Chaos

Hello, world. It's been a while, I know. That's good. It means that I've been too busy learning and growing and living to spend much time here, but I still miss it.

So here's a fast recap. I'm on a surgery sub-I at the VAH, which is notorious for horrifically evil surgeons but has one of the best teams I've ever worked on. The hours are long and the interns sometimes take advantage of having students to do scut work, but I find that it's good for me to figure out where to draw the line and stand up for myself and the 3rd year students. The attending is brilliant and kind, though she doesn't stand for incompetence and half-hearted answers. She's told me several times about what she sees in me that is good, and it has helped so much.

Wednesday is my official 6 month anniversary. It seems much longer, honestly, because I'm so ridiculously, contentedly happy. Nathan is...well, all of the things. If that makes sense. Yes, he occasionally leaves his wet towel on my bed (!), and more often than not I yell at him for wearing his shoes on my carpet, but at the end of the day...and the middle, and the beginning, he's home to me. There's nothing I would change.

I was standing in line with him yesterday, actually, and turned around to a young man waving a baby in my face. I was absolutely delighted to recognize him and his wife as the parents of the 4th baby I personally delivered, Gavin, who is now one year old with the most adorable chubby face. He let me hold him, and I loved watching his little one-toothed grin at Nathan over my shoulder. That encounter made my day fairly evanescent.

I'm sitting in a hotel now. I have the last official mega-test of my medical school career happening in the morning, and I'm apprehensive and excited all at once. At the end of this week, the majority of my pressing issues will be resolved. I can't wait.

What a life I have. What a good, complicated, beautiful chaotic mess.

Pneumothorax (with cursing)

This is a right-sided pneumothorax. The lung has collapsed down, leaving only free space in the patient's right chest cavity

"Ahh, doctor, fuck! Please, doctor, please."

The resident jammed the needle between his ribs, rapidly injecting his side several times in a hasty attempt to numb him against the coming pain.
Oh crap, my gown isn't going on and half the ED is watching and I know I'm supposed to scrub for this but let's be honest, I am only here to learn in a situation where only essential personnel need to be present and oh god, I almost dropped my glove. I'm going to look like a moron.
The resident whipped into his gown and gloves much more rapidly than I could hope to manage. By this time, the patient was starting to hyperventilate.
"Fuck, fuuuuuuck! I can't breathe, I can't breathe doctor, fuuuuuuuck! Help me, please, help me! I can't breathe!"
The pneumothorax was pretty straightforward on CXR. His vitals are stable, heart rate and blood pressure are in a normal enough range for someone who's been stabbed in the back. This isn't a tension pneumo, his sats are good. I wonder why he's having trouble breathing now? Agh, finally got the glove on. My hair is in my face. I need a haircut.
"I can't...doctor...please!"
Everything started moving in a rush. The resident abandoned attempts to wait for the numbing medication to kick in and snatched up the knife, quickly slicing through skin and muscle through the ribs. The patient jerked his arm but it was held firmly over his head by the large respiratory tech to the left of the bed. The jerking synced with the yells as the resident quickly inserted a pair of scissors into the wound and spread them, simultaneously breaching the parietal pleura and widening the gap. The air hissed out in an audible rush, visibly deflating the chest wall.
"Aggghhhh fuuuuck!"
Wow. That...was cool. His trachea just moved back to center instead of being squished to the side by all the compressed air. I actually saw it move. I shouldn't be so giddy about that. I can't see very well. I wish I actually knew what to do--I'd feel much more comfortable.
The resident whipped up the large, 1-inch chest tube and began to work it into the bleeding wound. The patient's shouts became screams and quickly reached a new intensity as over a foot of tubing disappeared inside him.
"OH GOD OH DOCTOR HURTS PLEASE STOP FUCK FUCK FFFFFFUUUUUCCCCCKKKKK! STOP! It hurts, it hurts! STOP!"
Oh. This is horrible. Is it supposed to hurt this much? Is he doing this right? Oh god, I wish he'd stop screaming. It makes everything so much worse. 
The screaming wildly increased in decibels as a sudden rush of bright red blood swept down the tube and into the catch.
Oh bloody hell. Is this supposed to be happening? Did we just puncture his HEART or something? What do I do with my hands? Why am I hungry right now? What if I didn't eat enough for dinner, and I pass out in front of everyone? Why am I thinking about food?
The resident finished his insertion and began to stitch down the chest tube as I held it in place, the patient's yells fading off into the occasional whimpers, with his ever-constant, unimaginative "fuck" providing a tempo for the sutures.
I'll bet there's asparagus in the garden right now.

There really isn't a better way to end this story. We stitched him up and he got the chest tube out today. This dude is actually a douchebag, even when he's not being stabbed open, and he hasn't stopped swearing since he came in the doors. Still, he was my first pneumothorax, and I'm glad I was there for it. It...was awesome. Don't judge me for my thoughts, they are as close to accurate as I can remember--and really, the things your mind offers up during stressful situations are pretty funny.

Need It Sleep

I dragged myself to class this morning...barely. It was a close thing, especially on my three hours of sleep. Call last night was filled with almost-emergencies, several adolescent appendectomy cases and one sweet older man who had to have an emergency exploratory laparotomy for what ended up being a perforated bowel from diverticulitis. Now THAT was crazy. I was primary assist and as soon as we opened him up, this nasty tan fluid started pouring out. Med students are primarily given free reign with the suction, and I gotta tell you how much fun it is to suck that crap up--seriously, it's very instantaneously gratifying. This poor guy, though, had large areas of the small bowel that were wrapped around this huge pocket of pus. It smelled...well. I stopped breathing for a while and it was still hovering in my mask even after we cleaned it out. Bowels are slurpy and hard to shove around, by the way. For some reason that seems funny when you're leaning over the operating table at midnight.

Yesterday seemed to be "tease the student" day. I snipped a tube that my attending had stretched between his fingers. He gave a yell and said I'd cut him, and started laughing when I yelped, "Are you serious?!" He laughed even harder when I started ranting and muttered about throwing something at him, especially when he asked me to repeat myself and I sweetly told him "nothing, I said nothing." The scrub nurse was also cracking up at my horror when the whole team managed to convince me that the x-ray tech frequently took leftover human bits home to feed his cat. In my defense, they were very convincing. I was appalled.

I have six hours of class standing between me and the weekend. And it's going to be a good one--the boyfriend is taking me somewhere with no hints beyond the overnight bag I need to pack. I. Can't. Wait.

Sunflowers and goodness

I'm feeling a little personal tonight, and instead of writing funny or horrifying stories about my patients, I thought it was time for another chapter that means something to me.

Several months ago, at the end of December, I wrote about the struggle where I had to put the last piece of a broken relationship into a box and close it up. It was a hard night that turned into a pivot point, as such things do. I wish I could describe it better, but so much changed after that. It was as if knowing that he'd moved on was the thing that finally set me free of the guilt I felt, the wretched sadness of knowing that I hurt him. The healing after that, the peace, the growing into myself were and are still amazing. The pain is finally gone, over half a year later. I don't know that I've ever been happier in my life, even with the stresses of school and choosing residencies, passing shelf exams, you name it--life is just, good.

Part of that goodness has been learning to fall for someone again, to trust myself and my judgement, to take the chance and start something that could be wonderful. We met by chance, but he is warm and he is kind, this man, and the way he interacts with and treats the people around him calms my heart. It's been a little scary, making the decision to let someone in, but I haven't regretted a moment, and I want more. More of the contentedness and the feeling that something very sweet is growing, that it feels like I've found something worth exploring and hanging on to, more of experiencing someone who believes that a good relationship is a precious thing. And I feel like I'm finally learning to ask the right questions, the important ones. Learning to be honest with myself, otherwise it's all guessing and mistakes anyway.

I don't know what's going to happen, and that's okay. I am content, and happy, and life is simply good.

Psych Day #3

Random moment from my drive home last night--I was stopped behind an ambulance at the last light before the hospital. The back windows aren't completely dark, and since the sun had already vanished for the day I was able to see inside the lighted square. The gurney was just below my line of sight, and I was absentmindedly watching the two medically inclined dudes in the back and wondering who they were transporting and how their day was going...until this little chubby fist reached up and tugged on the man's sleeve. Instant attention grabber, that. I almost got whiplash. For some reason, I never expect to see a little kid in one of those things, but there she was, and she was adorable. Just one of those things.

Another not-so-random story from my second day on psych unit. So, there's this lady. We're gonna call her...well, Nutsy or Teeth are the first nicknames that spring to mind, but there must be something better. She's scary. Massive lady, stature and girth, absolutely bonkers, coming into our unit with at least ten prior instances of attacking staff at other institutions. During one of those attacks, she nearly severed a male nurse's finger...with her teeth. It had to be reattached. I am not making this up.

We've had her for about 24 hours. This morning I come in and find out that she got her hands on the charge nurse (after refusing her medications), ripped out a chunk of her hair, and came within an inch of clawing her right eye. The nurse has these massive scratches all down the side of her face, and she along with another staff member had to be taken down to the ER last night after they managed to hold this lady-animal down and sedate her. I am not prone to swearing or cursing...but the term "batshit crazy" blares in my head every time I see this lady shuffling down the hall towards me. She scares me to death.

Psych in general is a difficult rotation for me. I admitted a man yesterday who started having what might have been a panic attack in front of me, complete with hyperventilating and clenching his fits on his kneees, but I had a moment where I literally didn't know if he was having an emotional breakdown, or if he was about to launch himself at me and strangle me. I just can't tell, and having to constantly wander about that and assess every person within 20 feet of me is stressful.

Antisocial Personality Disorder

I just finished my week on the addictions unit. The best summary I can create is that, "People. Are. Crazy." And these aren't even the real crazy people. I'll meet them all in the ward next week.

At the same time, it was very humbling. I attended an AA meeting earlier this week, and I was astounded when I walked in the door at 6:25 am. There were so, so many people in that gym--I'd expected a small circle of about 15 people, mostly older broken men, in a small room somewhere. Instead, I encountered more than 70 people seated in a gym, and among them I saw fellow students, attendings, and nurses I recognized from the hospital--there as patients. Young people, professors, grandmothers. Guys in ripped shorts and guys in suits with stethoscopes around their necks. It was inspiring.

Also, I met my first Antisocial. This personality type is the most common "sociopath" identifier and is recognized in test questions as having childhoods involving prolonged bed-wetting, the habit of setting fires, and animal mutilation, all before the age of 15. Of course, as I was admitting this guy, nothing he told me had anything to do with urination or cutting up cats and setting his room on fire. Turns out that these guys (or girls), in reality, usually have pasts that include abuse and are currently extremely manipulative, with no qualms about hurting anybody and everybody to get what they want. I didn't realize that's what this dude was like until he started trying to strong-arm the staff into giving him privileges he didn't have, and after I heard him unabashedly lying to and manipulating someone he "loved" over the phone. Or maybe after he tells me he's abusive towards his pregnant girlfriend, or I find out that he requires sex from her much more often than she wants it (his average estimate was twice a day). Yeah, all of that.

Meeting him underscored for me that there will be patients I do NOT want to interact with. Patients that I may come to despise, even, and may see no worth or value in--but I need to figure out how to love these people. At least, how to interact with them in a way where they feel as valued as they would if they had spent time with Jesus. Which sounds ridiculous. I can't do that. Not even close. I'm not even sure I want to try, to be honest. But I think it's a worthwhile goal and I would like to learn how.

Shirley

Her name was Shirley, she was 76 years old, and the last thing she told me was that she was looking forward to drinking tea with me, but that she was going to go home and rest awhile. I hugged her granddaughter goodbye, went out to the elevator, and cried. She was so tiny, in that hospital bed, with great bruises on her arms from the blood thinners and a tear on her shoulder from a piece of tape that took the skin with it. Even when I held her hand, the skin turned dark under my thumb. Her eyes were still so blue, but she found it hard to talk to me much. She just smiled and called me "honey" as we got her ready to go home for the last time.

There were more tears, three days later, when Sherrie told me that her gran was dead. How odd, to be sincerely mourning the death of someone I've only spent a few hours with over the course of several months, but I do, regardless.

After they took her home, one of the last things she had them do was hang this picture. That's us, there in the middle--my mom, dad, and siblings. She always wanted to hear about my family, and one night I went to see her, late, and took a picture so she'd know what they looked like. When she went home, she added it to the family tree on her living room wall. It was one of the most profound gifts I have ever experienced, to be so welcomed into a family like that.

They tell us not to let people in, to leave work in the hospital and separate your life and emotion from the people you treat--that they will sap your strength and break your heart if you give them too much of yourself. And that is the truth of it. But every once in a while, you meet people who are worth it. Tears are such a small price to pay for being able to feel like I meant a great deal to that family, that I could actively make their lives better with just a little time and caring. Those are such small things, sometimes.

Anyway.

Reflection

Here I am. A little older, a little sadder, but...the world is still full of wonder. It is bright and brilliant and sharp, vague and colorful and made of movement and moments; and it buoys up my soul that I still have it in me to pull courage from somewhere deep, to take those moments and run with them. To ask the right questions. To dare to hope for new dreams. To forgive myself for what I couldn't change, and remember that the beautiful parts of human interaction are really quite simple. It actually feels strange, letting joy chase me again, but...man. So worth it.

Skin Deeper

It bemuses me how unlike myself I feel tonight, freshly showered at an unusual hour, with the unfamiliar scent of brand new shampoo and soap drifting around me. It's like being in the skin of a stranger, and I'm surprised every time I move and the air stirs. I catch myself breathing deeply and looking over my shoulder before I remember, again, that the unfamiliar feeling is nothing more than a trick of my senses.

I received a text from an unfamiliar number yesterday. My patient, the one who was in several weeks ago, is back in the hospital--I'd given my contact info to her granddaughter in case that happened, and so I went in to see her this afternoon. She is diagnosed with esophageal cancer, now. I sat and talked to her for half an hour, and she held my hand the whole time. She's so tiny...lost a great deal of weight. My heart breaks for her. It isn't very often that you meet people who just seem good, but she is like that. You can tell it in the way her family surrounds her and the way they interact. It's good, and strong and loving, and she's decided that I'm also just another one of her kids--told me that, today. And then she followed that I needed to make sure and remember to take care of myself. It put a warm spot in my heart. Of all the patients I see every day, everyone I interact with, she got under my skin and it looks like she's there to stay. I'm pretty happy about that.

We use that phrase, "getting under my skin", to describe something that slides past our defenses to the core of who we are underneath, where it matters. Much of the time it's a negative connotation and comes with a lot of pain attached. I know that in my more self-effacing moments I tend to wonder if mine is too thin, but in the end it just turns out that I'm no good at defending myself against people I love. I just won't do it. I carry them under my skin all the time, as close to my heart as I can, where the most damage could be inflicted if they so choose; but where, in turn, that love is a shield, a strong, warm, living guard against the pain that is a byproduct of living. I've got such a strong family, and such good friends. I feel quite loved tonight.

Also, I am lying in my bed smelling my hair because it is new and different and ridiculously soft. This new shampoo stuff...wow. I smell delicious.  What can I say? It's the little things.