I've been meaning to do this for months...

So, ever since I got this blog started for Natalie, I've been meaning to show my face on it, but never got around to it. Tonight, Natalie is sick and went to bed early and instead of reading on one of the innumerable topics I need to know more about, I thought I would write a few thing for all to read...

Well, I guess I've been a "doctor" now for a few months, and I've learned it is not a job for the light of heart. The hours are long, but that's not what I'm talking about. As the intern, I get paged somewhere between 40-100 times in a given day. Each of those pages involves me making a decision about the care of a patient which could affect their health. On top of that, I make many other decision on a daily basis for patient that could alter whether they look better or worse the next day when I see them. I'm not trying to sound like a hero, far from it. Many of these decisions are very minor things, but even the small things come back to haunt you some times.

Life is tenuous at times. 2 months ago I was in the NICU. Newborn babies are normally a joyous occaision, but when things go wrong, the tragedy is great. During my time there, one of my patients was a baby born at 22 weeks gestation. I had never heard of even trying to resucitate a baby at that age--I thought they were not viable and we let them die due to the futility of the situation, but that was not the decision that was made in this case. The baby did well for about 1 day, but then one organ system after another started to fail. For the 7 days that baby was alive, I practically lived at its bedside. I would leave for 10 or 15 minutes when I had to take care of something else, but always found myself next to her isolette as soon as I completed my task. I learned immeasurable amounts about the care of very sick neonates, but despite that, felt completely inadequate to answer the parent's questioning faces each time they visited. The baby's mom was an 18 year old girl who was overwhelmed by the weight of the decisions she had to make. There were differing oppinions among those involved in the baby's care about how aggressive to be in therapy. By day 4 of life, the situation seemed clearly hopeless to me, but we supported her life for several more days, advancing our care. Finally, on day 7 of life, the family requested withdrawl of care, and I stood in the background as the mother held her child for the first time as we turned off the medications and ventilator that were keeping her alive. When the monitors showed no heart beat, it fell upon me to place a stethscope on her chest and declare her dead. That moment will be with me as long as I live. I briefly spoke with the parents, but had nothing to say--what could I say? I didn't know how to deal with it either. Ultimately, I excused myself, filled out the necessary paperwork, then went to my call room where I dictated her death summary. At the time, I was confused because I didn't feel grief, but looking back, I realize I wasn't allowing myself to--I had distanced myself so as not to be hurt when she died. That night, sleep did not come easily.

Death is not the only thing that weighs heavily upon me. Sometimes things go wrong with patients, and you are never sure if it was something you did, or if it would have happened anyway. When we do procedures on patients, we always warn them of the risks of the procedure. A few weeks ago, I performed a thoracentesis (putting a needle into the chest cavity to collect fluid that has collected around the lung) on an elderly woman with many medical problems. It was the right thing to do for her, I had explained the procedure, why we were doing it, and the risks involved, and she had agreed to the procedure. The procedure itself went very smoothly, a "textbook" case. She seemed to respond well to it initially, but by the next day she was doing poorly, and ultimately she ended up in the ICU. It turned out she had bled into the chest cavity on the side I did the procedure. I have walked through the procedure I did to her in my head many times over, and I am confident I did it right, but there is a distinct possibilty what I did was the cause of her worsening status. The fact that I had warned her that she might bleed after the procedure did not comfort me in the least.

I am getting pretty long-winded. I don't want people to think I don't like my job. I love what I do, but am reminded daily of what I lack. I have also seen patients recover and benefit from my care and efforts. Those moments bring joy, but do not provoke thought and introspection the way the difficult cases do. I could continue for hours with stories of patients I have learned from. As a medical student, I saw similar cases, and I did learn from them and recognize how difficult they were, but as a medical student you are sheltered to some extent from this. Now, the prescriptions, the hospital orders, the daily notes, the discharge summaries, and so much of my patient's care proceeds with my name attached to it. I have spent many late night reading to try and bridge the many gaps I have in my knowledge base (something I should be doing now).

Anyway, overall I am enjoying residency. Not a day passes that I don't learn something (usually many things) new. I am inspired and impressed by my many colleagues who help me learn and develop the skills I need. I only wish I didn't need to learn and develop skills, I wish I had the complete package now.

On a closing note, I am so greatful for my wife and children. What a blessing it is to come home to them. I know it has been hard on all of them. Laura asks me every night if she will see me tomorrow, and sometimes the answer is "no", often it is "I hope so", rarely is it a confident "yes". Natalie is so supportive. By the time I get home, she is as exhausted from her 14 hour day of work as I am from mine, but she listens to me as I release my daily frustrations, and supports me in so many ways. I am certain that having a family to remind me of where my priorities need to be has been an essential part of my education. I only wish my kids didn't have to wonder when they would see thier dad again.