Wednesday, June 27, 2007


A keep-moving, no-sleep, two-declarations-of-death my-signature-on-the-death-certificates, multiple-family-meetings, this-is-great/I-totally-suck medical intensive care unit call night, in which I had some of my best and my most horrible times in my medical training so far. Post-call after a night like that--not like I've ever had a night quite like that one--I'm always emotionally raw.

Ms H and I have our call schedules off sync right now; she's on call in another MICU tonight. So I'm alone after a long nap; wandering through Harvard Square in the hot summer night, and now at home, everything seems beautiful or tragic or profound or all of the above. A pair of young guys singing bluegrass harmony in the square; a schmaltzy tribute to Paul Simon on TV; the Hemodynamic Cat stretching out on the bed. Pop songs make me cry. Time for bed. More soon.

Friday, June 22, 2007

Wise words: internship starting

Illustration: William Hogarth, Industry and Idleness, Plate V (1747). "The idle apprentice: turn'd away and sent to sea." The British Museum. (Sad: he probably violated rule #8, below.)

Internship starts tomorrow. I'll be starting with the medical ICU, and my first day will include an overnight call night.

Amidst all the emotions associated with the anticipation of such an event, some of the graduating interns came up with tips for us while on rounds, and one of them wrote them up and sent the list out to our email list. Here's an excerpt (the first six are mostly hospital specific):

7. Send each other funny pages--it will keep your spirits up. And make you laugh in the middle of an otherwise serious conversation.
8. Get your coffee on the way to work. Otherwise you'll never get it, and nobody wants that.
9. If you're thinking about writing an order, just write it. Don't make a box on your to-do list to write an order.
10. If you don't know the answer, don't lie and make it up.
11. Don't forget to pee. They trigger patients for more urine output than some interns have. And drink a lot of water.
12. We know you're scared to death. Under no circumstances (unless you are [name of graduating intern]) should you memorize ACLS protocols.
13. And from [name], a graduating senior: "Nobody ever died of note-penia. Just take care of your patients. The note will come."

Saturday, June 16, 2007

The bag kills the fear. The bag is the mindsaver.

Above: retro/vintage flight bags from KLM and Aeroflot, from Below: my bag..

Today, I bought a bag, and I fell in love with my bag.

My bag is a dorky bag. I wouldn't buy or wear it under other circumstances. It's like a wierd zipper-heavy backpack-influenced re-creation of airplane bags that the airlines used to give out in the 1960s, but without the cool retro airline logo design.

REI calls it a "Boarding Bag"; like its predecessors, it's designed to be a small carry-on bag that holds the stuff you want on an airplane journey. Probably only someone who was a little worried about flying would buy such a thing. I didn't buy it for flying. I bought it for the hospital. But I did buy it because I was worried.

To explain this dorky-bag purchase, I must first explain that among medical students, interns, and residents, there are white coat people and there are bag people.

White coat people take their notes and reference books and PDAs and energy bars and reflex hammers and shove them all into the various pockets of their short white coats. The very disciplined or the wildly neglectful can get away with this easily: either you pare your carry-around stuff down to an incredibly small amount of stuff, in which case your white coat can easily handle it; or you simply leave all your stuff at home and try to get by without it. (In which case you never look anything up unless you're sitting at a computer terminal, and you test your patients' reflexes by hitting them with the end of your stethoscope.)

The much more common approach is to jam your pockets full of as much stuff as you can get into them--and at my hospital, the pockets are really big, and durable. A woman at the education office said, "I had students show me how big the other hospitals' white coat pockets were, and then I went bigger." My hospital is nothing if not scrappily competitive.

Unfortunately, this creates two more problems: the gunfighter problem, and the water-carrier problem. Because there is so much stuff bulging out of your pockets, you have to walk around with your arms out, like a gunfighter, or a police officer. Also, the stuff is heavy and usually poorly-balanced, and weighs down on the doctor-in-training's shoulders and back, leading the unfortunate coat-wearer to walk around burdened as if constantly carrying water from a well.

For these reasons I've almost always been a bag person. But my bags are usually too big. For instance, I have a big black messenger bag that can carry a whole desk inside of it, and I'm a little bit of a pack rat, so that by the end of a rotation the bag usually does actually have about as much in it as my desk at home has on it. That means that the bags are heavy, and therefore they solve only the gunfighter problem but not the water-carrier problem.

Worse still, I'm constantly having to leave the bags in places like underneath desks in nursing stations, or in call rooms, because I need to go do something where I don't want the extra weight. Or I take the bags off when I'm examining patients, in which case I end up leaving the bags in patients' rooms. Having to come back into a patient's room to retrieve my stuff is a little embarrassing; it seems like a pretty amateur move, and not very confidence-inspiring, especially in terms of my confidence in myself if not for my patients' confidence in me.

I saw an intern this spring with a bag that seemed to solve these problems. Small enough to keep with him, large enough to carry the right amount of stuff, it looked just right. I asked him where he'd got it; and today, I chose this bag as my version of it.

Afterwards, I kept looking at the bag; looking inside it again to think about what I would put in its pockets; zipping and unzipping its various compartments. I would be able to put private personal things in private personal places, my notes in easily accessible places, and my reflex hammer somewhere handy. I could carry my medicine manual and my energy bars and my headache medicine and a little bottle of water. But the bag won't carry more than that--so I don't think I'll be able to jam it so full of stuff that it will become unwieldy and impossibly heavy, like most of my other bags.

I was so in love with my bag that it became clear that my love had gone far beyond the bag itself. My bag had become my metaphor: it would give me organization, control, and my own little secure space within the hospital, even if it is only about 9 inches by 12 inches by 4 inches. Seeing all of these things in my bag, I realized not only why I loved my bag--or at least, the idea of my bag--but also what I had been fearing the most about internship. I fear becoming disorganized; losing control; and never having a space of my own. The first two might harm my patients; the third will make me crazy. Until now. Now I have my bag. Now I need not fear, and I will not. Because fear is the mindkiller.

Friday, June 15, 2007

khakis and button-down

Today at our hospital's ACLS training for incoming interns, the Harvard boys were clustering together a little more than we should have been. (Knowing myself and the others, the clustering was more social anxiety than it was snobbery, but of course that's a fine line.) More remarkably, of seven Harvard Medical chaps who were there, all seven were in some variation of khakis and a button-down, no tie. I think five had blue shirts on, and two had white shirts. (Or was it four and three?) One of our group of Harvard boys was dressed slightly more casually yesterday, but he fell into line today.

No one else among the incoming interns from other schools was dressed exactly this way. Most were a bit more casual. It was a training, and therefore there was no clear dress code. A few were as formal as we were but in different ways: with different kinds of colors, fabrics, and so on.

I didn't dress this way before. I lived in San Francisco and wore jeans to work; when I bleached my hair my workplace credibility as a community organizer went up, not down. My lab boss in Bethesda wore all black clothes (except she wore bright yellow clogs) because she didn't want to be bothered with the problems of matching colors; no dress code there either.

Harvard changed me. Harvard somehow made me think that I should dress this way. And I think we tuned ourselves to each other: we looked more alike the second day of training than we did the first. But clearly, long before this training, without anyone explaining it or demanding it of us, we all became the guys who wear the khakis and the open-collar blue shirts.

"It's what I'd wear if I was coming over here to meet with my research advisor," said A, one of my co-terns. I said, "Of course; me too." On some level, we both felt--well, what else would you wear? In fact, I had semi-consciously run through the differential on both mornings before the training days, looking in my drawers and my closet. I thought about a dark plain polo shirt but it seemed some combination of too casual and too golf-y. Jeans were out of the question. Definitely not a t-shirt. Not even an untucked short-sleeved button-down. I don't own any brightly-colored button-down shirts; if I did I wouldn't have chosen them. Yet other men there made all of these fashion choices, and others like them.

When I told her about all this, Ms. Hemodynamics said, "Well, sure. That's part of why they were recruiting you guys."

"But I find this distressing," I said. "That somehow the institution has taken my aesthetics and eccentricities and ironed them out of me."

She understood this; but she thought my clothes were still the right choice. And of course, my program had been recruiting her too.

Fear really is the mindkiller

ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.

Thursday, June 14, 2007

All politics is local: Gay marriage is safe!

People in Spain celebrating their same-sex marriage victory in 2005; today, Massachusetts caught up.

The Massachusetts legislature knocked down the effort to try to advance a constitutional amendment to ban same sex marriage here. How did we win in Massachusetts? Well, many people made many different kinds of contributions.

From the New York Times today:
Senator Gale Candaras also voted against the amendment today, although she had supported it as a state representative in January. She said her vote reflected constituent views in her larger, more progressive state Senate district; her fear of a vicious referendum campaign; and the 6,800 anti-amendment e-mails, phone calls and faxes she received, one call every three minutes.

Most moving, she said, were older constituents who first supported the amendment, but changed after meeting with gay men and lesbians.

One woman had “asked me to put it on the ballot for a vote, but since then a lovely couple moved in,” Ms. Candaras said. “She said, ‘They help me with my lawn, and if there can’t be marriage in Massachusetts, they’ll leave and they can’t help me with my lawn.’ ”

More seriously, here's a lengthier statement from Senator Candaras on why she changed her vote.

Wednesday, June 13, 2007

In brief: fear=mindkiller, ACLS, medical grand rounds

Photo: "I will not fear. Fear is the mindkiller."

1. Medical Grand Rounds is up on Val Jones' blog.

2. Internship sort of started today with Advanced Cardiac Life Support training.

3. The movie Dune was on cable recently; it may be the best worst movie I've ever seen. Best of all, it featured the quote, from Kyle Maclachlan's thoughts, in voiceover: "I will not fear. Fear is the mindkiller." I have adopted this as my current slogan for the beginning of internship.

Friday, June 8, 2007

"Found Down": HMS/HSDM Commencement speech

"Each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?"
Photo: rescue staging area after Hurricane Katrina.

...More to write about graduation soon (it was yesterday, June 7). First, here's the speech I gave at the commencement ceremony of the Harvard Medical School and Harvard School of Dental Medicine.

I’m going to start with a story. It starts when a man falls down on the sidewalk. He might be drunk, or he might not. He might be unconscious because he fell, or he might have fallen because he became unconscious. Hopefully sooner than later, someone realizes that he has fallen down.

The call to 911 comes from the first person to realize this and to care. Next comes the ambulance crew, and even the cars that get out of the way when the siren goes on. As the story continues, there are triage nurses and doctors, x-ray technicians and respiratory therapists. Maybe the man found down has a strange rash, goes to cardiac cath, or needs a CT scan; maybe he has blood in one of his eyes, or a shattered bone. There will be more to the story, but this is its essence: a person falls, and in small and large ways, a huge network of people begins to pick him up again.

Today, we step into a new role within this network. But we have already been part of this group of people: those who go to the man found down, and try to help him up.

We can’t be too romantic about this story. Almost as soon as the man’s story begins, promises and demands of money start moving through the wires underneath the sidewalk onto which he fell, perhaps even before he has been picked up off of it. But today is not about that part of the story. Today is about what we do because of who we are, and not just who we are paid to be.

Each of us will encounter different versions of this story in our work. A child is frightened of her father. A veteran is overwhelmed with anxiety inside an MRI machine. And a family is just down the hall, waiting to hear the news of an operation, and someone must tell them that the operation went badly. Hundreds and maybe thousands of stories like this are unfolding at this moment, right outside this tent, in the hospital and clinic buildings all around us. And each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?

We’ll have to answer this question day after day. I once heard an ICU nurse in an urban hospital say, “All of our patients have the same chief complaint: found down.” July’s novelty and excitement will be followed by February’s bleak repetition. Just about any hospital has many people found down for reasons that are easy to diagnose, but can seem impossible to solve.

To respond to this sometimes relentless suffering, we’ll have to push back against huge impersonal systems, even when those systems beat us back again and again. And we’ll sometimes have to forgive terrible human frailty even as that frailty pushes us to our limits of forgiveness. And so nearly all of us will succumb to frustration and even cynicism from time to time. This is nothing to be ashamed of, as long as we don’t wallow in it, and as long as we don’t mistake bitterness for truth. We are graduating from medical school, not saint school.

Nonetheless, we can hope to meet the basic moral standard of looking towards suffering instead of away from it. In clinics and hospitals, in our personal lives, and in research and policy, we’ll constantly face this moral challenge. Even the best of us will often fail it. But that should not stop us from continuing to try.

When we do reach this standard, we have one final important task: to avoid congratulating ourselves too vigorously for our own forms of benevolence. Sentimentality about our special virtue as doctors can be as dangerous as cynicism, because it causes us to forget that we are joining something much larger.

Our medical training means that we will bring our expertise, our intellectual curiosity, our readiness to work hard. We can be justifiably proud of ourselves for what we have already accomplished, and we know for sure that the people in the audience today are already proud of us.

But today we also join others—paramedics, nurses, social workers—and dentists—and many others who spend their lives responding to suffering. In the few blocks around us, there are thousands of people like this. And even more importantly, there are many other people who are not healthcare workers, but just caring people who also see suffering and find ways to respond. I came to medical school because of people like this—people who responded to the crisis of the AIDS epidemic in San Francisco, people who taught me about courage in the face of disaster.

In small or large ways, most of us have probably come to sit here today partly because of people like this, people who taught us how to behave in the face of suffering: teachers, friends, family. They have usually taught us by example, often because they cared for us when we were suffering. Some of those people are here today. They have seen us fall; in one way or another, they have found us down and helped us up, sometimes many times. As we graduate, we honor their acts of faith in us. Today we mark a moment in which their gifts to us have come to fruition. Now, we will join them in helping those who are found down.

Monday, June 4, 2007

In brief: Poz blog carnival, internship preparation

1. The International Carnival of Pozitivities was kind enough to include my AIDS vaccine post in its recent round-up of blog posts related to HIV, AIDS, and especially, living with HIV.

2. I went to pick up my Advanced Cardiac Life Support manual from the hospital. Walking back from getting the ACLS manual, I saw a woman and a man walking in the corridor in the opposite direction; the man was in scrubs and was carrying a portable defibrillator. As they passed me, she said, "So, you're going to do the spiel to the new interns, right?" "Yeah," he said. She said, "That's a big one. Like, 200 MDs."

I thought:
--People are preparing for us showing up, and it's a big event.

--Ha! She said, "MDs!" She meant us! Ha ha ha! ... oh crap! I realized that other people think of us as doctors, more than they distinguish us from other doctors--even when, as in this case, they understand the distinction between us and other doctors. And that means that I won't be just an intern--I'll actually be a doctor also. Of course I know that the two categories of intern and doctor overlap, with intern completely contained within the larger sphere of doctor. But I've been a sub-intern and I can imagine being an intern. Imagining being a doctor seems harder. Even though, as I remember with a combination of delight and dread from time to time, it's actually the same thing.