I only live here sometimes...

At four in the morning, they are surprised to see me. 

The halls are dimly lit, about half of the big overheads turned off; the nurses' station is white and gleaming and bright, busy with a sort of unhurried business.   There's no rush at four in the morning.  There are no orders being phoned in and no tests being run.  There's time to sit and chat and stock carts.  I am somewhat of an anomaly in their world, a doctor in the night world of nurses, but they make room for me in the little cubicle in the corner, find me vital signs and updates, glad to have something to do. 

It's a far cry from the bustle at six-thirty, when the shift changes and the day nurses come on and the lights flicker into a facsimile of daylight.  When I come at six-thirty or seven, I meet the morning labs coming off the printer and the fresh new sheets of overnight vitals, step into a bustle and chaos of phone calls and notifications and getting things done.  They know to expect me early; I like my cubicle and its three walls of privacy right next to the intermittent beeping alarms of the remote telemetry, and so do all of the other doctors.  First come, first served.

It's easy to lose time inside a hospital: patient rooms have windows but the curtains are usually drawn, and the hallways exist in a perennial brightness of linoleum tiles and flickering lights.  Morning looks like afternoon looks like evening looks like midnight.  There are always nurses -- more in the daytime, but there are always nurses.  When I come down at four in the morning, euphoric from a delivery or half-awake while awaiting one, there are nurses who know my name and greet me by it, and more often than not the people I am there to see are as awake as I am. 

Visitors move around the hospital in elevators with wood panel walls and bright signs advertising hospital events.  I move in stairwells with unsealed concrete steps and railings that are nothing more than pipes and joins, where the lights are never the same color as anywhere else and the sound of my footsteps echoes eerily while I climb.  I walk through wooden doors marked "Authorized Personnel Only," knowing that my authorization is that I know what's behind them, cutting through back hallways with faded paint and abandoned clinic rooms, passing from hustle to bustle and back.  I have a tiny grey circle on my keychain that makes black boxes go "beep" and magnetic locks click open.  I have a list of codes for keypads that don't beep.  I know which doors are locked at night.

When I am attending a delivery I live in a sort of temporary camp: I put fresh folded pillowcases on plastic pillows and unfold the pale beige blankets around myself when there is no work to keep me awake, sleeping fitfully in the folded-up futons in the call rooms on Labor and Delivery, with the door half-cracked and my socks still on, my glasses lying beside my outstretched hand.  Time doesn't matter: there is food in the little glass-fronted refrigerator in the doctor's lounge, sandwiches and hard-boiled eggs and fruit and yogurt; there are chips and peanut butter and granola bars and bouillon packets stashed in the kitchenette on Labor and Delivery, the one with the sign on the door reading "Patient Use Only".  I eat when I am hungry, whatever I can scavenge.  I sleep when I do not have work to do. 

And at four in the morning, if I am awake and have patients to see, I go downstairs to greet the nurses in the half-twilight of the hospital night.

God Within

One late post-call morning when I was a family medicine resident I went to make sure all was well with a patient I’d admitted early that morning.  I don’t remember the details of her diagnosis or the reason I felt like I had to check on her, but I do remember that as I took my stethoscope out of my ears she smiled at me and said “Are you a Christian?”

This is not a question that I am frequently asked, and to be honest hearing it always makes me a bit uneasy.  It’s not the answer that concerns me: I know the answer.  It’s the followup questions that always seem to delve into deep theological issues best not discussed with strangers when you are going into thirty hours without sleep.  But I said that yes, I was, and quietly, fervently prayed that she would leave it at that.

“I knew it,” she said triumphantly.  “You have something about you.  I can always tell.” 

What do you say to a statement like that?  I said “Thank you,” and finished my exam, and told her I thought she’d feel better soon, and left. 

But things that people say to you when you're going on thirty hours without sleep sometimes have a direct line into your subconscious – and here I am, five or six years later, telling you about a momentary encounter when what I’m supposed to be doing is talking about finding God in other people.

Except that’s what I do every day.

Every time I walk into an exam room, or sit down at a hospital bedside, or huddle tightly with family members to speak in low tones, I am facing God in every person.  It’s not always an easy thing to remember – people get drunk, or angry, or belligerent, or apathetic; they drink too much and they don’t take their medications and they can’t figure out why they’re always so short of breath, but it can’t be those two packs of Marlboros I smoke a day, I smoke Lites. 

It’s easy to see God in newborn babies and happy parents.  It’s easy to see God in the toothless and gap-faced smiles of children.  It’s easy to see God in the cancer patient who comes in with a brave smile and a chemotherapy update, filled with prayers and hope. 

It’s hard to see God in the diabetic who doesn’t show up for appointments until  I see her in the hospital on an insulin drip.  It’s hard to see God in the fifth admission in six months for alcoholic pancreatitis when he promised me the last four times that it wasn’t going to happen again.  It’s hard to see God in the frequent flyers, in the patients who make your heart drop when they’re on your schedule in the morning, in the angry and resentful and combative and uncaring.

Sometimes, I have to look really hard.  But it’s in the looking – in the moments when I’m standing outside an exam room taking a slow deep breath and reminding myself that even this woman is a child of God, and is created in the image of God, and is a reflection of God – it’s then that I find God most certainly in me.

Last Rites

My mother is amazed that I'm a doctor. She is amazed at the things that doctors go through. It's a charming sort of attitude that manifests itself in comments like "You're so young to be dealing with all this heavy stuff."

She's right, in a way: I'm thirty-three going on a hundred some days.  Those are the days when I tuck my kids into bed, or bring them to the hospital with me, and I sit down and talk seriously with family members. The days when my spouse hears "I'll be there inside of twenty minutes" and sets his expectations that he'll be going to bed alone. The days where I dine with death, and walk the halls with death, and sit vigil waiting for death to come. Those are the days when I only know that I don't know what it's supposed to be like to be thirty-something, but I'm pretty certain it doesn't involve asking someone's sons and daughters how hard I am supposed to be trying to save a life.

The easy nights, when I have come so far as to ask that question, are the ones with tears and tissues and hugs and half-formed sentences.   Those are the nights where I know that I may not be able to cure what's wrong, but I can still heal something. I can do what is in my power to ease pain, and answer questions honestly, and I can be the one to say the things that I can see in everyone's eyes. Those are the easy nights, when death is quiet, and sits by the bedside holding someone's hand, and waits.

I have had this conversation before: by now I have had it a hundred times. I still tear up, and reach for my own tissue from the communal box. I still mourn. I hope I always do. It is hard to let go of someone -- it is hard to step away from your own self and grant another person the freedom to die if they choose, without trying to nail them to life.

Sometimes, there are hard nights. Those are the nights when decisions come too hard, and there are codes and chemicals and pressors and antibiotics and machines: we set great store by our machines, we doctors. We have machines to breathe for you and machines to pump your blood for you and machines that take the place of hearts and kidneys and lungs and stomachs.

But we have no machines to replace the soul.

Call it what you will: a life force, the essential energy of being, the will to live, the soul, the animus, God within. By any name, it is the thing that animates us, that makes a pile of blood and bone and flesh and synapses a person. It is the thing that makes us be, and it is the thing that leaves when we stop being. And I have seen its struggles, like a butterfly on a pin, on the altar of technology, vivisected by the hands of medicine.

Just because we can does not mean we should. There are some things that are universal: when the thing within desires to live, then we should support it: that is the time for machines, and for technology, and for the doing of heroic deeds. That is the time for the saving of lives. But when it is finished, then we should let it go. We should let it slip as gracefully away as we can; we should practice the art of medicine and the art of healing -- which is not the same as the art of fixing things. And we should look for peace, where we can.

When we have reached the point of this conversation, it is rarely a surprise to anyone that it is occurring. I can see it in the eyes, and the crumpled tissues, and the lingering touches. But it is not my doing that will decide whether a person lives or dies, and that seems sometimes to come as a surprise. I tell families that I can start pressors to raise the blood pressure, and ventilators to keep the air moving, and I can call the big city doctors at their big city hospitals and I can find an ICU bed, and we can keep the body alive, but that does not decide when a person dies. Only the person -- only that animate thing within them -- knows when it is ready to go. And without it, a body is nothing but a body.

Sometimes, I have this conversation, and there is agreement, and then people get better. They go home. They see their families again, and they stretch out their lives another week, or month, or year, or decade. Sometimes, they don't. There's no science that I can divine that says that this woman will recover from the point of death, while this man will not. I tell families that, too. I tell them I don't know what's going to happen. But I tell them if I think something will happen soon.

That's the best I can do.

Two Hats

Cap’n has a history of atypical febrile seizures (we have Valium in our house for these because his first one lasted over 20 minutes), with 102.5 axillary (about 103.5 oral) being the danger zone for this.  He's been as high as 105, but that was with the first one.

We’ve been to the neurologist after the first twenty-minute-plus ordeal (I drove him to the ED, still in status epilepticus, because he was breathing fine and I didn’t want to call an ambulance; he wound up getting IV valium and spending the night), on the recommendation of any number of pediatric specialists that I’ve had casual contact with.  His EEG is normal.   There’s a strong family history on both sides and so she felt that this was just a case of bad genes. 

We now take fevers very seriously. 

He had an ear infection with the first seizure, and since then he’s had three more ear infections and one more febrile seizure, so we went to see the ENT doctor of my choice to talk about getting tubes put in.  

Cap’n has flat tympanograms: his eardrums don’t move much because there’s fluid behind them.  They didn’t even do a hearing test, and it took the ENT doctor about ten seconds to agree with my assessment.  He also suggested I consider getting Cap’n’s adenoids out.   “Does he snore or mouth breathe?” 

“Oh, not really.  Only when he has a cold.” 

I hadn’t thought about the adenoids.  I went home and did some research, and read up on them.   And then I started paying attention to the symptoms.  That was when I started noticing how much mouth breathing and snoring took place in our household.  And also how many colds he really had.  It’s one of those things that makes you feel a metric load of retrospective parent-guilt, for not noticing. 

Surgery is scheduled for tomorrow and I have been a nervous wreck for a week already.  Then I got the call from daycare.  “Just letting you know he’s running a little fever, just 100.1.”  They gave him Tylenol.   An hour later it was 102.  We went and got him and I gave him the rest of the Tylenol dose for his weight and set to watching him and worrying.

He didn’t eat much dinner (although he liked the apples in the pork chop sauce) and whined more than usual (although he liked being pushed around on the tricycle), and then two hours after the Tylenol he started getting warm again.   My preoperative instructions said no NSAIDs for 2 weeks before the surgery, so I went to the other homegrown remedies and put him in the bath.

After 30 minutes in the tub, he was starting to shiver, and I couldn’t tell whether he was just cold or whether he was starting to get the tremors that presaged another seizure, so I took him out and checked his temperature, and he was 100.4 axillary still.  He was also still having tremors, so  in flagrant defiance of my preoperative instructions I gave him ibuprofen. Then I called and had the ENT paged at 8 PM so I could talk about whether we needed to cancel. 

There are some privileges that come with being a doctor.   Sometimes I use them.  I try not to abuse them.

He called me back and gave me his cell number.  "Call me any time."  I went over the physical exam with him (ears still dull and a little red, not acutely infected; snotty nose; lungs are clear) and asked if we needed to reschedule.  He said "maybe not."

We are tentatively still on for tomorrow morning, but it will be Anesthesia's call ultimately.   I want this done.  I want my son to be able to hear more clearly and sleep more soundly.  But I don't want to put him in danger to do it.

He’s cooler now; sleeping soundly in the middle of our bed where I can keep an eye on him as I type.  He’s allowed clear liquids until 4 AM so I will be making sure he gets his ibuprofen at about 3:45. 

I spent today reassuring parents and seeing patients.  Today, I was an efficient and effective family physician.  Tonight, I am a worried mother. 

It’s hard to wear both hats. 

Match Day

Today is Match Day.

Seven years ago today I was sitting in the big open central hallway of my medical school, next to my spouse, forgetting repeatedly to breathe.
At my school, they call you up one at a time and tear open the envelope and tell you where you're going to spend the next years of your life in front of the entire school. Until Match Day, your fourth year of medical school ends in a great gaping chasm; you don't know where you're going to live, who you're going to spend your time with, who's going to teach you.
You make plans, of course: everyone told me that in Family Medicine you get your first choice. You only rank the places you want to go. You know that if you didn't get called by the office in the days leading up to Match Day that at least you'll be going somewhere.


We'd gone house hunting in the city where my first choice was, and I had my eye on a pretty yellow dollhouse with crown molding and an airy feel. I knew the residents there, and the city, and it had the opportunities my spouse needed as well, to further his career.
But there's a giant computer somewhere that makes these decisions: it takes in rank lists from medical students and rank lists from residency programs, and it shakes them all up and it spits out the future.

And they called my name, and they read my program match, and I forgot to breathe. It was my second choice. Nobody gets their second choice in Family Medicine. Nobody but me. And in that moment, everything changed. We were going to a different part of the state, to a place where I didn't know what kind of house I was going to like, to a program that had been, dizzyingly, one of the first I'd interviewed at. For a moment I thought I'd heard it wrong. But I walked up and I took my envelope and I read it again and I sat down and I looked at my spouse and he smiled.

"It's got a great school for me to study at. And they have a rural track."

I don't know what would have happened at my first choice program. No one is ever told what would have happened, to cite C.S. Lewis, but I know what did happen. What did happen is that I was pushed, and pushed harder. I was given opportunities and training and encouragement, and I was left just enough on my own.
I have not looked back with regret on the decision the computer made for me, not even once, since the first day I started at the residency it chose. And I know that it made me what I am today, and I'm glad.