Becoming the Right Kind of Doctor
Even though my residency training was only three years of my life, I felt like I had aged thirty years by the time I was done. The biggest reason was the immense pressure put on me to absorb an overwhelming volume of knowledge and skills in rapid sequence while not killing anyone in the process. Think Neo from the Matrix, when Morpheus shows up at his door telling him it’s his responsibility to save the world, and then helps him download a crap ton of information on how to fly helicopters, dodge bullets and master kung-fu. Another reason was just the constant sleep deprivation that should honestly be illegal to put anyone through, let alone physicians-in-training who need to make high-stakes decisions. We averaged 80-hour-work weeks, usually with at least one 30-hour overnight shift per week in the hospital. Those long shifts were the most brutal, often leaving me feeling like I had just been hit by a train. After one of my shifts, I got into the elevator to head down to the parking lot, where I was joined by one of my co-residents and one of my pulmonary/critical care attendings. While the elevator was going down, my co-resident asked me if I was post-call, making me fully aware of how disheveled and dejected I must have seemed to him.
“Do I look like I’m post-call?” I asked him.
Our attending quickly stepped in, “Don’t answer her. You’ll be in trouble no matter how you answer that question”
But despite the grueling process of doing these weekly overnight shifts, these were the nights when I could actually feel myself transforming into a real doctor. There was one call night in particular I remember very clearly. I was called to the bedside for a medical rapid response, a situation when one of the patients in the hospital wards is crashing. As soon as I saw the patient, I knew what needed to happen even before the nurse gave report. He was an elderly man, his chest heaving up and down as he struggled to draw breath, his heart rate shooting through the roof, his oxygen levels tanking, his eyes losing focus on the people around him. And as in most rapid response scenarios, the room was filled with what felt like hundreds of people: nurses, residents, pharmacists, respiratory therapists, secretaries, other patients – half of them not really having any business of being there. I asked the respiratory therapist to get a ventilator, then found the busiest looking nurse (because if you want something done quickly and competently, you always look for the busiest person in the room) to page anesthesiology because this patient was going to need to be intubated. I tried to talk to the patient, but he could only respond with a look of intense fear. I tried Spanish in case he didn’t speak English, but same response. I prepared to help deliver oxygen through a bag valve mask, while simultaneously telling my nurse and intern which labs were needed (nurse needed to know to draw blood, intern needed to know to place orders), while also coordinating with the radiology tech that we were not ready for his x-ray and to please wait outside. Amongst all of this chaos in the space of a modestly-sized closet, there was one person in particular who caught my attention as just being in the way. He was not medical personnel, he was the patient’s son. He stood right by the patient’s head, which was blocking a lot of the team’s ability to perform essential life-saving procedures, and he was speaking very loudly to his father, often requiring us to repeat instructions to each other. I firmly told him that he needed to wait outside, and that I would be out to talk to him once we’ve stabilized his father. He refused. “I need to let him know what is happening,” he said to me. I reassured him that what he needs right now is for us to save his life, and he could not stay in this room while we were doing that. He again refused. So I had my nurses escort him out. In the heat of that moment, I was livid. Could he not see what we were trying to do here? The life of this patient, his father, was in our hands. In the end, the anesthesiologist arrived, we sedated and intubated the patient, connected the ventilator, allowed the radiology tech to shoot his x-ray (which was almost completely “whited out” consistent with acute respiratory distress syndrome), then transferred him to the ICU. After debriefing with my intern, I learned that the patient was visiting his son from Mexico for the holidays, when he developed some difficulty breathing. Not having any insurance in the US, he was brought to our hospital, where he was admitted for treatment of a pneumonia. That night was his first night at the hospital, and he had decompensated very quickly. After confirming the plan of care with the team, I went to the patient’s room. His vitals had stabilized now that he was hooked up to the life-support machine, and he appeared comfortable, despite the breathing tube sticking out of his mouth, and the myriad of electrodes and IV lines emerging from under his gown. I then saw his son sitting on the opposite of the patient’s bed, looking like he had consumed a thousand gallons of battery acid. I tried to introduce myself, but he interrupted me.
“Why did you do this?” he accosted me.
I started to explain that his father was in severe respiratory distress and we had very little time to turn things around so I did not have a chance to ask him for permission, but he vehemently shook his head, repeating the word “no” to me. It was clear that I would get nowhere from continuing to talk to him, so I left the room. If I was mad at the guy before, I was hulking out about him now. He was just an ignorant jerk who thought he knew better than me because of my age, race, stature and sex. I had done my job. His dad was alive. I didn’t need to waste any more time trying to justify my actions to him.
Flash forward to almost exactly one year later. I was on-call again, this time for the cardiac intensive care team. I was paged to the Emergency Room for a code STEMI – a patient confirmed of having a massive heart attack that would require immediate revascularization with a cardiac cath procedure. My fellow (one step above a resident, but not quite an attending) and attending were en route to the hospital. My intern and I were the first from our team on the scene. The most recent EKG was thrusted into my hands, and the ER resident was already giving me a list of the patient’s medical problems, his vitals and troponin levels. Similar to a rapid response, the scene was utter chaos. Nurses, EMTs, pharmacists, physicians flurried from one corner to the next, every single machine beeping its own tune, papers and other medical equipment scattered all across the floor. And then the patient sat in the middle of the room, not a single person paying attention to him. He had the same look of intense fear that my respiratory distress patient from Mexico had. But I didn’t miss it this time. This time, I responded to what this patient needed – to be treated like a human being and not just a set of statistics. I walked over to his bedside and introduced myself. He nodded to show he could understand me. I asked him if he knew what was happening. He shook his head. I explained that his tests were concerning for a massive blockage in his heart, and everyone in the room was working really hard to stabilize his heart until the cardiologist arrived and could reverse that blockage. It would help him feel better and will save his life.
“Am I gonna die?” He looked up at me through his tired, brown eyes.
“We’re not going to let that happen”
He took my hand and thanked me. Then I could see the fear start to disappear from his face. Did I know for certain that he wasn’t going to die that night? No, not really. But what he needed was not a statistics lesson on what his chances for survival were in that moment. What he needed was to know that although he was in a very overwhelming and scary predicament, he was not alone. We might have just known each other for only 5 minutes, but I was going to be his advocate, and I was going to help him through one of the worst moments in his life. I confirmed that he had received the right medications, and then consented him for the cardiac cath procedure. My attending and fellow arrived shortly after, and transported him directly to the cardiac cath unit, where he had one stent placed in his left anterior descending artery (the “widow maker”). He had an uneventful recovery and spent 2 days in the hospital before he felt back to normal and then subsequently discharged home. No unexpected appearance of the Hulk in this story.
So what changed between the first and second scenario? The answer may surprise you, as it was the result of something that I never in a million years expected would happen to me-the birth and death of my first son.
On October 16 exactly three years ago, I was finally in my last year of residency, preparing to become the next chief resident (because I had nailed that interview I told you about in my last post). My partner and I had just purchased our first house, and we were pregnant with our first child. All of my prenatal visits confirmed that my pregnancy was progressing without any hitches, I had just gotten over the worst of morning sickness, and we just found out that we were having a boy. Everything was absolutely perfect – I was blissfully happy.
It was on this day that I went into pre-term labor. I started experiencing extreme cramping, which prompted us to go to the emergency room at 7 PM in the evening. We waited a few minutes before the OB physician-on-call walked into the room. She was all business, much like I used to be whenever I was on-call. She asked questions, instructed me to the right position so that she could examine me, glanced over at the vital signs before turning to the nurse and said “it’s bulging membranes, she’s going to deliver tonight.” In that moment, my world came crashing down all around me. Denial, confusion, grief, anger, determination, and fear – all of it swallowed me whole in one gulp. Through tears and trembling hands, I demanded to know what the next steps would be to save my baby. She just looked at me. And I knew what she saw. She saw a diagnosis. She saw numbers. She saw statistics. She didn’t see me. She didn’t see my husband. She didn’t see my unborn child who was fighting for his life. She explained that the baby was too young to attempt any life-saving measures. I was already too dilated to try to stop the contractions. There was nothing they could do but wait for the baby to come. And she told me all of this while standing at the foot of the bed, one step away from the door, waiting for the right moment to leave the room so she did not have to be in what was an uncomfortable situation for her, but the most unimaginable hell for us. My husband quickly asked for a second opinion. I went over a game plan with him while we were alone: we need to ask them to give me IV fluids to slow the contractions down, and steroids to help the baby’s lungs mature. We needed to have them hang me upside down if that’s what it took. The second doctor came in, and again stayed at the foot of the bed. She confirmed what the first doctor already told us, but then offered me something for the pain of the contractions, and a consultation with the neonatologist. I wish I could say that the neonatologist was any better. She arrived several hours into my labor, for which I only had morphine for pain control, and started with the fact that there was nothing they could do, and gave the same spiel of statistics and numbers, saying that infants born at less than 21 weeks gestation never survived. I told her that my son was 21 weeks and 6 days, and he always measured on the bigger side in my prenatal appointments. I wanted to know what my options were. She just smiled, and said she would ask the OB to take some measurements of the baby, but that it would unlikely change her recommendations. Then she left, probably to go back to sleep, since it was now close to midnight. In the end, I delivered our beautiful baby boy at 1:37 AM on October 17, 2017. He measured 1 lb, and 1 ft long, he had my nose and his dad’s chin. And he was perfect. They allowed us to spend the rest of the night with him before they took him away to the morgue. And then they discharged me. Despite just experiencing the absolute worst thing I have ever endured physically, mentally and emotionally, from their perspective, I no longer met any criteria to stay in the hospital so I was not their problem anymore.
Losing a child is so awful that the English language does not have a word for someone who’s gone through it. If you lose your spouse, you are a widow/er. If you lose your parents, you are an orphan. But if you lose a child, then what are you? You’ve not only lost a piece of yourself, you’ve lost your child’s future, and all of the hopes and dreams that goes along with it. It gets even more confusing when you’ve lost a child before the world has had a chance to meet them. Everyone has experienced some type of loss in their life, so they are able to relate and at the very least sympathize with people who have lost a loved one. But not everyone knows what it is like to lose a child, and not everyone knows what it’s like to carry life in your own body. The result is that so many well-meaning people who want to help fumble with what to say.
“Well, at least you can get pregnant” Yes, but my son’s life is not replaceable with another child’s life. If you lose your husband or your wife, imagine if someone told you “At least you get can married again.”
“It’s good that you never got to know him” But I did know him. I knew him from the moment I found out that I was going to be his mother. I knew that he loved peanut butter and jelly sandwiches, I knew that he would teach my dog how to love children, and I knew that he was sweet and kind. I also held him in my arms the night that he died, and I had to say goodbye to him before I ever had a chance to say hello.
“You’ll make a great mother someday.” Just because my son is no longer here with me, doesn’t make me any less of a mother. In fact, I’ve experienced more about motherhood the night I gave birth to him than most mothers would ever experience their whole lives. I had to fight for my son’s life, and after he died, I had to fight for my son’s memory.
And then the one that I struggled with the most. “Everything happens for a reason.”
I heard that last phrase on repeat in the months following my son’s death, and still hear it from time to time when I share with people what we’ve been through. I know that it’s meant to provide some peace for me, that God has some higher plan for my son and my family, but the truth is, it only made me angrier. There is absolutely no reason for taking any child’s, but especially my son’s, life. You could have told me that my son’s death was necessary to end world-hunger and I would not have traded his life for it, never without his consent. But after three years, I learned this truth: that although I will never know why my son was taken from me so early in his life, it happened and I cannot change that. I may never find peace or solace over his death, and my heart will never fully heal to what it was before, but I can work to ensure that his life meant something. Through my actions, I can show the world my son’s kindness and give his life purpose.
In his short life, he was taught me more about love than anyone else ever could. I learned that to truly heal someone is to sit with them in their pain and sorrow. You can make their vitals and lab values look better with medications and procedures, but all the medical knowledge in the world isn’t going to help unless you treat them as a person, acknowledge their fears, and understand their values. I’ve spent so much time and energy in the months after my son’s death learning everything there was to know about pre-term labor. Medically speaking, the physicians who cared for me and my son had been right with their medical assessments. There wasn’t anything that they could have done differently to save my son’s life. But that doesn’t mean that they did their duty as physicians to care for me as their patient. They had failed, much like I had failed the night that my patient went into respiratory failure and I kicked his son out of the room because he was “getting in the way.” As my son’s death was approaching, I needed someone to be my advocate. I needed someone to show me compassion. I needed someone to honor my son’s life. Even if the overall outcome was the same, I might have left the hospital the following morning still completely heartbroken, but not bitterly traumatized. Every human deserves to be treated with respect and dignity, yet so often patients who are in the most vulnerable moments in their lives get treated like they are just a collection of medical diagnoses and lab values.
So when I returned to work, it was as if my son had unlocked this superpower inside of me to really see my patients’ disease processes in the context of who they were. Finding a new lung mass on a patient’s CT scan was no longer just a 15-minute conversation about the potential of cancer and the need to quit smoking. It was going to entail sitting with my patient, learning about their fears and concerns, understanding their values, and reassuring them that they will not be alone through the next steps. That’s what it means to truly heal someone, even if I ultimately can’t save their lives. That’s how I became the right kind of doctor. And I owe all of this to my beautiful and strong son, whose legacy will continue through my dedication to make a positive change on the way that we deliver healthcare and help our patients thrive in spite of their medical diagnoses and health ailments.
Epilogue: I could not end this post without sharing with everyone what happened to my first patient who was intubated and transferred to the ICU, because we all need more happy endings in life. The patient ended up recovering, but only after a two-month long hospital stay after he was disconnected from the ventilator. As luck would have it, when he was transferred out of the ICU, he was assigned to my team so I became the resident overseeing the rest of his medical care. Even after his respiratory failure had resolved, the patient had become severely debilitated from his prolonged hospitalization, so that he was not able to walk on his own. He no longer met criteria to be acutely hospitalized, but he also didn’t have insurance so was not able to go to an acute rehab facility. His only option was home physical therapy, with close outpatient follow up. He didn’t have a primary care physician in the States, so his son chose me as his interim doctor until he was strong enough to get on a plane to fly back home to Mexico. That ended up taking another month. Needless to say, I got to know him and his son very well, and had a second chance to repair the relationship that I had damaged from our first impression. We actually became good friends, so much so that on their last appointment with me before he was preparing to fly back home, they invited me to stay with them on their ranch if I was ever in the neighborhood (in Mexico). And I almost considered taking them up on it, until I watched the movie “Sicario” and then was like “then again, maybe not.”
In loving memory of my first born son. Thank you for the gift of your life and your love. We miss you every day. This post is dedicated to all of my sister-mothers and the children we lost. Thank you for inspiring me to have grace in the face of darkness. I am here because of you, and for that I love you all.
