one hand, I’m pretty stoked about getting married to someone that I know will be a good life partner, and planning a ceremony and concomitant celebrations to mark the event. On the other hand, because of my beliefs about feminism and female independence and the importance of defining oneself firmly outside of the bounds of a romantic relationship, I’ve often felt the way Liz Lemon did when she was planning her City Hall wedding:

liz-lemon-wedding-planning

The other element in all of this is that as an Indian-American woman, I always knew that I wouldn’t have the same wedding experience I was exposed to in the media growing up. There would be no white dress, only a traditional maroon sari; no talk of me being a princess or my fiance being a prince (though to be fair, I rejected that narrative early on because of my own problems with it). Besides, I have been trying for years to train myself to focus on the marriage, not the wedding, and so I’ve approached the process of wedding planning with a grain of salt.

…But a few weeks ago, I went shopping for my reception lehnga in the narrow alleyways of Chandni Chowk:

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We visited three different stores before settling on one. There, I sat in between my future mother-in-law and her niece while salespeople showed us outfit after outfit. I told them what I liked and what I didn’t like, which colors I was interested in, styles I preferred, patterns I didn’t. Once we narrowed the field down to 4 lehngas, I got to try them on with the help of a mostly Hindi-speaking saleswoman, who helped me dive into the skirts (I dove, seriously, just like on SYTTD. Finally my years of “Friday is Bride Day” being put to good use!), draped the dupatta over my head (just like a bride!), and patiently advised me to walk “aaraam se” so as not to trip over myself. Every time we finished donning the heavy outfits, she’d give me a moment to pause and look at myself in the mirror before opening the fitting room door. “Kaisa lag raha hai? Accha?” My 2 years of college Hindi half-failed me during the whole encounter: I could understand what she was telling me but effectively suffered from expressive speech delay, so in response to her question all I could do was smile or nod. Then we’d wrestle open the fitting room door and I’d make my ungainly way to the small stepstool on which I stood to model the gowns. I got responses from my entourage and the other entourages in the store. I turned around and looked at myself in the mirror once more, and then I shuffled back into the fitting room for another round of dress-diving. Eventually, I settled on a beautiful lehnga for the reception, an ombre number with delicate floral designs. I tried to take a picture of it (“To show my friends!” I protested to the salespeople), but they wouldn’t let me–just like at Kleinfeld! The tailor came and took my measurements so that they could custom make the gown to fit me just right (just like at Kleinfeld! Except the tailor in this case was a slight Indian man and not an Eastern European woman named Vera sporting a blonde bouffant hairdo). As the bargaining process was wrapping up, we made small talk with Chandni Chowk’s Randy Fennoli, a young man named Hanu who looked uncannily similar to a childhood friend of mine. All the dresses in the store, he mentioned, were inspired by designer lehngas. When he told us whose design inspired the gown I chose, my SYTTD fantasy was complete…As it turns out, I’m an Anushree Reddy bride.

[Literally] Losing It

On Father’s Day, I went to a cute little boutique in my neighborhood and purchased a sentimental, thoughtful card for my dad. I came home, sent a picture of the card to my sister (because in this day and age, what good is liking something yourself if you don’t have the added approval of friends?) , and took it downstairs to my living room along with my laptop, intending to write a message in it and send it on its way the next morning.

And then I just lost track of it. I lost the darn card in my own apartment. I didn’t realize it was lost until a day later, when I absentmindedly wondered where that nice card had gotten to. I walked around my place, lifting up the detritus of my life that clutters its tables and floors. Under my laptop case? No. Stuck between books on my bookshelf? No. Under my bed? Still no. 5 days later, the darn thing is still missing, and it’s making me a little crazy.

I’ve written before about how much I hate losing things, about how much it makes me fret and worry and become an even more anxious version of myself. But these days, 2 years into residency, 2 years into working an average of 80 hours a week and having a constantly shifting sleep schedule and being exposed to the extremes of life on a daily basis, I find that I have less energy to stress about loss. Instead of spending every waking moment thinking about the thing I’ve lost and wondering where it could have gotten to, I just get sporadic flashes of guilt and angst when something suddenly reminds me of it. Don’t get me wrong, this new equilibrium between Chaya and Losing Things isn’t any better. It’s just…different.

The lack of constant concern over the things I’ve lost is just one of the many symptoms of my new state of living.The simple truth is this: I am always, constantly, never-endingly, perpetually tired. The other simple truth is this: I always have a staggeringly long list of things I need to do, ranging from “buy milk” and “cook real food for dinner” to “learn to be a doctor” and “read about triploidy” and “write that case report” and “prepare that presentation and “prepare that other presentation.” It’s emotionally and mentally exhausting to simply be a human under such circumstances, let alone put in the effort it takes to cross things off a to-do list. This explains why most nights this week, I’ve come home from work, half-heartedly rifled through some papers to look for the card, cooked myself a real dinner (the one goal I can consistently meet, because not having homecooked food makes me way too sad), and sat on the couch watching TV until it was time to go to sleep and get ready for the next day.

The problem, of course, is that despite the current state of my life (or will this always be the state of my life? Is this forever? Do I just have to get used to this as the new normal? Insert spinning hypnosis wheel of feeling out of control), I still want to get things done, to accomplish. I want to write and read and learn and be, and my persistent low-level panic about not-achieving-and-progressing-in-my-career-and-writing-goals is a constant hum, just a few Hz above my low-level anxiety about where-did-that-damn-card-go-and-also-where-is-that-necklace-I-lost-months-ago-and-why-do-I-always-lose-things. But when I’m always so exhausted that I often have word-finding difficulty, even when I’m not overtly sleepy, how am I supposed to write an intelligent case report about vitamin deficiency or muster up the energy to write about a topic that requires hours of research on the front-end?

People say that when the going gets tough, the tough get going. Now, I like to think of myself as a tough person, but when the going gets tough, the Chaya just hunkers down and tries to shelter in place until the storm has passed. It’s difficult to break oneself from the inertia of the daily routine, especially when the tasks at hand seem daunting, or like they have an undesirable opportunity cost. So instead of actually doing the things I need or want to do, I just keep listing them aloud to myself and others ad nauseum–a habit, incidentally, that I learned from my mother, who inherited it in turn from her father. Except she always seems to get the to-do list completed after saying it aloud a bunch of times.

In any case, as a golden weekend begins, here’s hoping that simply sitting down and writing something helps break my general life block. [Those of my friends who write will understand what I mean when I say that I’ve felt hampered for weeks now by the simultaneous desire and seeming inability to write something.] And here’s hoping I find that card. In the mean time, here’s a picture of it. [Thank goodness for the uniquely modern, crippling, semi-existential need to obtain external approval on nearly everything, right?] I mean every word of it, Daddy-o, and hopefully you’ll see it in the flesh soon.

Card for Dad

 

And the only solution was to stand and fight

I finished my pediatric ICU rotation yesterday. It is no exaggeration to say that it was the most difficult rotation I’ve ever had. There were the complex patients, the terrible tragedies that befell them, the families that loved them, and the long, sleepless 28-hour shifts every 4 days, to boot. I was challenged in the emotional, mental, and physical realms. Other than the tremendous blessings in my life, for which I’m always grateful, two things sustained me for the last four weeks: 1. I learned a great deal, about a great many subjects, and was challenged to become a better doctor. 2. No matter how tired or frustrated or scared I was, I was never having as bad a day as the patients and families I was charged with caring for.

When patients came in with horrible infections or serious injuries or any other number of things, I slowly realized that, as Florence says in this song, “the only solution was to stand and fight.” I was surprised at the number of patients who did well, considering the hits their bodies had taken. There was the patient who had cardiac arrest and a resultant bleed in the brain, yet woke up after we removed his breathing tube, and was likely going to make a pretty great recovery. There was the cancer patient with severe septic shock who needed dialysis and medications to keep the blood pressure at a safe level and prolonged ventilator support, who was extubated and talking incessantly by the time my rotation was over. And then there were the two children with bacterial meningitis, who developed seizures and pockets of pus in their brains that needed to be surgically drained, whose development was stunted or pushed backward. During rounds two weeks ago, a father told us how he worked in admissions at a medical school, and, though not a doctor himself, looked closely at candidates to predict how they would behave with their patients one day. Then he told us, voice breaking, that he and his family were grateful for our compassion, our expertise, our kindness. Must as he hated being in this situation, it was gratifying, he told us, to see things come full circle. I’m pretty sure there wasn’t a dry eye on the team.

The thing is, it’s hard to tell (at least for me, with my limited knowledge of critical care) which patients will do well, and which won’t. So we stand, and we fight tooth and nail, with medicine and ventilation and surgery and dialysis and everything else we can think of, to save our patients’ lives. Because what else can you do in such a situation?

I admitted a little boy on my second-to-last call 6 nights ago, with a new diagnosis of leukemia. It was my first encounter with a situation like that, though not my last, I’m sure. He was irritable and tired; his mother was tearful and attentive to our every word; his father was stoic and anxious. Through a terrible series of events, he became so sick over the next few days that his family decided to withdraw care, realizing that their little boy was never coming back. Little by little, his extended family trickled in to say goodbye. Once I walked into the room and a sweatshirted teenager was sobbing on the couch. Another time, the patient’s little brother pointed at him on the hospital bed and asked, with genuine confusion, Is that him? As part of his medical team, I had the privilege of being in the room when the machines were shut off, the tube pulled from his mouth. His mother lay in bed with him, cradling her son. I silently recited Hindu prayers, adding mine to the silent cacophony I’m sure was present already. The room remained silent as gradually, his heart slowed down, then stopped. When we quietly said that he was gone, fresh sobs arose from the circle of family standing vigil around him. His father kissed him on the forehead, whispering that he loved him. Everyone in the room was crying, including me.

Later, in the workroom, my co-resident asked me if I was okay. “I mean, who would be?” I told her through tears, “But we have to keep working, so we keep working.” Deaths are so rare in pediatrics that I have usually had sufficient time to reflect on them. With this patient, I just keep thinking about how a week and a half ago, he was a happy child, and now, he no longer exists in the physical world. But Florence has it right. We stand, and we fight, and we keep on fighting til we can’t anymore. And for those who are no longer with us, we do cartwheels in their honor. That’s the only solution I can think of.

Forgetting, and trying not to

Sometimes I don’t know how to hold all the sadness in my heart.

For all the joys of being a doctor (last week, a patient’s mother thanked me for caring so much about her son; a month ago, I saw an incredibly complex patient in clinic, whose mother kept saying, through her translator, “God will pay you for your work”), there are also so many moments of sadness. This week has been rife with them.

On my last overnight call, I admitted two teenage patients back to back. One was a 14 year-old with a litany of psychiatric problems, some of which predated, but most of which were precipitated by, her mother’s death from brain cancer a year ago. The patient came in because anxiety was causing nausea to the point that eating was near impossible, leading to striking malnourishment. Another was around the same age, coming in for new-onset diabetes, but recently admitted to a psychiatric hospital for depression, in the context of exceedingly difficult life circumstances.

Yesterday in clinic, I saw my medically complex patient again. I continue to try to manage and coordinate this child’s care as best I can, a challenge that has made me feel more like a doctor than many things have lately. Yet I wonder about the child’s quality of life, and the stresses placed on the mother, and I’m not sure if I’ll ever be able to do enough. Another clinic patient was a teenager with sadness and possible depression and staggeringly poor reading skills. I see these patients, and I try to remember to make all the referrals they need. I do my best to establish a rapport, tell them they can always talk to a doctor if they need help or have questions about anything. But I can’t fix their lives, can’t take away their tragedies, can’t erase their emotions.

This morning, one of my patients became incredibly upset, partly in response to something I told her. She screamed and shouted, her voice reflecting a level of pain I’ve known before, but not one that’s landed me in a psychiatric hospital for my safety. She later calmed back down, becoming again the child I met when she was first admitted. “Did you curl your hair?” she had asked me earlier in the morning. “It’s so much curlier than when I first met you! It’s so long! Can I touch it?” Sure, I told her. She could touch my hair, as soon as I finished the blood draw I had to do on her.
She was discharged from the hospital late this afternoon. I forgot to let her touch my hair.

Feeling the Burn

In medicine, we talk a lot about how much “reserve” a patient has. “She doesn’t have much pulmonary reserve,” we’ll say, or, “Let’s keep in mind that this patient has a low cardiac reserve at baseline.” We talk about how little or big of an “insult” a patient can take before they’re tipped over the edge of the cliff that separates well from sick. Can we give the patient as much IV fluid as we would give one without congenital heart disease? If a patient with chronic lung disease due to prematurity catches a cold at daycare, we expect that patient to get sicker, and need more respiratory support, than a healthy child with no underlying lung disease. We know to treat our patients with low reserve–whatever organ system that may target–with care, because just one little thing can tip them over the edge.

Lately, I’ve been feeling pretty low on reserve of another kind–emotional. When I started residency, I knew that I was in for a long hard road, and I knew that I would be tired and stressed and constantly learning and sometimes doubting my abilities and always challenged in some way or another. I saw the residents who went before me, and, especially as a medical student, I thought to myself, “Surely I won’t be as cynical as them one day.”

But as I reach the end of my intern year, I find myself becoming jaded, a little cynical, and generally less spiritually resilient than I was this time last year. I no longer have the emotional wherewithal to deal with challenging families without having to rant to my co-interns about how difficult it all is. I find myself literally trembling when I leave rooms of particularly tough patients, patients who are dying or very sick, patients whose parents seem to have no hope in their eyes. I grit my teeth as I interact with parents who, for some reason or another (many of them circumstances outside their control), cannot or do not care for their child the way they should. When I get a “social” admission–code for a patient for whom we may well have to call Child Protective Services because the home situation seems neglectful–I sadly mutter to myself, “but I’m sure this child will go right back home to this family.” I say this because I’ve seen it before, more than once, and it makes me sad and it makes me feel powerless. For many of my patients, the sad truth is that being at home with parent who is at best unreliable is better than any other alternative. Two years ago when I was doing my pediatric sub-internship rotation, I would volunteer to take on socially challenging patients, in order to build my skills and in hopes of using my empathy to work with the patient and the family. Now, when a challenging discussion has to occur with a family, I turn to my senior residents and ask if they can do it for me, because I just can’t.

The emotional and spiritual and mental homeostenosis has invaded my life outside of work too. I am more absent-minded than normal. I make snap decisions that aren’t fully informed or educated. I literally scream in my apartment when I realize I’ve done something stupid and ended up wasting a few hours of the precious little free time I have. I’m a generally high-strung person at baseline, but I am also very quick to cool off once I get upset. These days though, being unable to fill out an insurance form online or attempting to make yogurt that stays milky despite my best efforts or an extra-long morning of rounds will push me over the edge into a grouchy mood for hours, or even the whole day or longer. I perseverate on my mistakes and the time and energy wasted in making those mistakes. I cannot seem to uncoil myself from the tight ball of energy and gritted teeth and determined-to-make-it-through that I’ve become. My health seems to show it too: I went to the doctor the other day and my blood pressure was higher than it normally runs.

Ever since medical school, my peers and I have been hearing lectures about burnout. You know what I mean, the ones entitled “How to Thrive, Not Just Survive, in [insert challenging period of school or training here].” I have generally been fortunate enough that I haven’t experienced the kind of mind-numbing, emotion-stunting burnout that we’re all warned physicians may get. For better or worse, more often than not, it’s my personal life that stresses me, and work generally is an engaging escape from the worries in that realm. This year though, for the first time, I am beginning to understand how it feels to burn out. My peers and I have all been go-go-going for the last 11 months, and we’re starting to run on empty. The novelty of being a real doctor no longer outweighs the frustrations we sometimes (not always, I should say) encounter at work. Still we press on, and we try to bring our best selves to work every day. I’m not sure that I always succeed, but I guess trying is half the battle. Let’s hope things get a little bit easier once we’re on the other side of intern year.