Inspiration

After flipping through JAMA, I stumbled across these words of wisdom. I thought I'd share. Timeless wisdom.

"It is not the critic who counts; not the man who points out how the strong man stumbled, or whether the doer of deeds could have done better. The credit belongs to the man actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly, who errs and comes short again and again; who knows the greatest enthusiasms, the great devotions; who spends himself in a worthy cause; who, at the best, knows in the end triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those timid souls who know neither victory nor defeat."

-Theodore Roosevelt (1858-1919)

Devouring Donuts at 8AM

As I looked at the pink box, I thought to myself about whether donuts were such a good idea. After all, donuts are simply balls of fried dough coated in sugar syrup, not the most healthy choice for breakfast. The lack of nutritional value is probably the last thing one thinks about when devouring this tasty treat. Despite the initial hesitation, I realized that donuts can also be a wonderful gift, especially at 8 AM.

So, I walked to campus happily carrying the pink box and made my way to small group. Today, I was facilitating a group of twelve first-year medical students. We were going to discuss a case of coronary artery disease. So, maybe the donuts were actually a bad idea. Whatever the case, donuts were well-received.

Interestingly, I was leading the same group I had attended as a first year during the cardiovascular block. It's so odd and funny how quickly times flies. One day, you find yourself squirming in those uncomfortable seats, dreading the 8 AM small group. And then you wake up a couple of years later, sitting in the front, teaching and hoping your students like you and learn something (anything) during the two hours you spent with them.

It's really easy to stand in front of a class and lecture. What is harder, is having students discover critical learning issues and topics on their own and having students teach other. Our job as small group facilitators is to guide students to discovering and disseminating knowledge. We have the answers, but at the end of day, it's not the answers that are important, it's the learning that takes place in the process. Consequently, we hope students can start to see things from different perspectives.

Small group can be a battle to stay awake. I remember those days. The donuts were a peace offering. By feeding my students, I hoped to appease them and make them happier people, so they could engage in the material just a little more. Maybe peace offering is a little extreme. The correct word should be incentive.

Surprisingly, none of that was needed. My students came prepared to learn, asking questions and teaching each other, which made my job so much easier and rewarding, even sweeter than a traditional glazed donut.

Giving Thanks

Thanksgiving is my favorite holiday. At it's core, it comes down to two simple things--food and family.

I had the pleasure of celebrating the holiday with my family in Davis. The four days at home were a welcome respite from residency interviews and the ongoing city trekking that has consumed my life during the last few weeks. After making the decision to apply into obstetrics and gynecology, I feel like my life has been moving so erratically with residency applications, interview invitations, rejections, and wait lists. Above all, I feel like a broken record, repeating my life story over and over again to complete strangers around the nation to prove my commitment to the career I have chosen to pursue for the rest of my life.

When I first stepped foot in my parent's house, there was the initial barrage of questions relating to the places I have visited. "So, which place did you like the best?" my mother asked.

"What's your number one, Eisha?" my dad asked.

After dodging the obligatory questions (I have yet to figure all this out), I was able to settle down and finally sit still in one place.
The serenity and calm of being home was a welcome change and reminded me about the simple pleasures of life-- the aroma of curries, warm blankets fresh out of the dryer, crunchy red and yellow leaves, runs on crisp autumn days, cups of chai with my mom, walks with friends, and family dinners around the kitchen table.

I know many families have Thanksgiving traditions. Interestingly, our Thanksgiving dinner is so far from traditional, we have created our own culinary rituals that have been inspired by western and Indian traditions. We have never had turkey. Every year we have baked chicken with potatoes, boiled corn, baked fresh naan, and cooked curry; it makes quite a feast.

As we gathered around the table and savored every morsel of food, I felt so lucky to be surrounded by family.

For me, Thanksgiving is a time to remember all the blessings we have in our lives. I came up with a list (in no particular order) to remind myself about all the blessings in my life.

1) My Health- having the ability to see, breathe, get out bed each morning and face each day
2) My Family- the people in my life, who love me unconditionally, define and support me. I owe them everything,
3) My friends- the people who ground me and care for me, functioning as my extended family.
4) Learning opportunities- being able to pursue my dreams and creative endeavors
5) Food- makes life worth living. I live to eat and exercise to eat.
6) Shelter- despite the high cost of living in the city, I am lucky to have a roof on my head, a kitchen for cooking, and a place for entertaining
7) Golden Gate Park and Running trials- the natural beauty in an urban setting rejuvenates me
8) Running- a pass-time that has helped me maintain my physical and emotional health, taking me to new heights
9) Medical school- a place where my dreams started and have only begun to evolve as I venture forward
10) My patients- their stories inspire me and remind me why I chose to pursue a career in medicine
11) My teachers and mentors- their patience and dedication to my learning has allowed me to grow
12) My experiences- have shaped me
13) Living in San Francisco (and California, for that matter)- the possibilities are endless
14) My blog- having a place to express myself, reflect, and communicate with an audience (although I have not met you, I hope I have affected your life)
15) Freedom of speech- I talk so much (so I benefit from this protection)

Before I left home, my mother repeated to me the same advice she gives me every Thanksgiving.
"Eisha, we celebrate Thanksgiving once a year. But, remember every day is a day to give thanks for all the blessings we have."

She is right. Among the blessings in our lives, each day serves as a blessing and an opportunity to give thanks.

Lessons from the Bedside

When we donned our pristine white coats three years ago, we were told that we were about to embark on an exciting journey of lifelong learning. We have only just begun. In four years we are expected to transform from civilians to student doctors charged with taking care of patients. During the process, we become like-minded beings, equipped with the knowledge and skills to think and act in a particular way. We also become problem solvers, who are programmed to quickly work through differential diagnoses. Most of this reshaping happens at the bedside, where our patients guide the trajectory of our development into physicians.

In medical education, we are grounded in two years of preclinical education, when the basic sciences marry the clinical medicine. We start with the basics and build a foundation, fact by fact, during a series of structured, small groups, labs, and exams. A problem-based approach is applied to simulate what we will experience in the world of patient care. With our glossy syllabi, objectives, and neat clinical cases, we venture forth, mastering the pathophysiology of disease, highlighting every word and digesting the well packaged information, fully aware of the expectations, while completely sheltered from the reality of patient care.

When we transition to the clinical years, reality hits us hard. We are indoctrinated into an entirely new culture, where we feel alien in our short white coats and lack of experience. In recognizing our limitations, we also remember that we are bestowed with the responsibility of taking care of human life—a great privilege and challenge. We quickly realize that lessons from our early doctoring class have little place in the world of 10-15 minute clinical encounters and overflowing emergency rooms.

“Human lives are just plain messy,” my medicine attending once told me.
He is right. Although the first two years prepare us with an extensive knowledge base, nothing can truly prepare us for the reality of the clinical years. The complicated pathophysiology of disease pales in comparison to the intricate complexities weaved in the stories of our patients.

As we serve patients during the lowest points in their lives, we become acquainted with the intimate details of their histories. In managing my patients, I have seen a spectrum, everything from the IV drug user who overdosed to the wife abused by her partner to the patient dying from his metastatic cancer to the homeless patient with HIV to the victim of nonaccidental trauma to the pregnant patient actively using meth. The spectrum of disease pathology is oftentimes grounded in social pathology that exposes us to the dark sides of human nature and cruelty of society. When we see the intersections, we are reminded about the fragility of life and complexity of managing diseases.

In these encounters, we fumble through our words, break down emotionally, and struggle to understand. With new admissions and high patient turn-over, there is no time to process and we are not equipped with the coping skills to process the gravity of what our patients tell us. We initially fall back on the pearls we were taught during our first year of medical school to express compassionate words that merely fill the silence and void that separates us from our patients. Slowly, we outgrow our discomfort and we begin to learn, gaining valuable experiences. And despite our inadequacies, we are humbled, when our patients turn to us and call us “doctor,” a reminder that we are growing. We may not see the change, but our patients recognize the doctor in us.
***

Although the reality of patient care challenges us, the best lessons in medical education rest in our patient encounters, where disease takes on a human form and becomes cemented in our memories. On the wards, we are oftentimes assigned patients based on the learning value of their presentation. The “active patients” represent the gold, a source of intellectual stimulation, full of learning issues and “pimping” topics. Interestingly, when the diagnosis and assessment have been made and the plan is implemented, many physicians feel there is limited learning to be garnered from the “rocks” of the service.

As students, we adopt these patients as our own patients. Physicians, teams, and nurses switch, but the medical student remains, representing the one constant for these patients. We outlive the transient teams, oftentimes relating more to our patients than to the long white coats that surround us. And each day we arrive like clockwork to preround, round, and check-in on our patients. In following patients through their hospital course, we learn more than just the details of managing disease, we learn how to become healers through lessons that can only be experienced.
***

As medical students our learning represent a series of firsts, where our first exposures to disease manifestations and patient encounters shape our subsequent learning, oftentimes reinforcing the concepts that were introduced during the preclinical years. Initially, we lack the ability to actively apply our knowledge in the moment, while everyone around us processes and works at rapid paces. We lag behind because we are constantly readjusting to new environments with limited experience.

At the times, the process can be numbing. As a student, your role remains somewhat undefined. Your primary job is to take care of patients and learn medicine, in all it shades—the language, the skills, and the details of the culture. Many of us place unreasonable expectations on ourselves. We always forget that we are nomads, traveling from one rotation to another every couple of weeks, whereas our fellow residents and attending physicians have far more extensive experience.

The uneven learning differential skews the expectations. And we oftentimes remain uncertain, unprepared, and overwhelmed by the constant pressure of being evaluated. We strive for completeness and efficiency, streamlining our patient’s stories into one-sentence sound bites—the one liners. Like a shadow, we follow our intern around, unsure where we are supposed to go. We are driven to impress our team by referring to obscure references or citing the evidence-based medicine. In this process, many of us take on a new identity, while losing a piece of ourselves. But no one really teaches us how to learn.

In speaking with fellow medical students, we agree that the clinical years require a great deal of relearning; we have teach our selves how to be self-directed learners. Aside from the occasional didactic session or presentation from the attending, we are responsible for our learning. We spend our spare moments reading and reviewing the literature. At the end of the day we remember very little and our patients represent the best teachers. Education comes from managing our patients, even when we are just beginning to figure out the basics.
***

When we look at ourselves in our soiled and overstuffed white coats three years after beginning this journey, we can acknowledge how far we have come in such a short amount of time. We have become somewhat conversant in the medical language and familiar with the details of the medical culture. More than anything else, we have gained unique experiences that have changed us. The budding physician in us is slowly emerging.

With one year standing between me and residency, I feel frightened and excited. As I move forward, I know I will always feel unprepared. However, I will always remember that my patients will continue to be the best teachers.
There are many lessons I have learned. They can be best summed as follows:

1. Be present for your patients.
2. Listen to your patient.
3. Do what is right.
4. Be true to yourself
5. Treat your patient like you would want to be treated.

Although these principles are fundamental, these lessons are sometimes forgotten. Such lessons have a central role in the education of not just medical students, but also represent an integral part of the lifelong learning we will experience in our careers.
***

This essay was recently published in the San Francisco Medicine Magazine.

Sea of White

The new first year medical students filled the auditorium floor, a sea of white coats.

The UCSF Alumni center president provided some interesting advice to this eager group of soon-to-be doctors.

"Now do not get khaki. Even butchers wear white coats."

I recently attended the white coat ceremony to celebrate the induction of the class of 2014. I had a unique perspective--that of a fourth year student and of a photographer capturing the key moments of the ceremony.

When our Dean stood on stage to introduce the 150 first year medical students, I was struck by what she had to say.

"You are just starting. And in about 45 months, you will be attending another ceremony--graduation."



It's interesting how graduation lurks ahead, and I feel like I just started--eager, excited, and ignorant, just like this new batch of students.

Three years later, I feel like I have grown a litte bit, but at the same time, feel like I have so much more to learn.

In addition, I find so much more meaning in the Oath of Lasagna, a modern-day version of the Hippocratic oath, that the newly coated medical students recite in unison to culminate the white coat ceremony and commence their journey into medicine.

I have included it below. I'll be reciting it again about nine months from now...



Oath of Lasagna

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Source: http://www.pbs.org/wgbh/nova/doctors/oath_modern.html

All Eyes on Me

Do you ever get the feeling you are being watched?

When I sat down in the reserved chair, a part of me was a bit anxious and part of me was scared. And there was a small part that felt calm and ready to take on this challenge. Having finished three years of medical school, I have learned that sometimes courage is all you have at the end of the day, and that is ultimately what takes you a step further.

So, I sat there. I could just feel all 100 eyes starting at me, taking me in. Analyzing me, the way I sat, what I wore, my choice of shoes, my messy hair style, my overstuffed and sullied white coat. They were all processing the minute details that defined me--I am sure. It was not so long ago that I sat in their seats doing the same. I shut them all out and just focused on the task ahead of me.

***

In medical school you are always being watched. You are supervised at every step of the way. At times, it's comforting knowing that someone double checks everything you do, from writing a note to writing an order to performing a physical exam. You always have confirmation. But at the same time, you also find yourself wanting to develop autonomy and independence to prove to yourself that you are capable of being a doctor, who will one day be responsible for patient lives (on your own).

***

My patient was fifty-something year-old woman. Her dark brown hair was neatly party. She had dark red lipstick and blue clothes. She sat down in front of me. And I began the interview. She had abdominal pain and her son was recently hospitalized in the ICU after a motor vehicle accident.

It was just like any other interview and I focused on my patient in front of me, fading out the sea of white coats.

There were over fifty first year medical students watching me perform this interview for their doctoring class.

I got through the interview and was able to an adequate patient history, while drawing on the clinical pearls they taught is in the first two years of doctoring class.


By the end of the interview, I looked out and saw the glowing and exciting faces of the medical students. They are just in the first week of their training and I could see the excitement in their eyes, the same excitement I had in my eyes three years ago, which I hope I can carry with me in the years to come, when I am not being watched.

Step by Step

There is nothing quite like a double choclate chunk cookie that has been melted due to the summer heat. I can honestly say that I rarely indulge in such a wonderful creation. However, we all have exceptions to our rigid rules. And today, was the perfect day to indulge. The best part is devouring the cookie after a 9 hour test.

I completed Step 2- Clinical Knowledge Today. The mental marathon was long and at times felt endless. Every click got me one question closer to being done.

I am releived it's over. Now, it's time to catch up on life.

Lessons in Urban Survival

“You can tell a lot by a person’s shoes. One look tells me if they are worth my efforts.” he said.

My patient, a forty-something gentleman, was educating me about what he called “urban survival.”

As a native of the Tenderloin, he relied on certain tactics to make ends meet. He was an expert-level street hustler. He was one of the successful ones and was capable of making a small fortune, probably enough to pay rent and live comfortably in a nice SF apartment somewhere outside the Tenderloin.

Sadly, he burned through his earnings, spending massive amounts on one thing—crack cocaine.

“Sometimes, it feels like I am drowning just thinking about how much money I owe. But I want it (crack). I need it. And I have to get it.”

***
Cocaine is derived from Erythroxylon coca leaves, a plant endemic to the Andes. In historical records, cocaine chewing was documented in South America as far back as 4000 years ago and for the last hundred years has had medicinal uses because of its vasoconstricting effects (1,2). Cocaine has multiple actions, acting as a local anesthetic effects, CNS stimulant, appetite depressant, and vasoconstrictor. The effects are largely mediated through the inhibition of norepinephrine, dopamine, and serotonin (3).

Cocaine has become a popular street drug, which can be sniffed, smoked, or injected intraveneously. As a recreational agent, cocaine has variable purity. The purest forms are white powder, while less pure forms are more yellow and have been cut with other drugs, such as lidocaine, caffeine, methamphetamine, ephedrine, and phencyclidine (3). When cocaine is heated in an alkaline solution, it transforms into “crack,” which is sold in 100-150 mg “rocks” and can be smoked, while a “line,” weighs 20-30 mg and is snorted (3).

***
When I first met him, he was completely suicidal and was brought into the SFGH Psychiatric Emergency Services after being placed on a 5150 hold for being a danger to himself. After the initial evaluation, he was transferred to the inpatient psychiatric unit. At the time, he had no home and was completely out of money.
He was a tall, thin middle-aged man with a pinkish complexion. His hair was combed and slicked back. He wore a lime green collar shirt over blue hospital gown pants. His two front teeth protruded outward and had been eaten away and were stained brown.

During our first meeting, it was like everything was in slow motion. He moved aimlessly and spoke slowly when recounting the details of his suicide attempt. He had a flat affect, showing very little facial expression. He appeared remorseful, but remained deeply depressed. At times, he would become teary eyed when talking about being abused as a child and his life in the Tenderloin. He was diagnosed with bipolar and polysubstance dependence.

“When I get low, I get really low and go into these dark bouts of depression. There is no reason to live for me. No one gives a shit about me.” he said.
His past addiction was alcohol; his current substance was cocaine. His heavy drug use required excessive amounts of money, which he often did not have. Thus, he borrowed from street lenders and still had to pay back his debt.

The chronic use had left his life in shambles. He went from having it all—a condo, a girlfried, and a stable job—to now having nothing. He was living on the streets, had made many enemies, and relied on hustling to get his daily fix.
He had been admitted to our inpatient unit numerous times before for suicide attempts and was in and out of residential treatment programs. He was followed by a case manager and was plugged into an extensive network of social support services, but had difficulty committing to appointments and taking his medications. The hospital had become his security net, a revolving door for him.

***
Addiction to drugs results from alterations in neurochemical processes, which ultimately lead to increased drug-seeking behavior. Cocaine, like many other drugs of abuse, is highly addictive because it blocks dopamine uptake and results in increased dopamine levels in the nucleus accumbens (4). With respect to behavior, dopamine promotes reward-seeking behavior (5).

Interestingly, with increased cocaine use, dopamine release results in the setting of exposure to certain stimuli, such as drug paraphernalia or environmental cues, findings that have been demonstrated in animal models (6). This conditioned response explains the drug-seeking behavior observed in chronic users, who are driven to do whatever it takes to get their neurochemical fix.

***
Over his two-week hospitalization, I came to know him really well. Although initially reserved, he opened up and enjoyed talking about himself and his urban life; he was always seeking an audience. He became animated when he described the subculture of street hustlers.

He was vague when describing exactly what he did when he stood on the streets of the financial district wearing an expensive European blazer and pair of polished Italian shoes. He had mastered the art of “talk,” and was able to assume an entirely different persona, when he worked in the shadows of the black suits, he desperately desired to be.

Like himself, many of his colleagues were substance abusers, who generated funds through a similar fashion. He admitted that his tactics were aimed at getting money from the “sharks,” the men in business suits. Unlike other hustlers, he felt his tactics were less seedy; he did not pursue women and was not overly aggressive.
“I just have a way of getting what I want,” he said.

Despite his skills, he was consumed by what he called “self-destructive behavior.” He had made many street enemies and there was no escape living in the Tenderloin district, where every street corner harbors a dealer and the environment reinforces his addiction-forming habit. He felt powerless and weak, completely disabled with an inability to break the habit.

“I am spiraling and digging himself deeper and deeper in an early grave,” he said.

***
With an expanding drug economy, a subculture of hustlers has emerged as a powerful force with a unique social identity. In a study that examined the social identity formation of street hustlers in a group of 28 criminals prosecuted for violent street crimes, the authors cited how hustlers involved in the drug economy made every effort to differentiate themselves from the crack-heads, who represent a lower social status (7).

The following qualities were identified as central components of the hustler identity:
1. Being Clean- The hustler has morals and pays close attention to hygiene and dress.
2. Having Things- The hustler seeks to acquire material wealth
3. Being cool- The hustler is characterized by a detached persona and calm demeanor.
4. Being criminally able- The hustler has the knowledge to accomplish the necessary acts to sustain a living
5. Having heart- The hustler can protect oneself from victimization or danger.
The authors conclude, “The self-described hustlers in our research succeeded, at least in their own minds, in establishing an identity whose status is at the top of the crack economy rather than at the bottom,” much like my patient who prides himself for being successful at his line of work (7).

***
Closer to the end of his hospitalization, my patient laid out his requests— he wanted to be admitted into one particular residential treatment program in San Francisco and after he completed the program, he wanted a new apartment outside the Tenderloin. These were his stipulations for recovery.

At times, it felt like we were negotiating the terms of an agreement. And when we could deliver, his attitude changed. He instantly became invested in recovery and the treatment program, seeking immediate discharge even before the bed was made available. When we had trouble securing the bed, he drifted into a depressed mood and pleaded with us.

He intrigued me. A part of me was drawn to him, sympathizing with him, completely consumed by his story. I could not even fathom how he survived years of childhood abuse, living in the streets, and relying on urban survival. I wanted to see him recover to help me get back the life he once had.

At the same time, the skeptic in me awakened. At times, I wondered how much of his story was true and how much of it was actually concocted. He was well-versed in the art of talk. He knew exactly what to say to get what he wanted. After all, he was an expert hustler. I often wondered, was I being hustled like everyone else who had entered his life?

When he left the unit, I wished him well. I never knew what became of him. One can only hope he was successful this time in his residential treatment program. A part of me fears he might have tried to kill himself again, while another part of me thinks he may have ended up back on the streets, hustling his way to bricks of crack.

Whatever the outcome, his story reminds me about the intersections of substance abuse, addiction, and psychiatric illness, a sad reality in our urban neighborhoods. Although it easy to blame the patient for his addiction, we must remember that addiction is an illness, which like many other medical diseases, requires an interdisciplinary approach to treat the neurochemical and psychological basis of disease.

***
Works Cited
1. Nunes E,. “A Brief History of Cocaine: From Inca Monarchs to Cali Cartels: 500 Years of Cocaine Dealing.”NEJM- Nengl j med 355;11 www.nejm.org 1182 september 14, 2006
2. Murphy Nancy G, Benowitz Neal L, "Cocaine" (Chapter). Olson KR: Poisoning & Drug Overdose, 5e: http://www.accessmedicine.com/content.aspx?aID=2683517
3. Luscher Christian, "Chapter 32. Drugs of Abuse" (Chapter). Katzung BG: Basic & Clinical Pharmacology, 11e: http://www.accessmedicine.com/content.aspx?aID=4519820
4. Volkow N, Wang G, et. al. “Cocaine Cues and Dopamine in Dorsal Striatum: Mechanism of Craving in Cocaine Addiction.” The Journal of Neuroscience, June 14, 2006, 26(24):6583-6588; doi:10.1523/JNEUROSCI.1544-06.2006
5. Schultz W, Dayan P, Montague PR (1997) A neural substrate of prediction and reward. Science 275:1593–1599.
6. Di Ciano P, Everitt BJ (2004) Direct interactions between the basolateral amygdala and nucleus accumbens core underlie cocaine-seeking behavior by rats. J Neurosci 24:7167–7173
7. Copes H., Hochstetler A., Williams JP., “‘We Weren’t Like No Regular Dope Fiends”: Negotiating Hustler and Crackhead Identities.’” Social Problems. Vol. 55, Issue 2, pp. 254–270, ISSN 0037-7791, electronic ISSN 1533-8533

A Long Overdue Update

I've been spending my days staring out the window and at a screen, clicking away. I am still here. Officially a fourth year. And with that transition comes another test-Step 2.

Studying has been unexciting, to say the least. Needless to say, there is not much to write about. Just counting days to test day and being done with these artificial case vignettes.

Once this exam is over, I look forward to reflecting as I begin my fourth year.

For now, I am posting a recent essay I published in the San Francisco Medicine titled "Lessons in Urban Survival."

Warm Blue Water, Beaches in France, and Spinal Anesthesia

“You are tentative,” she said.

My patient was a 73-year old women, who spoke with a heavy Russian accent. I met her in the Preoperative area, where I initially caught a glimpse of her limping and approaching the nurses complaining about how she had been waiting over an hour to go to surgery. She looked her age. Her silver hair was thin and her pale skin was streaked with a yellow hue. She was frail. Her face was sullen and wrinkled, covered with dark pigmented freckles. Her teeth were brown and chipped.

She was already annoyed with me when I asked questions relating to her medical history.

“I do not see why I have to tell you. I already gave all that information. It’s in the chart,” she said.

After eliciting as much of a history as I could, I carefully gripped her hand and pulled her paper-thin skin back to better visualize her veins. Even with tourniquet in place, the blue threads that coursed her hand, left little room for error. I knew that I had one shot to pierce the needle.

The tension was palpable in corner of the room occupied by her bed. She was anxious and she made me fully aware of my role as a student. She could sense my anxiety. I could feel her eyes on me, watching every move I made. Later, I was joined by my resident. And I knew the last thing she needed was to hear a resident instructing me how to pierce her veins.

Despite her overt discomfort, I stayed calm, visualizing the steps of placing a peripheral IV in my head. My resident talked me through the steps, giving me confidence and direction; I had done this before and I knew I could do it again. But at the same time, I knew that the more he talked, the more she doubted my ability.
As I made my first move, positioning the needle in my hand, holding it like a pencil at an angle parallel to the vein, I pierced, and before I advanced, my residence instructed me to reposition. Before I could move the needle, my patient interrupted us.

“Can I have someone who knows what they are doing do this,” she screamed.
Her words were stinging, reminding me about my inherent limitations as a student. Without saying a single word, I handed the needle to my resident, who was able to complete the job, which I had meticulously planned out in my mind. I resumed my position as an assistant, handing him the tape and cleaning up the mess—a familiar role I had come to know as a third year student.

Although I was taken aback by her response, I can understand her frustration. She was alone and exposed in a completely sterile and unfamiliar environment. Strangers rushed passed her and she was completely ignored. She wanted general anesthesia, but the surgeons had decided spinal anesthesia was a better option, given the lower risk of blood clots and quicker recovery. She did not want to feel any pain or be aware of the surgery. And from her perspective, she was not being heard.

Although she was keenly aware that our hospital is teaching institution, she had very limited patience. She was simply expressing what we would all want if we were in her situation. She did not want to be pricked like a pin cushion, or be treated as an experimental subject.

At the same time, her case made me think about how to balance learning with deliver high quality patient care. As a student, you are stuck in the middle. Your patient’s needs come first. However, we all need to learn, so that we can take care of our future patients. A part of me always feel guilty when I am performing a procedure for the first time—be it delivering a baby, suturing a wound, performing a LP, or a placing a peripheral IV—knowing that a more trained provider could do the same job in a shorter amount of time (and probably more successfully). But everyone has to learn and we all have a first time.
***

When we arrived in the operating room, she became visibly anxious.

As the resident began prepping her back for the spinal anesthesia administration, she kept repeating, “Why can’t I have general?”

At first, I was hesitant to go to her side, having just been berated by her. However, I knew she was vulnerable and could really use emotional support. I moved from watching the placement of the spinal and came to her side. I grabbed her hand and attempted to engage her in a conversation.

Using visualization techniques, I worked with her to think pleasant thoughts. She saw herself sitting at a beach in France with rolling mountains in the background. She was sitting next to good friend and her feet were immersed in warm blue water. French music could be overheard.

As the needle pierced her skin, she gripped my hand and I reminded her about her special place, repeating the details of the French beach. And with each detail, she became a bit calmer. And before we knew it, the spinal was in. She looked at me in surprise at the end of procedure.

“That’s it?” she said surprisingly.

“Yes. They are done.” I responded.

In my role at her bedside, I was able to talk her through a procedure that she had deemed impossible. In doing so, I was able to develop rapport with my patient and optimize her care. I was able to salvage our therapeutic alliance. I put her needs first and enabled her to overcome her fears through visualization techniques.

My experience working with her reminds me about the power of mind over matter. In many ways, these types of experience are just as important as learning technical skills. And sometimes it’s this connection that makes all the difference for our patients.
***

The Lottery

It's that time again. LOTTERY TIME!

Nation-wide, the lottery is exciting because there is a chance of winning a jackpot. Our medical school lottery does not promise such fortune. Instead, it's anxiety-provoking as we rank our preferences for our fourth year schedules. Once everyone ranks their preferences, a computer goes through and randomly assigns us our electives.

As I rank numerous selections, I am reminded of highschool precalculus, thinking about all the possible permutations. If only I knew game theory to maximize my chances of constructing a perfect fourth schedule.

In truth, it feels like being back in college. Having spent my whole life in public school, I am familiar with the process that comes with allocating scare resources to meet a high demand. In our cases, there are just way to many students coveting the same spots in certain sub-internships, fourth year electives.

Inevitably, we all have to compromise and realize we will never get the perfect schedules. Regardless of the lottery results, I hope my schedule has some resemblance to some of my 60 rankings.

The Small Things

Sometimes, it's the small things that make your day.

Today, I was moved when my patient gave me the gift of chocolate to celebrate the birth of her son. The choclate was wrapped in light blue foil, one was a square piece with a picture of baby boy and the other was cigar-shpaed piece. My first patient gift.

As I was walking be her room, her mother greeted with me a hug.

"Eisha, it is so good to see you. You need to come and see the baby." she said.

I walked into the room and was instantly greeted by the patient, who looked up at me with relief and joy.

"He is big. 9 lbs and 11 ounces. My pelvis was just not big enough for his big body. So, we had a C-section. It was not what I had expected, but he just was not coming. Oh well, it was worth it."

She smiled as she looked at her son with his chubby face and full lips. He looked just like his dad. He was sucking on his fingers and sleeping quietly.

***


Over the course of the three weeks I spent on labor and delivery, I got to know the patient and her family very well. This twenty-something year-old,, first time mother, had recently moved to SF from the South. She retained her southern accent and her mother maintained a certain amount of Southern hospitality. The patient always wore her straight black hair down. Her face was framed by thick-rimmed glasses. She was friendly and seemed to always be concerned.

She had become my longitudinal patient. She always came with her mother. I had seen them regularly in triage, where she came concerned about contractions that the she thought were the harbingers of labor. Each time she came in, we would connect the monitor and reassure her that she was not in labor.

She returned in the days leading up to her delivery due to concerns that she was not feeling her baby move. There were also some non-reassuring changes noted in her fetal heart strip. For some reason, when she showed up to triage, everything returned to normal.

"He makes a liar out of me," she would say, right before we let her go home.

On her last triage visit, she realized she was not in labor. She was close to her due date, so we decided to induce her labor. We all knew that if we discharged her, she would be back soon enough.

***

I gave her hug and made my way to the crib. I was finally getting to meet the baby we had been monitoring with ultrasounds, fetal heart monitoring, and cervical exams over the last three weeks. I had come to know his 2-d black and white ultrasound image, as well as the amniotic fluid levels that bathed him in his in-utero home. He had been a constant source of worry for his mom. Now, he had entered our world. And it was such a pleasure to see his face and his little hands.

Over three weeks, I felt like I had really become a part of my patient's life. In her room, I was surrounded by strangers, who had come to know me.

It these small things that make it all worth it.

Great Catch

"Is this your first catch?" My patient asked.

"Yes." I responded sheepishly. Is it that obvious, I thought.

"Well, Great catch." She responded

"Cheers to you and cheers to the baby." Her husband said.

Five days ago at 1:19 AM, I delivered my first baby. The baby boy, weighing 8 lbs and 4 oz came into the world crying loudly after his mother labored for nearly a full day. I held him in my arms and watched as he opened his eyes to see the world he had just entered.

***
I remember the first time I went to the labor and delivery floor. It was within my first weeks of medical school. I made my way up to the fifteenth floor, where I attended three births and stood behind a gowned team of doctors. I was a spectator, the mirror girl holding a large oval mirror to show the patient her baby emerging into the world through her legs.

Almost two years later, I returned to the same delivery rooms. I am currently on my OB-GYN rotation. And for my first week, I have solely worked nights, from 6 PM to 8 AM. Surviving these unnatural hours has required a large cup of coffee and many cups that follow during the night.

In many ways, things have changed. This time around, I am standing in an entirely different place with a completely different job. While I have grown in my role, some things have not changed; I continue to marvel at birth and the views of SF from the 15th floor.

***
My patients room was in the East corner. The glittering lights of downtown skyline were visible through the darkness. The room lights had been dimmed. Her bed was close to the window right next to a pull out sofa. The infant exam area was nestled in the opposite corner of the large room.

When I met my patient for the first time, a woman in her late twenties, she was lying in her bed wearing a hospital gown. Her black hair was pulled back and beads of sweat were forming on her light skin. She had gray eyes. And the only clue to knowing she was pregnant was her gravid abdomen. She was well-trimmed, the result of weekly sessions with a personal trainer. Her toenails had been painted a nice shiny silver. She breathed through the contractions and spoke through the contractions.

She was joined by her husband, who was by her side the whole time, holding her hand. He was in his late twenties. He had brown hair and dark blue eyes. He looked like the poster child of fitness; he was thin with a build of a runner.

"We are hoping, the baby will have a mix of my blue eyes and her gray eyes. And maybe a touch of my brown hair." he said.

This was their first baby and he was arriving close to his scheduled estimated date of delivery. She started having contractions at 3 AM of the previous day. When she arrived to our triage room, she was examined, after which her water broke. She was placed in a delivery room because she was in active labor and had been laboring all day.

During my shift, I coached her through the last five hours of her labor. With the guidance of a seasoned labor nurse, we encouraged our patient to take deep breaths and then push. Breath and then push. Over and over again. This became our mantra. And slowly, the baby made it's way down.

In between the painful pushing; she would briefly pause and take a deep breath. Through the entire process she requested on only one thing.

"Can I have some ice chips?" She would ask.

She had decided to have a natural delivery, so there were no epidural or pain medications. There was no IV sticking out of her arm. She was able to move out of her bed and change positions as needed to help position herself more comfortably, which became incredibly difficult. As the labor progressed, the deeps breaths turned into grunts and screams as each contraction became even more painful and intense.

With no pain medication, we could only offer encouragement, guidance, and ice chips (by the end she had gone through three large cups of ice chips). And that's what we did. And slowly, she was able to push harder and harder, until we started to see the black hairs on the baby's head.

"Babe, I can see his hair. He's almost here." Her husband said minutes before we went on to deliver the baby.

The delivery itself represented a small fraction of the entire of laboring process. It was the climax of an entire day of contractions and pushing. Once the head started to crown, we prepared to deliver the baby. So much seemed to happen in the those minutes. The instrument tray was uncovered and we quickly put on our masks, gowns, and gloves. The lights were turned on. We were joined by the other doctors. With my hands and some assistance, I guided the baby's head, while protecting the mother's perineum.

Inch by inch, and with each push and contraction, more and more of the head could be seen. Between pushes, the head would pop back in, almost like playing peek-a-boo. Eventually, we were able to safely guide the head, followed by the shoulders and then the rest of the body out. Before I knew it, he was in my arms, covered in blood and fluid. He was also very slippery and warm (as I had been warned).

There was a sudden calm, as we rejoiced in the end of the delivery and waited to hear the baby to introduce himself with a loud cry.

For a second he was a silent, but within seconds, he started to cry. His color transformed from a ashen blue to a dark pink. We clamped his cord and dad cut the cord between our two metallic instruments. I handed the baby to the pediatrician, who was standing behind me with an open blanket in her arms. After he was evaluated, he was returned to mom and dad.

We went on to deliver the placenta by applying supra pubic pressure and applying traction of the cord. Once the floppy structure fell into the bucket, we worked on repairing the laceration that comes from having a baby pass through a vagina.

***
The whole process of birth, from labor to delivery, is simply magical. At times, it can be difficult to watch as you see the mother experiencing such intense pain with each contraction. At the same time, you are simply amazed by the instantaneous change that happens with the birth of a baby. You see the whole spectrum of human emotion, everything from pain to anger to anxiety to joy to happiness all in the course of delivery.

In many ways, it's transformative process for the people involved. In one day, many lives change. The nine months of waiting and wondering and worrying culminate with a new addition to a family; parents are sloe born.

In my small role, I helped my patient and her husband transition to the next phase in their lives--parenthood. For me, it was more than just catching a baby; it was one of the most memorable experiences of medical school, one of the greatest gifts anyone could have given me. I feel so lucky to have delivered their baby; to have held their baby for the first time. I feel so humbled and thankful for this catch.

Marveling at my Greeters

For the last month, my morning has always started the same. I turn my key clockwise until the light turns green and the door unlocks. Before opening the door, I carefully make sure no patient has crossed the yellow line and will AWOL the moment the pink door opens. I quickly slip in and close the door, letting myself into the unit, while gripping my coffee in my hand. And my day begins.

In may ways, it's like Groundhog Day, it is the same routine over and over again.

***

And it always starts with my greeters, who have become a part of my routine. *Lena and Joe, without fail, have been there to draw me into their world, daily reminders of this new habitat I visit.

From the common room, Lena stares at me. She is a forty-something year old woman, with the mental capacity of a child. She intermittently laughs, claps, or throws tantrums. Her frizzy black and gray hair is pulled back in a pony tail and she wears a stained white t-shirt that tightens around her mid section. Today she wears blue hospital pants instead of her usual patterned dress. The daily antipsychotic medications have calmed her down, but caused her to gain weight and retain water; her face is swollen and she looks sedated as she pouts with her arms crossed across her chest. This morning, she ran up to me to give me a hug. Later on, she finds me while I interview a patient to give me some of her half-eaten animal crackers. I politely decline and she moves on to offer the food to one of her peers.

In many ways, she appears blissfully unaware of her mental illness and the discussions that happen each morning during acuity rounds that focus on transferring her to another facility. "She was evaluated, but they don't think she is eligible for placement," her providers say. So, she has taken residence in the unit. As far as she knows, the unit is her world; her major concerns are when she gets to eat and if she can get an extra soda.

There there is Joe. An older gentleman in his seventies, whose face has been thinned down to the bones. With his dark eyes and bony face, he reminds me of my childhood image of a walking skeleton, who lurks in the shadows. He speaks no English and when he talks, you can barely understand what he says; he has barely any teeth. He likes to opens his mouth, which reveals the darkness of his oral cavity. His yellow skin is accentuated by his silver hair. You intermittently hear the gurgles from his throat when he sits quietly to watch the afternoon Court TV.

He is infamous for his pranks, which have included clogging sinks, jamming locks, and hiding things. He always wears the same dark blue jacket with red stripes over blue pants. He shuffles around the unit with small steps, shifting from one chair to another. Each morning, he utters something incomprehensible to call my attention. Each day, his goal has been the same- "get out of the hospital."

But for some reason, he has remained in the hospital, becoming a resident of the unit.

Similar to how the greeters have become a part of the unit, they have become a part of my world.

***
At 9:30 AM every day, the chairs and sofas are arranged in a circle. Patients emerge from their rooms to congregate for the community meeting. Some patients stroll in after being prompted, some wander after being waken up, while other patients are already seated from the previous stretch session. The providers join the meeting later.

It's the same process every morning. Go around the circle, introduce yourself, tell everyone how you are doing, and state a goal for the day.

Today, many patients were feeling good. A common goal was to get out of the hospital, or go to the patio. One patient declared he wanted "to take over the world." Another patient, said, "F*%@ you all. I do not belong here."

It's also a time to bring up community issues, read the unit rules, and orient new patients to the staff and daily schedule. Today, occupational therapy had scheduled an art exercise and a movie matinee for the afternoon. Patients would be able to select the movie to be played.

You can learn from the community meeting. You get a sense of the patient's mood, their goals, and how they interact in a group setting. I could see Lena pouting at me from the corner of the room. Joe arrived late and slowly made his way to his usual seat. Today his goal, like every other day, is the same. "I want to get out of the hospital," he said in the few English words he knows.

"If the weather holds up, we'll go out to the patio. You need a patio pass to go. To get a pass, participate in your care and go to groups," said the occupational therapist.

To conclude the community meeting, one of the patients picked an affirmation from the "I Can Can." Today, the laminated card echoed Aristotle's words. "In all things of nature there is something of the marvelous."

"You can marvel at your recovery. That concludes community meeting. Now, go have a good day." the group leader said.

***
The patio is in the center of the seventh floor surrounded by the units. You have to use your key to enter and leave the patio. The square area has a basketball hoop and a seating area made of metallic-shaped blue sofas. There is a painting on concrete the wall of a nature scene. The patio can be viewed through the windows from inside the unit.

Lena and Joe had both earned patio passes and were outside in the patio. Everyone was standing in a circle completing a series of stretches. I joined the circle, feeling weird standing still. I was reminded of the childhood game, Simon Says, where you imitate the action that someone tells you to do. During the exercise, we each went around the circle and choose a stretch and we all followed. I was amused, when the taller more fit patient, had the patients run in place; many of the patients could not keep his pace. The more unsteady patient had us roll our heads. I choose the calf stretch, since my legs were tight from my morning run. Lena had us put our arms in the air and move side to side. She was uncoordinated and clapped afterwards.

She always know how to put a smile on my face.

It's an odd scene. A bunch of grown adults locked out, standing in a circle and performing stretching exercises. I could see the staff watching us from inside.
It's a strange feeling to be watched.

***
Although I did not directly take care of Lena and Joe, I feel as though I have come to know them vicariously through our daily interactions. They have been the constant during my time in the unit. My other patients have come and gone. But Lena and Joe have been in the unit on conservatorships, completely distanced from the outside world. The unit has transformed into their homes; they have outlived many previous residents and medical students.

They will repeat this same cycle when they are transferred to another facility during the remainder of their lives. I wonder what their lives were like before they were admitted to the unit.

Lena and Joe remind me about some of the greatest responsibilities we possess as physicians. We are charged with making decisions for our patients, who are gravely disabled, either because of medical or mental illness. Joe and Lena can not function in the world we live in; they would be unable to feed themselves, take their medications, communicate with others appropriately, pay their bills, ride the bus, and find their way around the city. They are severely impaired and vulnerable. We become their conservators, taking on a parental role in these patient's lives, figuring out what we view as being in the patient's best interests. And it comes down to one thing--institutionalization.

For these patients, I feel we are placed in a precarious position. We are limited by our lack of understanding of our patient's true wishes. They have no family and our patient's can not clearly communicate with us and they lack insight into their illness. We resort to using the medications in our tool box. And when the medicine fails, we have to move to the next step, placing our patients in a facility. It's a bitter bill we swallow when we have exhausted all of our placement options, even when our patients do not want to go. What other options do we have?

It's a daily reality we confront on the unit. Today it's Lena and Joe. Tomorrow a new patient will arrive in the unit with a similar story (and probably the same outcome). And the cycle continues.
***

On my last day, Joe and Lena were in the community room watching Court TV. They were there greeting me, reminders of the world I was about to leave and the reality of the inpatient unit. As I walked out of the unit for the last time, I marveled at the lives of my greeters.

*Names have been changed to protect patient identities*

Trapped

The pattern in the brown wooden floor is quite ironic. A small square is encompassed by another larger square, which is surrounded by another square. The pattern screams entrapment. It's an odd design choice for an inpatient psychiatric unit. Perhaps, it's just a mind game.

When I started my psychiatric rotation over three weeks ago, I instantly noted this pattern on the floor. I'm not sure why it called my attention. One of my colleagues elegantly pointed to a reason, drawing on Freudian themes.

"Perhaps, the pattern in the floor reflects you own internal preoccupation/conflict with being trapped on the unit," he said.

Quite an insightful comment not to far from the truth. Sometimes, you can feel trapped, even when you know you can leave.

***
The Seventh floor inpatient psychiatric unit at SF General Hospital is an interesting place. I'm situated in what used to be a themed women's unit. However, the themed units have disappeared due to budget cuts and the need to place acute patients in inpatient beds for stabilization.

The unit is set-up much like a traditional inpatient psychiatric hospital. There are individual units on the seventh floor with a central patio area. A key is required to enter and exit the unit to prevent any patients from AWOLing. A common room set up with chairs, tables, a TV and a piano, is located right next to the entrance. The Nurse station sits in the middle of two long pink hallways; one hallway for the male rooms and the other hallway for the female rooms. The charting room, where the physicians, nurses, and social workers congregate is just across the Nurse's station. The charting room door remains open during the day and patients pass by, sometimes demanding to see their physician or asking to be discharged, other times requesting for Ativan or food, or stopping to stare at you.



My experience on the unit has been a unique experience with it's share of ups and downs. In many ways, it's been a whirlwind learning experience that has made me reevaluate my emotional boundaries.
***

With inpatient psych, you bear witness to some of the most difficult patient situations you will see in medicine. You will see patients at the lowest points in their lives. You see the entire spectrum, everything from suicidal patients that attempted to jump off the Golden Gate Bridge to manic patients who in a fit of rage threatened to hurt others to psychotic patients who believe they are emperors of the world to violent patients with personality disorders to psychotic patients who hear the voice of God telling them to hurt others to delusional patients who believe they have HIV despite negative testing.

While on the unit, I've had patients yell at me, flirt with me, lie to me, cry in front of me, refuse to speak with me, talk only to me, write notes to me, or stare at me.

Many of our patients are admitted from the Psychiatric Emergency Services, where they are initially evaluated. Typically, patients can self-present, be transferred from the medical emergency ER, or brought in by the police or other providers. In the process, some patients are placed on a 5150 legal hold for either danger to self, danger to others, or grave disability.

The stories of our patients are heart-wrenching; you see the frailty of the human mind due to mental illness. You also see the darkest shades of human nature and behavior. Common themes thread through many of their stories-- histories of substance dependence, violence, abuse, neglect, lower socioeconomic status, marginal housing--just a few of the common themes that pervade the lives of our patients.

Mental illness deteriorates the lives of our patients. Some patients are just driven by basic instincts to survive, while other patients are completely out of touch with reality. Sadly, many of our patients with debilitating mental illnesses crumble in society; the hospital becomes a revolving door and their only security net. We become responsible for these patients.

Amidst the emotional turmoil, you (the provider) must take a history and determine the next steps. You are called to "stabilize" these patients and develop an appropriate discharge plan. For patients placed on a hold, we are given a 72-hour window to act (unless we obtain a 5250 hold, which extends th hold to 14 days). At any point, a patient can contest their hold in front a judge. Until the patient demonstrates insight into their condition, you make decisions on their behalf, quite a responsibility.

At times, you find yourself getting devoured by patients who seek your undivided attention so they can yell at you for hospitalizing them.

Other times, you struggle to process the gravity of your patient's words, trying to assess if they actually plan to hurt others, or if they are truly that ruthless. You find yourself losing your patience, having to remember to monitor your countertransference.

At times, you are simply overwhelmed by a patient's history of abuse and the tragedy of their life that you find yourself searching for the empathetic words to say (those PEARLS we were taught in first year), knowing well that what you say can not change or offset the damage. You remain silent, as your patient cries.

You either become skeptical and jaded, or you become emotionally overwhelmed and confused as you process the unimaginable. The constant exposure chips away at you, testing your boundaries and patience. Despite the challenges, you must find a way to remain dedicated to helping your patients.

All day long, you hear similar strokes of the same song. Through it all, you try not to let your own voice be silenced by the noises of the unit, so you can find your escape.

My First Half Marathon

After many years of contemplating and many years of running, I finally did it; I ran my first half marathon (13.1 miles) and finished within my time goal.

It was a perfect running day. "The weather was selected specifically for this race," the commentator joked during the finish.

After many months of rain and cloudy weather, the sun shined. There was a light breeze. We were able to fully enjoy the outdoors as we traversed the path through the Golden Gate Park past the Pan Handle back to park all the way down to the great highway right along the Pacific Ocean. The views were breathtaking.



10,000 runners registered for the Kaiser Half Marathon and 5K. And the masses could be visible at the start line, jumping in place, stretching, conversing, or standing still. Proceeds from the race benefit organizations such as the Koret Family House, The Harbor Light Center for Alcoholism and Drug Abuse, and Support for Families of Children with Disabilities.

Although I've run these paths before, today it was special, because I went non-stop and was in the company of many other runners. The feeling is electrifying to be in the pack, and you are pushed to go faster and farther.

In many ways, running has been therapeutic over the last three years of medical school, getting me through the stress of exams, anxiety of evaluations, and uncertainty of third year. I felt so lucky to have this opportunity, counting my blessings for the strength, health, and determination to make it to the finish line.

My calves were a little tender at the finish line. But after some hydration and a hot long shower, the soreness has improved and I can say I feel good. We'll see if I can take the next step and train for a full marathon in July.

For now, I'm going to savor the feeling of completing my first half marathon.

Open Head

"I left my heart in San Francisco." In the background, the muffled voice of Tony Bennett coming from the old AM/FM radio was barely audible over the drilling. With the hand-held drill, the neurosurgeon slowly moved along the purple line he had drawn on the skull of the patient. As he moved his drill, the bone slowly detached from the skull. White bone powder sprinkled all over the field.

"Irrigate!" he said.

With a green dropper that fit in my palm, I carefully squeezed the bulb and a couple of drops coated the cracked skull, caking the bone dust. I squeezed some more not sure how much pressure to apply. It was not coming out fast enough. The surgeon grabbed the dropper from my hand and proceeded to squeeze all the clear fluid out.

"I never liked this song, until I moved to San Francisco," the neurosurgeon said to scrub tech as he continued to irrigate.

He said little to me except instructing me to irrigate. He spoke in a low voice and made general conversation with the operating room staff about everything from football to abstract art to the Grammy awards to weekend plans.

He had dark wavy hair streaked with some specs of silver and wore glasses that framed his dark eyes. He would squint periodically and the fine wrinkles around his eyes became more prominent. He was a couple of inches taller than me with a medium build. Originnaly from the East Coast, he had moved to SF and was completing his neurosurgery training, which probably made him thirty-something years old. He spent most of his hours in the hospital, either operating or attending to patients in the ward or ICU.

The circular bone flap eventually became detached and the neurosurgeon (with some pressure) pulled off the bone piece.

"These are good drills for these kinds of case. But probably would not be fast enough during the emergency craniotomies," he said to the company rep.

Prior to drilling he had started by making a horseshoe incision along the hair line just above the ear, he reflected the skin back. The skin was tethered with white plastic clips.

With the bone removed, a glistening layer of tissue could be seen. This was the dura mater, also known as the "hard mother," a protective covering of meninges that sits below the skull and over the brain.

To get to the tumor, the neurosurgeon carefully cut along the layer of exposed dura until he uncovered the maze-like structure below--the brain.

This was my first time seeing open brain surgery. As part of our neurology rotation, we have the opportunity to observe neurosurgery cases. On my last day of neurology, I was able to finally see the brain, a subject we had spoken endlessly about during our case discussions and rounds.

Open brain surgery is quite something.



***
The last time I had seen a brain was during anatomy of my first year. We had sawed the skull and pulled out the brain after identifying many anatomic landmarks, which have escaped my memory. With the brain outside the head, we used a kitchen knife to slice the brain in horizontal planes to see the cross sectional anatomy. The light brown slices were uneven and moist to the touch, having been soaked in tissue-preserving chemicals.

***

Our patient, a seventy-three year-old gentlemen had presented with acute-onset seizures a couple days prior to his surgery. After the seizure, he had imaging studies, including a CT and MRI, which demonstrated that he had a large mass in his left hemisphere with radiographic characteristics suspicious for a meningioma.

A meningioma is a tumor of the meninges (the layers covering the brain) arising from the cells the produce the cerebrospinal fluid, liquid that coats the brain and meninges. Over 90% of cases are benign and have a low recurrence after surgical resection. Oftentimes you'll hear the neurosurgeons say that "if you have a brain tumor, you want to it be a meningioma." The prognosis is usually pretty good.

Before the case began, we closely examined his MRI scans to strategize the surgical approach. The bright circular mass was penetrating at least 2-3 cm into the brain parenchyma, which means resection is a slow and meticulous process.

Grossly, the tumor was visible on the exposed portion of brain. The oval, light purple mass looked like it could be scraped off the brain. But the mass went deeper than the surface.

The neurosurgeon, examined the mass with fine instruments and started dissecting the tumor with a fine scissor, periodically cauterizing. I was surprised when he turned to me and asked, "why do I start dissecting here?"

As he asked the question, he pointed to nondescript area of the brain away from the midline. Although the terrain of the sulci and gyri of the brain looks identical all around, you always remember that there are some regions that are sacred.

"To avoid the motor and language areas." I said. (The most obvious answer I could conjure)

Satisfied with my answer, he continued to dissect away silently. He looked through a microscope to magnify the margins of the tumor.

As I stood there looking into the scope, I continued to wonder how deep he would dissect. He was guided by the MRI because the tumor tissue is almost indistinguishable from the brain parenchyma. But I still wonder how one really knows. That's probably what distinguishes "us" from "them" (the neurosurgeons), who from experience just know.

Whatever the approach-- it was slow, deliberate and meticulous. Every motion is precise. He would snip and pause, repositioning his pick-ups. He would take a closer look and then snip some more with a pair of fine scissors. And would repeat the same steps, slowly resecting the mass.

I stood there watching the fine cutting, in awe of the sight in front of me. With an open skull, we had a window to our patient's brain and we were cutting this man's tumor out slowly.

It was only hour two of the operation and there was long way to go to fully resect the tumor...

The Last Breaths

It had been raining all week. The soggy gray weather had shrouded the city in a wet blanket of haze. Today, the sun was actually shining. I got a glimpse of a crisp San Francisco morning through the window of Mr. W’s new room.

Earlier that morning, I had walked into his old room. As I made my way to this room, half-stumbling through early morning sleepiness, I looked in the corner, where he usually lay. I was surprised to find an empty bed covered in freshly laundered white sheets. I searched the room, identifying the three other patients, only to realize Mr. W was not in the room.

I turned my attention to the sitter, who was staring at me from behind a computer in the middle of the room.

“They moved Mr. W’s body to Room 10,” she said.
***

Mr. W had died earlier that morning. I still hear the words echoing in my head as I sat and listened to our resident dictate the discharge/death note, “he expired at 5:50 AM.”

I had been following Mr. W through the later course of his illness during the last week. I never directly spoke to him; I made use of translator phone, which connected me remotely to an interpreter, who echoed my questions in Cantonese.

This 84 year-old man had been admitted to the Neurology service two weeks ago after he had been found unresponsive in his bathroom. The CT would later show that he had suffered a right-sided stroke after a major artery (middle cerebral artery) had been acutely occluded. As a result of the ischemia and subsequent brain damage, he was left with a left-sided paralysis and facial droop; he neglected his left side and preferred to look at his right.

Even before his stroke, his days had been numbered. He had advanced lung cancer with metastasis to his liver and bones.

He was initially observed in the ICU and later transferred to our ward team. When he first came out of the ICU, he was coherent, answering our questions, verbalizing his complaints and actively trying to move his flaccid left arm, using his good arm.
Initially, he was set on participating in acute rehab, despite the intensity. His family remained committed to recovery and even interested in continuing his chemotherapy for his lung cancer. But within a couple of days, his health started to decline.
***

Mr. W finally got his own room with a window that overlooked a busy SF highway. As the cars buzzed by, the stillness in Mr. W’s room could be palpated. A big red sign that said “Caution, Fall Risk” hung over his bed. I could not help but note the irony in a note that hung over the body of a dead man.

His mouth was still open, as though he was gasping for air. His two large brown front teeth and a row of overcrowded bottom teeth were visible. His face had a yellow hue and his eyes were closed. His frail body looked stiff. A name tag was tied around his big right toe and a large white bag was folded below his feet.
I walked up to his body. I lay my hand on his right side; his skin was still moist and slightly warm. I stood there alone, lamenting his death—wondering about how he suffered while he gasped for his last breaths. I closed my eyes and prayed he would find the peace he had been denied during the last days of his life. And I said good bye.
***

In the week that I took care of Mr. W, I had become familiar with his neurologic exam. He could not move the left side of his body and did not even withdraw from painful stimuli. He had a left facial droop and looked to the right. Initially, he was alert and oriented and would follow commands.

Sadly, during the last week of his life, I watched him decline, becoming more delirious and agitated. He became hypoxic and required more oxygen to be comfortable. Because he was at risk for aspirating the food he ingested, he required a feeding tube, which was placed in his nose. He had to be restrained because he tried to pull out the plastic tube. And he was flailing his right leg and tugging at his restraints to be freed. A shrill moan was audible from the hallway anytime you passed by his room.
He was miserable.

Each morning, I could hear him groaning. And each day his mental status declined. He went from verbalizing his complaints, to responding to yes/no questions, to becoming completely unresponsive and only communicating with mumbling. The translator could not make out his responses. He needed a diaper because of his incontinence and would swat me when I examined him.

He lay in a room surrounded by three other patients; a sitter sat in the middle of the room. When I watched him flailing his leg and restrained arm, which was contained in a large white mitten tied to the bed, I felt pity for this man. It was undignified to keep him tied down during the last days of life. He was suffering and a part of me wanted to tell his family, he was better off at home surrounded by his loved ones instead of being surrounded by strangers in an impersonal hospital room tied down.

But his family could not make the decision we (the neurologists) felt was in the best interests of the patient.
***


Doctors are not very good at prognosticating, especially when it comes to predicting someone’s life expectancy. Thus, lifespan is presented in ranges—days to weeks, weeks to months, and months to years.

We gave Mr. W weeks to live. His death did not come as a total surprise. The writing was on the wall from the day he came out of the ICU. We (the neurologists) could all could see it, but the family did not. He was not a good candidate for acute rehab due to his weakness. And when his health started to decline, we all knew he would be better served by comfort measures.

Despite the inevitable, we were not able to communicate our expectations to the daughter early in the course of his hospitalization. The daughter, who was charged with making medical decisions, initially insisted on acute rehab and chemotherapy because she did not realize his days were numbered.

We did not discuss goals of care until after Mr. W had become restrained and started to decompensate. It was only after he had repeatedly expressed- “please let me die. Please let me die,” that we consulted the palliative care service.

Even when we presented the options relating to removing life-sustaining measures to the daughter, she could not make the decision we all wanted her to make—she could not withdraw care. And wanted to suspend making a decision.
***

At the end of life, we place a large burden on the families of our patients. We look to the families to make decisions with limited information because we expect the families to know what the patient would have wanted. As easy as it is for us to make our recommendations, we do not have to live with the consequences of such decisions. I can only imagine the anxiety Mr. W’s daughter faced, when she had to make the final decision about Mr. W’s end of life care.

We ended up agreeing on comfort measures, such as Haldol to help the agitation and morphine for pain. But his feeding tube remained in place and he still had to be restrained. He continued to groan.

In the end, Mr. W died of respiratory compromise, gasping for air.
***

When I left the hospital, I felt a heaviness inside me, feelings of guilt and sadness. I wondered what I could have done differently to help Mr. W in the last days of life. I respect the family’s wishes and only wish we could have included Mr. W in the discussion earlier to better understand what his wishes were. I kept replaying the conversations we should have had with the patient and family.

But in the end, I realized that we sometimes just need to accept death as it comes, even if it does not meet our criteria for a dignified/comfortable death. These are the things we do not control.

As I drove away, the rain started again.
***

Speechless

I'm probably one of those people, who can always find something to say. For some reason, I was searching tonight to find words to express gratitude. I had to improvise...a skill I have learned from being a third year medical student.

There is something to be said about accepting an award. It's harder than they make it out to be on the Academy Awards. It can be hard to collect your thoughts, when you are overcome with excitement and are faced with an audience looking to you. It puts new meaning to the old saying "all eyes on you."



Tonight I felt extremely humbled and moved, when I was named as the recipient of the David Perlman Award for Excellence in Journalism presented by the San Francisco Medical Society during the Annual Dinner for my contributions to San Francisco Medicine Journal. I am extremely grateful for this award and thank the Society immensely for the recognition.

For a writer, one of the biggest honors is to be recognized for your writing. In many ways, it reinforces your desire to write and makes you realize that there is someone out there actually reading and listening to your story.

It gives your writing purpose; it gives you purpose as a writer.

More than anything else, it is an honor, in itself, to share my stories and reflections with an audience. It brings my experiences to life.

Tonight, I count my blessings and also thank (you) the reader for being there to hear my story. I am inspired to continue writing. We'll see where this takes me.
Stay tuned...

Following the Limbic System

"The problem is that humans are driven by their limbic systems. As long as things are pleasurable, they will continue to do things even if they are harmful."

The words from our neurologist.

***
Another patient had been found down after using excessive amounts of cocaine; she had a history of previous neurologic insults and intercerebral bleeds. The CT scan was consistent with an intercerebral hemorrhage in both her hemispheres.

The patient was admitted for emergency neurosurgery to evacuate the bleed and to decrease the increased intracranial pressure, an operation involving removal of part of her skull. She then went directly to the ICU for very close monitoring.

The prognosis was unclear; she was comatose and her neurologic exam did not change--her eyes remained closed and she barely responded to painful stimuli. She had seizures continuously and no matter how high we titrated the anti-epileptic medications, her seizures remained.

Her pressures started to drop. And it was decided that her prognosis was poor in the setting of her decompensation. Life-sustaining support was withdrawn and the patient expired.

She died alone in the noisy ICU surrounded by machines.

***
In many ways, my neurology rotation has been sobering. Each day, I am reminded about the devastating impact of neurologic injuries on the lives of our patients. It's dramatic; one day the patient is normal and the next day everything changes.

I see it in the faces of our patients with facial droop, I hear it in the voices of our patients with dysarthric speech, I feel it in the muscles of our patients with hemiparesis, and I sense it in the frustration of our patients with aphasia who communicate with a word salad.

You see it too in the eyes of family members, who look to you for hope that their loved ones will improve, when you know the prognosis is poor.

You localize the lesion and can explain the pathology, but sometimes have very little to offer for treatment.

***

"Will my husband every be normal again? Will he be able to walk again?," my patient's wife asked.

My patient could not move his entire right side of his body. He had bled into his left hemisphere.

The answer to her question is the same answer we give to many families.

"We do not know. We will just have to wait and see." I said.

***
I'm half-way through my Neurology rotation. I returned to SF General Hospital for this four week rotation. In taking care of patients with neurologic conditions, our focus has been on localization of lesions. Using the patient history and neurologic exam, you learn how to correlate symptoms with neuroanatomy. It's a constant puzzle; sometimes it's textbook, while other times, you struggle to put the pieces together.

More often than not, the neurologic symptoms are unusual and present in many ways depending on the location and severity of the injury. The exam is the key to help localized and clench the diagnosis before confirming with neuroimaging.

So far, I have seen a myriad of neurologic conditions--everything from ischemic and hemorrhagic strokes to headaches to intercerebral bleeds to degenerative diseases to CNS infections to Parkinson's Disease to neuropathic pain to seizures to CNS lymphoma, as well as the unclear CNS diagnoses. One of my patients remains a diagnostic dilemma. We are still trying to find an explanation about why he can't walk and why his face is weak.

***
Having returned to SF General Hospital, I am reminded about the harsh reality many of our patients face. Whether dealing with being uninsured, substance abuse, HIV, homelessness, social factors- you quickly learn about the intersections of the medical and social history, since both topics go hand in hand. Prevention sometimes is an afterthought in patients, who have had uncontrolled hypertension because they could not afford the anti-hypertensive medications or the doctor visits. It's too late, once they have a stroke.

The damage has been done. Sadly, it's irreversible.

***