Hospital | doc w/ Pen

February 27, 2018

The rime of the tired medical student

I recently finished the internal medicine rotation at medical school. Exhausting isn’t the word. How many hours of sleep you get hardly matters. Not when you consider all the listening, watching, walking, talking, typing, reading, and learning, all of it intense.

Most of my team’s patients were on the same floor, but a few were scattered elsewhere in the hospital. Our newly admitted patients, waiting to be brought to their rooms, were downstairs in the emergency department. Hospital elevators aren’t exactly known for their speed, leaving me all too much time to ponder life and death (literally) in the elevator banks.

It was then that I started to notice something: beds. Empty hospital beds that is, sometimes with sheets on them, pushed into corners, or against the walls. They seemed to me everywhere. Not in the way, not obstructing anything, but a constant presence, tucked away here and there.

In my weary state, I began looking at them with envy – especially the ones with a set of folded sheets lying on top.

“If only I could hop up and take a quick nap,” I thought to myself, and again, and again.

As the thought cycled through my mind, a line of poetry was born, inspired directly by Samuel Taylor Coleridge’s 19th-century “The Rime of the Ancient Mariner.” Coleridge was writing about deprivation of another sort – thirst. Here the most famous stanza from his poem:

Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.

That’s exactly how I felt: frustrated by the forbidden ubiquity of beds, and sleep. So as I stood waiting next to the latest set of tempting sheets, in a state of desperate fatigue, I took to whispering the following words under my breath, my modernized incarnation of Coleridge’s legendary verse:

Beds, beds, every where,
And not a place to sleep.

As I did this, I both laughed and sighed inside. I’d then hear the “ding” of the arriving elevator, step into the crowded car, and head to my next destination, thoughts of beds and sleep trailing behind me.

Note: The original version of this essay appeared on the online magazine “The American.” You can read it here.

February 9, 2018

My post-medicine to-do list

While on my internal medicine rotation, I’ve done lots of steps and stairs, as my iPhone attests. But when the clerkship ends, I need to get back into a regular gym routine.

As I write this, I’m almost done with my internal medicine clerkship. Just 12 hours to go. Wednesday was my last day in the hospital. Thursday I crammed for my exams. Today I plow through a 110-question multiple choice test, and a 2-hour EKG-reading test.

It’s been an exhilarating, and exhausting, eight weeks. I’ve taken more ownership of my patients than in any other clerkship. I’ve gotten to know them better, and been more intimately involved in their care. All of that has been immensely rewarding. I’ve truly felt like part of the team, like I’m contributing in a meaningful way. It has also been devastating, for example when a patient took an unexpected turn for the worse, a turn from which they were not expected to recover.

The work schedule has been intense too. Monday through Friday were generally 12-hour days, counting both in-hospital time and time I spent chart-reviewing my patients at home in the morning. Saturday, we generally were let go a couple of hours early. Sunday was my day off. But not really. It was really my day to catch up on studying. Because when I got home Monday through Saturday, it was hard to bring myself to do more than 10 (maybe 20) practice questions before my mind shut down. Forget trying to read or memorize anything. So Sunday was my day to study. Doing “life stuff” got put on the back burner. “Survival” was my mantra.

It’s been too long since I’ve visited the Tiffany windows at The Met.

That means that this coming weekend, I have a lot of catching up to do. It won’t all happen in a day. Thankfully, next up is my four-month research block. This will be plenty of work too, but won’t involve the same crazy schedule. So here are some items on my to-do list, in no particular order:

Spend time at places other than the hospital and my apartment. I’m looking forward to seeing the sun (other than through a window), and visiting some of my favorite NYC haunts (like The Met), as well as exploring some new ones (like the 9/11 Memorial).

Spend time with my friends and family. I’ve done very little of that recently, given my lack of time and energy post-work. It’s time to catch up, both in person with those who live in New York, and on the phone with those who live elsewhere. (You know who you are!)

For too long, my vacuum has sat abandoned in my closet.

Clean my apartment. I especially need to vacuum. Now that I have long hair, fallen strands have a tendency to collect in little clumps along my baseboards. Scooping up the biggest ones with my hands is really not cutting it.

Do laundry. I mean ALL of my clothes, and in actual washing machines, not just emergency items in my bathroom sink.

Do my dishes. Regularly. The other morning, I had to use a fork to stir the sugar and half and half into my coffee. Not ideal.

Eat better. I need to get back to cooking regularly, rather than slapping together a ham sandwich for dinner, or picking up unhealthy take-out. (E.g., no more orange chicken from Panda Express, which is directly on my way home from the hospital.)

Exercise. While working in the hospital, I run around a lot, from floor to floor, so get in quite a few steps and stairs. But I need to get back to a regular gym routine, and back to doing my mat Pilates.

Meditate. This is something I’ve wanted to try for years. Medical school is stressful, and I know residency will be too. I think meditation could help with that. Ironically, all the stress lately has prevented me from trying something that might reduce my stress. So as I head into a less stressful block of time, I want to establish the habit so it hopefully sticks when I really need it next. A friend of mine recommended a couple of apps to try, including the Headspace app pictured at left, so that seems like a good place to start.

On a side note about stress, I’ve had multiple residents tell me that they much prefer the stresses of residency to those of third year. In residency your day off is actually a day off; you don’t have to study. You’re also not worried about constantly being evaluated by everyone around you, which is one of the major pressures of these clinical rotations (and something I plan to write a separate post about). A classmate said that one resident told her: “My worst day as an intern was still better than my best day as a third-year medical student.” I’m not sure everyone feels the same, but at least some of the stresses of medical school (studying for exams in the evenings and on your day off; having to always be “on” since you’re always being evaluated) will dissipate. And, I’m sure, be replaced with other ones.

Be creative. Using my hands to make things is such a rewarding outlet for me. I simply haven’t had the time or energy for it lately. I’ve missed it.

I can’t wait to make more crane cards …

… and more beaded spoons.

One of my new favorite songs, Snake River Conspiracy’s cover of The Cure’s “Lovesong.”

Write. I have a long list of essay ideas that I simply haven’t had time or energy to tackle. Several of them relate to things that have happened during my medicine clerkship. I look forward to sharing those experiences with all of you in the coming days and weeks, as I process all that’s happened lately.

Find new music. Over winter break, my youngest sister, Joy, convinced me to join Spotify. I’ve managed (barely) to keep up with the “Discover Weekly” playlist that Spotify sends me every Sunday night, saving the songs I like to a new playlist I aptly call “New discoveries to explore!” I’d like to delve into that list (which currently has 119 songs on it) and to investigate some of those artists and their albums more fully.

Watch TV. I don’t normally do much of this to begin with, but I haven’t even turned on my set in weeks. It would be really nice to relax on my couch in front of a good movie or TV show episode without feeling guilty.

My purchases at City Hops. Several of the beers are local, brewed here in NY state — pretty cool.

Learn about beer. And drink it, of course. For the longest time, I thought beer was simply gross. The closest I got was Mike’s Hard Lemonade. I stuck to wine, or my favorite, gin & tonic. Then I dated someone for a little while who enjoyed beer, so I would try what he bought. Turns out it wasn’t so bad, though still not my choice of adult beverage. Then my sister started bringing craft beers to family gatherings, and not only did I tolerate them, I actually liked them. It was a revelation. I’m particularly partial to IPAs, of all things. But the selection at the grocery store down the street is atrocious, and a six-pack costs about $5 more than it should. There’s a place called City Hops on 2nd Avenue not far from me. I’ve walked by it dozens of times, and often thought about going it. Yesterday I took a study break and did just that, and about $40 later, was the proud owner of seven different craft IPAs. I’m definitely drinking one tonight night to celebrate making it through medicine intact.

Pamper my plants. Many months ago, I bought some lovely houseplants from Home Depot, and some lovely plant stands online. The idea was to infuse a little bit of “green” in my environment as I live amid the concrete jungle. Unfortunately, I dramatically overestimated the amount of natural light that would be cast onto the corners where I put these plant stands. My poor plants became bedraggled over time. Luckily, they quickly perked up when I put them on my kitchen windowsill. But I can’t really enjoy them there. So I want to buy and install some grow lights, so I can put my plants back on their stands, where I can see them better, and enjoy them more.

My plants are fine on my windowsill, but once I get some grow lights I can put them on my plant stands (which are in places that don’t get much natural light, but are where I can see my greenery better).

The home page for FREIDA, the American Medical Association’s online gateway to exploring residency programs … *gulp*

Think more about my future. Before I know it, September will roll around, and I’ll be submitting my residency application. That means I need to figure out where I’m applying. And THAT means I need to do some leg work (well, more like “finger work” as I explore residency programs on the Internet). This is a little terrifying, as you might imagine. It’s also thrilling.

Clearly, I have a lot to catch up on. But it’s good stuff, fun stuff, stuff that’s rewarding in a different way than patient care.

Now, in anticipation of this upcoming reprieve, I wonder where my TV remote has gotten to …

7 Comments

November 8, 2016

Learning EMR: an important attitude adjustment

Learning how to use the hospital's electronic medical record system via a series of videos and short practice sessions is not my idea of fun. But changing my attitude about the experience helped me see it differently.

Learning how to use the hospital’s electronic medical records system via a series of videos and short practice sessions is not my idea of fun. But changing my attitude about the experience helped me see it differently.

Yesterday, I spent a good hour and a half staring at my computer screen, watching modules on how to use the hospital’s electronic medical records system. I don’t think I’m even halfway done. And after the modules, I have a classroom session to attend too. This was tedious and aggravating, as you can imagine. Not to mention overwhelming — so many menu bars, buttons, and icons.

As I watched one of the early videos, I thought to myself: “I won’t learn the system by watching videos. I’ll learn it by doing it.” And then it hit me. As grating as this task is, what it represents — my transition from classroom to hospital — is something to celebrate. Soon I will be using this system to write notes and enter orders. How far I’ve come in such a short time!

That thought didn’t make the videos any more interesting, per se. But it altered my attitude. And that made a world of difference. While the short practice exercises I was doing alongside the videos wouldn’t be my definitive learning experience, I began to see them as an important first introduction to a foreign system.

Always a good reminder: attitude matters. In everything.

1 Comment

August 14, 2016

One who listens

In addition to this blog, I also write a monthly column called Bio-Lingual for the online magazine The American In Italia. I don’t usually cross-post. But the piece that was just published there is about my time in Uganda so I wanted to share it here, with those who are following my experiences. Here is the link:

One who listens

A brief preview, in case you’re deciding whether to click on the link: In the essay, I explore the kind of doctor I want to be. Being in Uganda for two weeks helped me better understand how I want to treat patients.

August 11, 2016

Does anybody really know what time it is?

The men’s ward at Naggalama Hospital. I would sometimes see Joshua*, a patient we cared for there, sitting in a wheelchair outside in the shade.

“Time” is perceived differently in Uganda than in the United States, at least by some people. In the United States, so often we’re tied to our watches, computers, and cell phones — all of which help us get where we need to be right on time. In Uganda, time is a more fluid concept. Many people think of their lives in terms of events and stories — not in terms of hours or days. Kenny, the Ugandan man who was assisting the documentary film crew working with us, explained this to us midway through our two-week time doing medical work in rural Uganda. After that explanation, so many mysterious things suddenly made sense. We asked patients many questions that relied on our American concept of time. Questions like this: “When you took the morphine, how long until the pain came back?” Some patients struggled with these questions. After Kenny’s words, it became clear that this difficulty might not be with our wording, but with a broader concept of memory and time-keeping. I’m not sure how you bridge that gap, but it’s something to think about for future visits.

Toward the end of my time in Naggalama, I realized that my own memories of this trip may have more in common with the Ugandan concept of time than the American one. The long days there, spent first rounding in the hospital and then in the community making house calls, quickly blurred together for me. I couldn’t tell you that on Monday, we saw patients A, B, and C, whereas on Tuesday we saw patients X, Y, and Z. Half the time I didn’t know what time it was — only whether I was hungry or thirsty or tired (which was most of the time, given the rigors of this work). It was all a jumble — a jumble of people and faces. And especially of their stories. Here are a few such stories that stood out to me during my two weeks in Naggalama, both from the hospital and from house calls.

This is the kind of home that most of the palliative care patients lived in.

While working in Uganda, we saw many women with breast cancer. In the United States, breast cancer has a high cure rate if caught early. But in Uganda, women often present late to the hospital, too late for treatment, and they die. Two women with this disease especially stand out to me. We met Margaret* outside her house. We all sat on straw mats in the dust to talk. Like many women, Margaret didn’t seek conventional medical treatment when she first became ill. Now, her tumor was very advanced. Surgery and chemotherapy were no longer options for her. But we could still help her pain, which we did, with medications. We could also help her in other ways. Margaret was extremely poor, even by Ugandan standards, and had only one dress. A Dutch woman who helps fund programs at Naggalama Hospital had sewn Margaret a skirt and a blouse. When I presented them to Margaret, she immediately slipped them on, stood up, and began dancing. I’ll never forget how something so simple brought this woman so much joy.

In contrast to Margaret, Elizabeth did have surgery for her breast cancer. She told us that as soon she felt a lump, she went to the hospital. We asked why she had decided to go the hospital immediately. Elizabeth softly started to cry, telling us that her daughter had developed a breast lump some years earlier. Her daughter did not go to the hospital and died. Because of this, Elizabeth didn’t listen when her friends and neighbors told her going to the hospital would be the death of her. Elizabeth’s situation represents the potential for public health education, in the form of patients telling fellow villagers about their positive experiences with medical care.

Cecilia was an older woman who had fallen and apparently dislocated her shoulder. That was months ago. At this point, it would take surgery to correct — a surgery that wouldn’t likely be done in Uganda. So Dr. Howard Eison, one of the New York physicians on our team, fashioned a makeshift sling. Howard rested Cecilia’s arm in a long, narrow swath of lacy fabric and tied the cloth in a knot behind her head. Then to further immobilize the shoulder, he wrapped a purple-and-white scarf around her upper body and tied it at her side. After applying the two-piece sling, Cecilia was able to be pulled into a sitting position. She started talking, even laughing — no small miracle.

We found Michael lying on a foam mattress in his small, brick house. His limbs were sticks. We learned from a neighbor that he had essentially been abandoned, unable to fetch food or feed himself. As we talked with the neighbor, she found a bottle of orange soda next to his mattress. She put a straw in the bottle and held it to his lips. Michael sucked until the drink was gone. Watching her care for him, we decided to take a chance and give the neighbor a small sum of money (about $3 U.S. dollars) to buy him food. Whether she would use that food for Michael or her own family, we didn’t know. But we had to do something.

I’ll never forget Jane’s face. Most of the time, I saw it behind mosquito netting. Even through the tiny pin holes, I could see the peeling burns. Jane had been brought in one night early on in my stay in Uganda with horrible burns over much of her body. But in Naggalama, there’s no intensive care unit. No dedicated burn unit. She was left on the general medical ward like everyone else.

Talking to Joshua in his bed, listening to him speak softly in Luganda entwined with broken English, he struck me as such a gentle man. Joshua was in the hospital with a very serious leg infection. He needed an expensive skin graft. We saw Joshua every day to check on his leg and his pain. Sometimes I would see him outside the medical ward, sitting in a wheelchair in the shade. We would both smile and wave to each other.

I may never know how these stories end. I can only hope that the small role we played made at least the tiniest impact. I can only hope that we brought some joy or happiness, some comfort or relief, to people who are, in my American eyes, experiencing so much tragedy.

*Patient names changed to protect privacy.

August 9, 2016

Typical weekday in Naggalama

The table in the guesthouse where we ate our meals.

While I’ve written extensively about my experiences in rural Uganda, it occurred to me that I never made it clear what a typical day was like. And that’s an important piece of my time there. Although I have listed times here, these varied by day. We learned to expect the unexpected.

7:30 a.m. – 8:30 a.m. — breakfast. Our group gathered at the table in the main guesthouse for this very important meal. I say “very important” because during the week, we never ate a full lunch, merely snacks on the go; we were out in the community all day. Breakfast usually consisted of hardboiled eggs, toast, fruit, and coffee or tea. (And after two straight weeks of daily hardboiled eggs, I still have no interest in eating one.)

8:30 a.m. – 10:30 a.m. — hospital rounds. Randi, Howard, Jemella, and I headed to check on the hospital patients who had been referred for palliative care, mostly pain management.

The view of a typical home in the rural community, seen through the window of the palliative care team’s van.

10:30 a.m. – 5:30 p.m. — house calls. After hospital rounds, we met up with the local palliative care team (a nurse trained specifically in palliative care and her two nursing assistants) to head out into the community for palliative care house calls. Some patients lived in nearby towns; others lived in villages an hour away on rutted, dirt roads. The distances we often traveled, plus visits that might last 30 minutes to an hour, meant we usually saw no more than four or five patients a day. I knew that these visits would be emotionally challenging. Some of them were. But I learned, through watching Randi, Howard, and Jemella, how to better listen to patients — and how rewarding that kind of intimate interaction could be. What I wasn’t expecting were the physical challenges of being out in the community for six or seven hours. We all got hot, sweaty, tired, hungry, and thirsty (and didn’t drink much water because there weren’t any bathrooms).

5:30 p.m. – 8 p.m. — decompress. After a long and intense day, we’d come home to both unwind and to process what we’d experienced. This usually happened over cheese, crackers, and hummus — delicacies procured in Kampala, the capital city. Sometimes we sat in the living room; sometimes outside on the lovely back patio.

8 p.m. — dinner. Meals in Uganda consist of a lot of starch — potatoes, also called “Irish,” as well as rice and pasta. Vegetables and meat were accents. That was a big change from my diet in the United States, which is mainly fresh produce and protein. So food was a challenge for me. Though I must say, the housekeeper certainly made some mean french fries.

10 p.m. — bed. Growing up, I always wanted a canopy bed. That never happened. But in Uganda, I slept every night under a mosquito net, which is pretty much the same thing, but with a purpose!

My “canopy” bed.

1 Comment

August 6, 2016

Reading the signs

Maybe it’s my training as a journalist — knowing that every whiff, sound, and sight might whisper a crucial part of the story I’m trying to grasp, and eventually tell. One facet of that story at Naggalama Hospital was the collection of signs scattered around the campus. In pictures and printed words, they revealed priorities, attitudes, and struggles at this rural Uganda hospital.

HIV testing and treatment. One of the few free things at Naggalama Hospital is HIV testing. HIV/AIDS is much more widespread in Uganda (and the rest of Africa) than in the United States. And it’s a major public health priority.

Malaria treatment. This is another major health issue in Uganda. Mosquitoes carry the disease, so people are encouraged to sleep under netting at night to prevent infection.

Blood tests. Some of the same laboratory tests that are done in U.S. hospitals are available at Naggalama, as evidenced by this sign. However, due mainly to cost (from my understanding), these tests are rarely done, even for the sickest patients.

2 Comments

August 1, 2016

The hospital stay in rural Uganda

When I had my tonsils out in 2014, I spent a couple days in the hospital after minor complications with the surgery. It was by no means a vacation. But I certainly felt well cared for. I expected it. And I took for granted the clean sheets, three daily meals, and constant (amazing!) nursing care. My time in Uganda taught me that my hospital experience is not necessarily the norm, and I shouldn’t take it for granted. These pictures are from Naggalama Hospital, but I also spent a day at Mulago, the government hospital in Kampala. The same principles applied there, from what I could tell.

Attendants must wash patients’ clothes and bed linens behind the hospital.

Three things that are expected in an American hospital — clean bedding, three daily meals, and constant nursing care — aren’t part of the hospital stay at Naggalama. As a hospital patient, you are required to bring an “attendant” to care for you. This person is usually a family member. He or she washes your clothes and bed linens (there is a washing station behind the hospital). The hospital doesn’t provide bed linens or gowns; you have to bring these in yourself. The attendant also either cooks or brings in your food (there is a place to cook behind the hospital, as well as a small restaurant called St. Peter’s). There are nurses, but few of them, and they serve many patients. Nurses administer IV medications, but attendants hand out the oral drugs, after receiving instructions from the nurse.

Attendants pay in advance for medical services with the cashier.

The attendants also play a major role in the patients getting proper medical services. If a patient needs a blood test, the attendant must take the doctor’s order to the cashier, pay for the blood test in advance, and then bring the receipt back to the ward so the nurse can draw the blood. Some medications must also be paid for in advance. The bulk of the hospital bill, though, is settled upon discharge. The patient can’t leave, however, until the bill has been paid. Supplies are precious and expensive, so the bills are incredibly detailed, down to every pair of latex gloves used in the patient’s care.

Having been both a hospital patient and a hospital employee (and now a trainee), I have a certain picture of what a hospital room looks like. At Naggalama, the majority of adult patients are not in rooms. They are in the male or female wards. There are a handful of private rooms, but these are very expensive, by Ugandan standards. The wards are made up of units (my own term). Each unit has two rows of three or four beds facing each other. The units are separated by walls that go about halfway from the floor to the ceiling, so you can see across the ward. Above each bed is a knotted mosquito net, pulled down at night to protect the patient from malaria-carrying bugs. Next to the beds you will find colored straw mats where the attendants sit during the day, and where they sleep at night.

Here is a brief, visual tour through the adult ward, and several other parts of the hospital. (Click on any image to enlarge and begin a mini slideshow.)

Adult ward:

The colored mat of an attendant under a bed in the adult ward.

Adult hospital ward

Looking into the adult ward.

OPD (outpatient department):

OPD (outpatient department).

The waiting area of the OPD (outpatient department).

Emergency room:

Emergency room

Hospital laboratory:

Entrance to the hospital laboratory.

Hospital’s blood bank.

Hospital pharmacy:

Entrance to the hospital pharmacy.

Interior of the hospital pharmacy.

Pills are dispensed in these paper bags.

Staff housing on the hospital campus:

Surgical gowns drying outside after being washed:

3 Comments

July 31, 2016

Creating a kid-friendly space in a kid-unfriendly place

Jemella, quite the talented artist, painting her masterpiece dolphin.

Jemella, quite the talented artist, painting her incredible dolphin.

The hospital is a scary place for kids, regardless of what country you’re in. Eva, a Dutch woman who funds various programs at Naggalama Hospital, recently had a children’s playroom constructed adjacent to the pediatrics ward. Before opening it to the kids, she wanted it decorated. So one Sunday afternoon, we (Eva, Randi, Howard, Jemella, and I) all got together and painted the long, narrow room in an aquatic theme — Jemella’s idea. We each took a wall as our personal canvas, then worked together to fill in the gaps at the end. Here are photos of some of the masterpieces. Click on each image for a larger version. (I don’t have pictures of Randi’s or Eva’s work, but it’s amazing too!)

After the paint had dried, Eva gathered toys and books to fill the space. Walking by the room now, even from the outside, you can hear the excited squeals of kids playing with those toys, happy to be away from their hospital beds. Happy to be distracted, if only for a little while. It’s a good feeling to have had a little part in that.

Jemella painted ocean mammals at either end of the playroom. On one end, a dolphin, and on this end, a whale.

Howard seems to have partially painted a “Little Mermaid” theme, with Flounder and Sebastian. Look at the school of fish on the right — you’ll notice three at the bottom are going against the flow. A subtle message to the kids, Howard said.

I consider myself creative and artistic, but I’m no painter. So I was happy with how my wall turned out (even if I did have to use stencils for part of it).

Howard, Jemella, and Randi shaking up the paint cans before starting our works of art. The only type of paint available was oil-based paint, and there were very limited colors. So we did a lot of mixing in the plastic cups you see here. As a result, the playroom is a vibrant mix of all colors, shades, and hues.

2 Comments

Tag: Hospital