Estoy de rodillas.

About to leave the hospital this evening, a last consult slides in. An appendicitis in the ED. I chart check, very straight forward. "Thank goodness" I think to myself as I walk to the ED. An easy case in the bag, and I contemplate, maybe I'll just stay late and do the case myself. That would be a fun way to end the year. Unfortunately, some personalities have a rather miserable way of taking something simple and making it extremely complicated. My appendicitis, for example, kept trying to find a way out of being appendicitis. I gave option A. and option B., so he kept trying to create a scenario in which option C existed. Rephrasing his questions, trying to catch me in a loop hole.  Which, of course, didn't happen. It really was too straight forward for that.  My appendicitis even tried to tell me he needed to think about it, and would go home and let me know tomorrow which option he wanted. This is when I start to become excessively blunt in my explanation of risks, benefits and options, because obviously.... something is not getting through clearly enough. Think.... option A: you live  vs  option B: you die...  level of blunt. Needless to say I did not get to finish out the year with a nice appy. I finally had to tag it out to my colleague, and it wasn't until hours later when he texted that Mr. appendicitis went with option A. (hallelujah! a decision was made.)

And now, as the year 2020 ticks its way into memory, I think back over the months on what could have been, what was, and now what will happen. 

I can appreciate the fact that we are living through history right now. The stories we will have to tell one day; fascinating, but definitely "you'd-have-to-have-been-there" kind of stories. And they will be stories I'll always carry with me, they are part of me now. Though I was not put here for such a time as this, God used it to teach me the lessons he needed me to learn. I may be a bit presumptuous in my past tense on the verb 'to use' as I fear I am still in the process of learn-ing those very lessons. But I'm running towards the new year trusting in God's faith in me to learn. 

There are three reasons for praise that immediately come to mind I have for the year 2020.

1. I have not spread the virus, and no one is sick because of me.

2. I have survived half of my chief year.

3. I have finally arrived at 2021.

In between those three, a million small blessings and the ever remaining constant... as constant as a new day is in coming, the love of a Father and Savior.

Psalm 113:3 From the rising of the sun unto the going down of the same the Lord's name is to be praised. 

Much Love and Prayer.

Estoy celebrando la Navidad.

 A few weeks ago I set a goal for myself. And after two weeks of productive studying, I rewarded myself by a trip to the city. Monica and I had a moderate list of coffee shops and bookstores on our list for the day. It was interesting to compare the emptiness of the city to my past visits, even during the holidays. For starters, the metro into Grand Central was almost empty. 

Monica & I at Bryant park. Three smaller trees instead of the one large tree this year.  

Coffee shop #1: Culture coffee

Would have been fun to sit here and enjoy our coffee, but as is, we contented ourselves with a picture and moved on. Perhaps next visit we'll be able to sit.

The Strand. Impossible to visit and not find 1, or 2, or 10 books you want to add to your collection.

Levain Bakery. Those cookies.. Worth it.

Not the only ones out perusing the bookstores of NYC that day!

Some coffee shops had longer lines than others, but when you have no schedule to keep just means you have that much longer to appreciate the sidewalk decor. 

A Chelsea Market Christmas

A Chelsea Market Christmas

NYC Christmas

NYC Christmas

 

The only place we did find crowds was Rockefeller Center. Nothing compared to the shoulder-to-shoulder of years passed, but probably too crowded for safety in the time of COVID despite 100% mask-wearing by all visitors. We appreciated our view from here.

 Merry Christmas! Wish you all a happy and healthy holiday!

Much love and prayers.

 

Estoy tratando dormir.

There a handful of uniquely significant people in my life. They inevitably were just minding their own business, and happened to cross my path at a point so divinely orchestrated that leaves me without a doubt that I am where I am today of no doing of my own. Olga is one of those individuals. She was our program coordinator, and retired this month.

Olga & I

I have often used the phrase, 'when a door closes, a window opens' and then put my own twist on it. Residency being the "house." Most US medical school grads are welcomed into the front door. I found the door locked, most of the windows as well. I climbed up a tree in the backyard to check one of the second floor windows back there. It was Olga that saw me hanging onto the tree outside that second floor window at the back of the house, and she cracked the window for me. 

During my year of research, my office was around the corner and down the hallway from Olga's. We crossed pathways often as the drinking water and the copier machine were located in my office. It was during the residency interview season, at the prodding of my research co-fellows, that I walked into Olga's office requesting a moment of her time. Two minutes later I walked out again with an interview for the general surgery residency. 

When a door closes, a window always opens. Just sometimes its a second-story window in the back of the house that someone left cracked just for you.

My chief year I've altered my path into and out of the hospital every day. I pass through the lobby of the Children's Hospital. Despite it being probably the funnest place on the whole campus, it's also usually one of the quietest, especially when arriving and leaving before and after most others. Ever since COVID, all of the chairs and couches have been removed so it's just an open area now. I'm glad they still decorated for the holidays!

There are a few items of decor within the Children's hospital, that puzzle me. This face is one of them. It graces the wall above the main entrance for the lobby of the Children's Hospital. I think it's supposed to be a moon... but it strikes me more frightening than anything happy or otherwise child-friendly.

How many chiefs can you fit into one case? Ash, Ansab and I found ourselves all scrubbed in on a case the other day. Vasu had left that morning post-call, and was technically on his vacation. We joked that we needed to call him back in to scrub so we could retake the picture with all four chiefs. 

I finally got my first COVID vaccine today. They are making appointments for everyone in the hospital, but due to my schedule being subject to change often multiple times daily, it's very hard to adhere to any appointment. So I went as a walk-in on a day off. The check-in process was quite extensive. Opposite of the yearly flu vaccine, which everyone is so used to, its almost automatic. I understand that the long list of questions is necessary for research purposes etc. But when she asked me, "Have you had contact with anyone positive for COVID-19?" That was taking it too far for me, and I could feel my patience start to escape. I don't exactly know why it upset me so much, but I had to reign in quite a few short retorts to her question, before I could safely respond and move on. 

Much love and prayers!

 

Estoy cansada.

 "I'm tired." I confessed to my attending. We were finishing up amputating a few toes last night, and I could have closed my eyes and fallen asleep right then and there. I hadn't had time to refuel with coffee throughout the day, so it was almost midnight, and I was just... tired. 

It's been full the past couple of weeks. Extra call due to my co-chiefs being gone. Busy in the OR. Dealing with unhappy residents, and passive aggressive attendings. Transition of services. I am now chief of the Acute Care Surgery service (a.k.a. emergency general surgery). Making it on time to all of my zoom interviews for fellowship, post-call hair and all! Each of these topics I could unbottle about, but time has demanded me to keep on moving, and thus I resort to the above sentence fragments and summarize them with "I'm tired." My attending nodded in agreement to my confession last night as my physical clinical presentation at the time reflected that description. I didn't elaborate beyond that, and let him believe it stopped with my needing a nap. 

I had another candle lit in heaven last week. Next confession: I struggled with... am struggling with this one, more than usual. It wasn't the first patient I had die, and won't be the last, but it was much more humbling for reasons that I won't elaborate on such a public forum. 

Medicine has an uncanny, and at times, almost brutal way, of keeping me humble. I'm left analyzing my efforts to perform what is physiologically right and technically perfect, are they all for nothing? My desire to help and not hurt, again is it all for nothing? 

I confess to myself, as much as I confessed to my attending, and I confess to you now. I am tired. I am not perfect. I am lacking, and I have need. 

I confess out of an effort of self-help, that I can come to accept my newly lit candle with respect rather than fear, and that I can keep it safe. 

I find it harder to stand up for my team and my patients as a leader and chief resident, when I know the truth to be as I confessed above. Makes me wish it could be June 2021 already that much more, but alas time only passes one day at a time. So I pick myself up, I smile, and I keep going, trusting in God's wisdom and Jesus's love. 

Much love and prayers.

Estoy tomando agua.

If you walked into his room early morning, you’d form the snap clinical picture of a harmless elderly debilitated gentleman who was unaware and unoriented. But, you’d be wrong. You see, as you were grabbing a pair of gloves from the box on the wall he had cracked his eyelid, just long enough to register who had entered his room, before closing it tight again having decided if you were worth his attention or not.

I quickly had caught on that he was, in fact, appropriate…. Just didn’t like mornings.  Kind of like a teenager who grunts in response to questions he/she doesn’t want to answer, he would grunt. Sometimes he’d crack his eyelid to stare at me a moment or two, maybe contemplating if it was a question worth responding to, before closing it again and delivering his grunt. Some mornings were better than others, and afternoons infinitely better than mornings. But even when most tired, he never avoided my questions, even his grunts would be in either an affirmative or negative manner.  

There’s no denying he was a sick gentleman, but after awhile there was no further intervention we could do for him at the hospital. One of the many limiting factors in his care, keeping him fully dependent on others, was his inadequate nutrition. If left alone, he would never eat enough. Grabbing his cup of water and holding the straw to his lips every morning he would oblige me and drink. Even grumpy in the mornings, he still wanted to be able to leave the hospital, and he understood that my cup of water every morning wasn’t to torture him. He had to prove he could maintain hydration to leave, so he would drink, sometimes without even opening his eyes for me, but he would drink.

One morning as he drank the water I held up to him, I went through my usual reassurances and encouragements. Unfortunately, my tongue got tied and I told him to “make sure it doesn’t go down the wrong poop.” Fumbling embarrassed, I tried to backtrack and correct myself, but then stopped as I looked at him. His eyes were wide open, his mouth cracked open in a long and hearty inaudible laugh.

You know... he’d never admit it, but he’s going to miss me waking him up super early every morning. Maybe, I’ll miss him a little bit too.

Much Love and Prayers.

Estoy practicando el coraje.

 I started listening to Christmas music a week ago. Granted my Mom had tried to get me to listen back in October, I'm not as bold as that. I confessed at work one day prior to Thanksgiving. My team, of course, attempted to argue the inappropriateness of my decision. To which I responded, "It's 2020." And they had no come-back. No response. Argument over.

There was an unspoken understanding shared amongst humans across social media. I watched as Christmas decorations went up right after Halloween. Artists releasing their new Christmas singles or even whole albums everyday. There is not only a need for Love, but a starvation for Hope this year. The same need and starvation that you find on the streets, in the shelters, and filling the jails on a daily basis, but it's been dwelling in the households, the school hallways, and the wards of the hospitals like never seen before. The world needs Love, and Hope and Joy. And as a nation, I see us reaching out to Christmas differently this year. 

I was expecting to be working the whole Thankgiving holiday, but for a handful of different reasons, there has not been a single transplant thus far. It's given our whole service a bit of needed rest. I took the time and challenged myself to work on counting my blessings. Sounds corny, I know, but truth be told, I'm ashamed to admit I have not done enough of that recently.

So I'm listening to Christmas, and acknowledging that I am blessed, and my future in the hands of my Saviour may bring me to even harder and more difficult years yet.

Estoy esperando que continúe la tormenta.

 The world had an anniversary this past week. Most didn't even realize it. It came and went unnoticed just as it did a year ago. November 17, 2019 was the first reported case of SARS-CoV2. Let that sink in, how the world has changed since patient zero.  Those infected. Those no longer among us. 

 How I have changed in that year. I did quite a bit of head-hanging today.  Inpatient admissions for COVID are becoming harder to ignore. Popping up on all services, and starting to fill the ICU beds once again. 

I want to continue ignoring it, but even with my head down, the smoke is noticeable. The smoke of a world on fire. It burns the eyes making them leak and cuts the heart making it bleed.

The transplant team has set and surpassed the record for livers transplanted in a year. I watch them; as they discuss their achievement. They get giddy about it. It's a carefully restrained high pitched excitement of fist-bumps, back-slaps and high-fives. I think.... I fear, they are getting greedy. They want more, and more. It's pushing their limits. They're tired. I worked last night as the transplant passed into the wee hours of the morning and I silently watched as they tried to convince themselves that the artery was going to be okay. Taking it down and redoing the arterial anastomosis would mean at least another 30-40 minutes minimum. The artery was not okay, and I kept waiting for them to admit it, but it didn't come. When I finally spoke up, the tide turned and we ultimately spent that extra time to fix the problem. I hadn't said anything they didn't already know, was maybe just that voice they needed to hear to break through their exhaustion and remind them of it. 

I wonder if we'll keep this pace through years end, or will our physical limits slow us down finally. Or.... will COVID slow us down. 

I'm betting it'll be COVID.

Much Love and Prayers

Estoy operando.

 

Photography is a hobby of one of my transplant attendings. Before he scrubbed in to join us, he amused himself for awhile. I'd say I got to benefit from it. :)

Much love and prayers

Estoy casi al fin.

 They say he's "on the edge", or "about to crack." Some are even nervous to go in his room, it just might be the moment that he attacks. You know.. claws out, fangs first. 

Really?.... our imaginations can get rather wild sometimes. He won't attack, but that being said, nothing about his inpatient course is going to be pretty anyways. He came to us paranoid, suicidal and homicidal. He flat out refused anything and everything, from making eye contact to taking his medications. Finger to nose, we called Psych. And they recommended a pill.... (blank stare)... for someone refusing all medications...  So, I explained it to the Attending. His pills, include his immunosuppression meds. If he refuses his pills. His body will reject his liver. And he will die. Him refusing his meds is essentially a suicide attempt. I got a light bulb finally, and they agreed to admit to inpatient psych. He started taking meds, and allowing labs to be drawn, which showed us that it was too little, too late. Liver was taking a swan dive from bad to dead. So he came right back to us for acute intervention and we subsequently slammed steroids and immunoglobulin into his veins as fast as we could. 

We talk about psych residents, joke how they have "banker's hours." They're the last ones in the hospital and the first to leave. Over the years I've had friendly relationships with multiple of the psych residents. Interesting to learn that they all have their own therapist. I never did quite understand why someone who could get more than 6 hours of sleep a night needed a therapist. But I think I get it now... if one single patient can literally drain the life out of you. Best to learn quickly how to handle those patients and yet maintain the plug in the drain. 

On a much less depressing side of things: I got my Letter of Nonrenewal. I signed it with a flourish and sent it on back to them. Much different place I am currently, than the last times I signed those letters as a prelim resident. My contract will not be renewed for the 2021-2022 year. I'm too tired right now to smile, but I feel a lightness inside, so I'll just say my heart is smiling as I say that.

Much love and prayers!

Estoy sobria.

 As we turned, and walked out of his room, he called after us, "I know how to hide a body!" 

He had been a homicide detective, and a good one. He prided himself boasting his impeccable track record, not a single open case left to his name. A pretty history and quite fascinating, I'll agree, but it covers up the ugly truth. The alcohol. What started as his escape became his crutch and the ultimate linchpin in the string of events leading him to us and that hospital bed. 

We all liked him. He was motivated and wanted to get better. Perhaps, maybe, we actually helped him. Here in New York that's not the usual story of alcohol cirrhosis. There never was a written rule, but in the past there was an unspoken requirement of 6 months sobriety prior to any liver transplant. We have not kept to that ideal in years. The main reason... these patients won't leave the hospital alive without a new liver. A ballerina. A lawer. A CEO. A father. A son. the list goes on and on. So... we transplant them, essentially providing a second chance at life. Once they wake up and their encephalopathy clears and they finally realize what happened to them.... we hope they are motivated and want to get better as our homicide detective friend. The transplant team I work with here will fight tooth and nail for these patients. They are determined to keep them alive, protect them, and support them. Will many of them go home and ultimately return to the alcohol. Yes, and it's a slap in the face....no, more than that, a kick in the gut. But it's the known risk of transplanting the patient who drank him or herself into hepatic encephalopathy oblivion. I hate alcohol.

One of our patients was transplanted for cancer rather than alcohol. He woke up from surgery feeling so good! Was in such a good mood that when we discussed the projected post op hospital course with him and mentioned going home soon. He was so excited he invited us all for a celebratory bottle of wine! I reactively froze out of fear for his future and the future of his brand new liver. Had to remind myself that a celebratory bottle of wine for this patient was just that and nothing more. Unclentched my throat in time to join in with a nervous half laugh, and subsequently was able to unclentch my fists before anyone noticed.  I wanted to smack him. Being honest, the term that came to my mind right then was "idiot".  Don't joke with a transplant surgeon about drinking alcohol fresh transplant, no matter what your etiology, they could have a heart attack! But smacking him probably wouldn't have gone over well, so I refrained.  

Love and prayers!

Estoy multiplicada.

 My return to work coincided with one of my co-workers leaving for maternity leave. Baby Arielle was born today, our newest member of W.O.W.!

There is a long story, and an unfortunate chain of events which I will spare, but it has culminated with me taking on my co-worker's service in addition to my own. The perpetual conundrum of the surgical resident... how do we be in multiple places at once? It's not the first time I've managed multiple services simultaneously. The first time I was only a prelim PGY2, so... a long time ago... and when I expressed concern to my chief, she shrugged me off saying, "you'll be fiiiiinnnnnne!" very obviously not worried about it. This time around, the roles are reversed. My team members look at me and concerned ask, "how will you do it?!" I shrug them off now saying, "it'll be fiiiinnnnnne!" And it will be, I've been a resident too long to think anything else. No, I still haven't figured out omnipresence, so I'll go to one place then the other, and so on and so forth. 

Yesterday we were back-up for a liver, when it ultimately went to a different institution I discussed with my attending how it's usually about 48hrs for the next offer, at least in my limited experience. He was not so positive in our prospects of another offer. It was then approximately 7 hrs later, middle of the night, and a liver was offered, accepted, procured, and I was in the OR working on the backtable preparation of our brand new liver for our patient. I refrained from tell my attending, 'I told you so.' 

Due to our new liver transplant, I had no time to prepare myself for morning rounds on either service. I guess that's why we have our teams, and everyone on those teams play a very important role. When I'm looking for my patient's fourth drain they can remind me.... this patient only has three drains. Mixing up my drains amongst services has to be semi-expected when one is post-call right?

Much Love and prayers!

Estoy corriendo.

 Running is one of my hobbies, my past times, and over the years served as a vital outlet at times. Perhaps saved a phone or pager or two from being smashed against the wall.  It gets me outside, into fresh air, and I can run until I feel normal again... whatever that is. In short, I used to run to "keep my heart happy". Which could be taken physiologically as well as psychologically and I ment it as such. 

Ever since COVID swept through New York, I had an additional motivation. My lungs. I ran to "Keep my lungs happy", in my own way refusing to succumb to the damage of any potential virus, and remind myself that I am still breathing.

As I started running more, and more on a random whim I entered the lottery to run the New York City Marathon... which of course I didn't win. And then surgeries started back up again. And then chief residency year start. And life returned to as it ever was, very busy. Running started taking up its previous role as an outlet reserved for any days off and post-call days. 

Then the New York City Marathon was cancelled, and went virtual, open to anyone. So I entered... paid a bit extra than the entrance fee so that if life happened and I wasn't able to complete it, I had still made a donation so it wasn't a complete waste of money. Next step I made was to download a training app, because honestly... I had no idea how to run a marathon.  I wasn't able to follow the training schedule day by day, due to work, but I kept as close as I possibly could. 

And I did it! I took advantage of the travel restrictions from COVID and ran a marathon this week! And in so doing checked something off the bucket list. Something I haven't been able to do since bungee jumping in New Zealand! Ran it in 4hrs and 23min. When I had entered the lottery I had put down 5hrs and 15min as an estimated time, giving myself 15min to run the last mile. Then as I ran the last few weeks, wondered if maybe I could do it under 5hrs. So I'm happy! I'm happy I finally did it! Completed something, I've wanted to do for many years. I can finally say, I've run a marathon, rather than I want to run a marathon one day! I can join that community from all walks of life, that spans cultural boundaries, no language needed, united by a goal and a joy and a support of each other, as we run. 

Few pictures from my week.

I did better with relaxing as the week has passed. Happy fall!

Got to love my nephews a little bit!

Much Love and Prayers!

Estoy tratando descansar

To say the new EMR went live without a hitch would be a drastic understatement. 

It doesn't really matter if this new EMR is better or worse at this point, because either way, it's new. It's change. And humans don't respond well to change. We get frustrated at what we don't understand. Perfectly happy and content employees have expressed their exasperation and threatened to quit this past week. And no amount of reassurance and aide that I can provide lessens their frustration....which then in turn frustrates me. 

The way I view it, we definitely can NOT go back to the antiquated barely functionable EMR that we used to have. The only way is forward, taking this new EMR and all its good, bad, and confusing aspects one step at a time. Unfortunately, us residents seem to be the only ones on board with that mentality. Nurses, aides, ancillary staff, etc seem to have differing opinions. 

Hopefully, things will calm down soon, and we can enter a new and accepted normal and stop struggling against this change. 

I am away from the hospital this week. COVID still preventing me from traveling and seeing this amazing world as I would like. So I am trying to simply rest this week. It's not working too well. First off, I was woken up early this morning to phone calls, texts and emails concerning the liver transplant today. My own fault really, outside of my own service I didn't exactly broadcast the fact that I would be away. At the same time, I can't really take a vacation from the administrative duties I'm carrying right now. Again my own fault for trying to take a week of vacation during the few blocks I'm designated the "administrative chief resident". Over the years, I've seen a plethora of chiefing styles. Everything from the lazy, checked-out and essentially absent chief, to the micro-manager. Where on that spectrum I fall... I'm not quite sure I actually want to know. But there are many changes in my style that I am noticing now as a chief resident, and one, not so good change, is my inability to separate myself from the work, from the patients. It's the first time that I have ever brought my laptop with me on vacation... so that I could still work. As ready as I am to be done with residency already... I can not understand how those before me have been able to ignore the fact that they still hold a responsibility, and an important responsibility, to their patients, to their services/attendings, and to the many junior residents that are looking up to them. Who knows.... maybe I'm the one that needs to let go more. So there you have it... trying and failing to relax. 

Much Love and Prayer!

Estoy orando para ti.

 Another year has gone by. Another year older. I think I'd like to settle here. Stay 35 for the next 10-15years. I could be content with that. Nothing special happened today. I was post call, and so slow on rounds with my team this morning that I couldn't make a clean and clear exit before transplant rounds got underway. Really dumb on my part, which I told myself that multiple times as different attendings kept interrupting each other, and pointing fingers about inconsequential patient orders. Preferring to have been able to go home post call and nap/enjoy my birthday, having to instead listen to attendings strut their egos, really kind of spoiled it for me. Then it rained all day. I like a nice rainy day.... but, I really needed to go for a run today. And not being able to run, well... ice cream couldn't even help me with that today. Then our hospital is going live with its new electronic medical record this weekend. So I'm going in extra to do computer work. Nothing about that prospect is exciting in any way. It is what it is, and just like time, it will shortly be behind us.

Grabbing my jacket from the call room to leave the hospital this morning, I appreciated how the black jackets of my fellow co-chiefs all hung in a row, waiting for their owners to finish their cases for the day and return from the OR.

Birthday Song time!! Dance with me!

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And this year... I've been feeling Hard Love as theme song to my life right now. Tell me you do that too right? What's your life's theme song right now?

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Much Love and prayers!

Estoy cuidandome.

It was 6:30am Monday morning, end of my call and waiting for my patient to be extubated, the Anesthesiologist joked with me. "We've still got 30 minutes left! We can squeeze in another!" To which I responded, "I can still go grab the gallbladder!"  The gallbladder to which I was referring had actually been the very first case I'd booked for myself on call, then traumas and other emergencies kept pushing it back. To the point that we ran out of time and I never actually got to do it at all. Not for a lack of operating, my anesthesiology colleagues we soooo mad at me that call. When I finally got home that morning, I crashed harder than I had in a long while. Absolutely dead to the world. When I finally came to and reaching for my phone, discovered I had missed a lot. Spent the short evening I had left attempting to organize myself... only semi-succeeding. It reminded me of the various conversations held over the past 7 years with my colleagues surrounding the best way to present ourselves and our lifestyle to society. Concerning the work/social life balance, how to keep it steady, what is enough, acceptable and appropriate. Questions and conversations that perhaps will never truly have a standardized response, as they are going to be different for every individual. The joy of work, the peace of purpose and the love of life shown and received different by each resident in their own unique way. 

A lot of times sacrifice is thought of at the expense of social activity in order to work. In my experience, knowing the need for social interaction, that sacrifice frequently comes at the expense of my work and/or rest. Which is what happened this past weekend, prior to another heavy call, culminating in the exhaustion that led to me falling asleep, sitting in a chair, mid-dictation and ultimately crashing when I finally got myself home.

The day before, on my day off, instead of sleeping, which is usually the #1 priority on an off day, I woke early to get work done in time to go apple picking! Monica, Alex and I drove up to Barton's Orchard. In this case, sacrificing sleep and studying to instead get outside, in the sunshine and separate myself from the hospital for a moment. And it was worth it. It's always worth it!

Alex, Monica and I picking apples at Barton's Orchard.

Relaxing in the middle of an orchard, because.... why not?

Sometimes you go for the highest apples, because those are the best ones of course! Plus, the most fun to try to get at!

 

There's never an easy answer to maintaining the work/life balance. Plenty of lectures, talks, books, etc on recommendations and advice and How To's. I tend to ignore the general recommendations, feel when the balance is starting to tip and then act to counteract the tip. In retrospect, more reactionary than proactive I suppose. But, I have very few regrets. One regret however.... that I didn't get more of Barton's apple cider donuts. They were. Amazing!

 

Much Love and Prayers!

Estoy escapando.

 Stayed post-call this morning to do a quick case with one of my favorite attendings. Patient had a gigantic cyst in the liver. I popped it, sucked out all the fluid, and the liver deflated like a balloon!  I then fenestrated the roof of the cyst and took care to make sure it never comes back again! Closing the port sites at the end of the case the scrub tech asked me if I wanted any glue, to which I responded "Por Favor!" Albeit, I admit, a bit more overly exuberant than necessary. But thinking that I had said "Praise the Lord!" The nurse in the back of the room joined in with a hearty, "Amen!" And we all laughed!

Managed to get W.O.W. together again. Expanded the event to include some of our fellows and med students interested in surgery. I reserved escape rooms. Had enough people that we had to split up into two different rooms. Both groups managed to escape in time!

Our task was actually to break into a police station and get the safe code off of the chief's computer for the bank safe! Consider the bank robbed! jk we gave the money back again afterwards ;) R to L: Clara (pgy4), Alex(recent grad, waiting to start fellowship in Boston), Aparna (med student), Christine (MIS fellow), me, Monica (MIS fellow)

The second room had to do with aliens, not sure of the story, but they escaped with 58seconds left! (Mary, Michelle (critical care fellow), Kira (pgy1), Thanh (pgy1), Sara (pgy2), Alex (pgy2)

L to R: Alex, Sara, Alex, Clara, Mary, Michelle, Me, Thanh, Monica, Christine, Kira, Aparna

Such a lovely bunch!

Much love and prayers!

Estoy enterrada.

 I was supposed to have time to study this week. Or even before getting to study, I was supposed to have time to catch up on paperwork, applications and presentations all with due dates looming over me. But that's just the thing with transplant, you can't predict when organs will become available. You can't really make plans, or you'll end up like me. I had planned to get my mountains of pending work done, and I am now a week later... still with none of it done. (Well, I did manage to squeeze one presentation in and off the list). 

I mentioned a difficult transplant on my first day on the service. By the time I was home post call from that liver, donor OR time for the next was already set. I went in early for the transplant, another difficult case taking all day. By the time we finished the donor OR for the next liver was set and the kidneys were starting to line up as well. The kidneys went all night long that day. Thankfully my co-chief who was on call stepped in for one of the kidneys so I could run home and take a nap. The following day liver and kidney were going simultaneously, I took the last kidney as it was for the same patient that I had just transplanted his liver the day before, and my rotator covered the liver transplant. I then waited for my attending to finish the liver so we could take our first liver transplant for a planned trip back to the OR. The same the next day as well. By that fourth day... I was seeing my attending start to crack. SEIGO is a machine. One of the other liver attendings, knows when he's reached his limit and calls is quits. Plus he has a huge elective practice that he has to spend time to keep up. He only lasted two livers long. Our kidney attendings, also know when to call it quits. Then there is one liver attending who is the newest to the practice and follows SEIGO's lead. He tried to keep up, but I noticed him start to nod off and have to take breaks. But SEIGO is a machine, he just keeps going, seemingly without sleep. I thought he was amazing!  But then, as I said, he started to crack. On the fourth day, during a long case with me, it actually scared me at first. He would spontaneously and suddenly look at me and scream, followed by a laugh. His hands were shaking and he frequently grunted. Then he started to repeat himself, asking questions that he had just asked two minutes before. But by the end of the case, I had slowly deciphered this new side of SEIGO. First, I finally recognized that he wasn't screaming, but it was actually his attempt at singing. Music is one of his escapes, one of his coping mechanisms. And while he's working, he frequently has a song going through his mind that he must suddenly and spontaneously let out. This song in his head does not always, in fact frequently does not actually match with the song currently playing on his play list. The more tired he is, the more he sings. Second the shaking and grunting, comes from plain old wear and tear on the human body. I realized, he is not machine, but merely man. Standing for hours, the physical toll on his body from bending over and holding the liver to work, he was physically in pain. Never complaining about it, but with every grunt, I could feel his pain. As for the repeated questions, at one point I was finally able to convince him to break scrub and grab a coffee quick. He could think a little bit clearer after that once again. I still think he's amazing, but not as a machine now, just as himself. 

I now have one day to attempt to get all of the work done that was supposed to happen this past week. But first sleep. I just hope I wake up again before Monday starts in order to do it!

Much Love and prayers!

Estoy parte de un servicio nuevo.

 Transitioned to a new service this Monday. For the next three blocks I'll be chief resident on the Transplant/Hepatobiliary Surgery service. Started out with a bang! Not only was I on call, but one of my patient's got a liver and the transplant went all night long.

It was a tough night for everyone involved. Our patient was incredibly sick to start with, my Attendings and the anesthesiologists had to fight and fight hard for long hours. While this was happening, level 1 traumas kept coming in. Working with my senior on call, at one point we had to pull our intern from the floor to cover the transplant as I needed to help with the level ones and our junior was already covering other cases that were happening. This left the floor uncovered, but when fires are burning, you work collectively on the biggest flames and then spread out again. I think my senior aged 5 years that night. Active resuscitation on multiple patients simultaneously, intubating multiple patients, playing musical beds in the ICU... for all those patients being intubated and resuscitated. So many decisions to make and make them fast. Our Attending AWOL throughout it all. We kept things under control, kept everyone alive, operated on those that needed it, and when all was semi-stable again I would head back to the transplant to free up our intern, and then our junior to once again tend to the floor and help with the fires happening outside of the OR. My senior would then come into the OR to run things by me... at that point he didn't really need my help, more my approval of his decisions and reassurance. 

It was also a long night for everyone. I actually fell asleep during the transplant. Was close to 5am at that point. I caught myself, and used peripheral vision to quick check if anyone had noticed, no one had. If it wasn't for SEIGO yelling at me every 30 seconds, "SUCTION! Christy SUCTION! look! look! like this, USE TWO SUCTION!" I'm sure it would have happened more than once! But when I finally rolled my patient into the ICU, the morning was well underway, the various surgical teams already running through the halls to check on their patients prior to heading to the OR. I ran into my senior one last time after he escaped from morning report, and I could relate to the look of absolute defeat in his eyes. I hated myself for not being able to help him more, and did my best to reassure him that he did a good job, and now needed to let go of the rest.

Welcome to Transplant indeed! We have another one tonight, so should probably get some rest quick!

It was actually a little bittersweet to leave Vascular behind. Crazy busy three blocks, but I enjoyed it. I was incredibly blessed to have fantastic teams for each block. You can like what you do, but when you enjoy your team and can trust them, it makes such a huge difference. 

 Block 1: Moe (pgy3), Nicole (pgy1) They did fantastic for being a small team for the first block of the year! And when I texted them to ask for a picture they both showed up and smiled! I hope that means their PTSD isn't that bad!  jk...i hope ;) 

Block 2 I don't have a picture of because my intern was then on night float, so need to get a picture now that she's back on a regular schedule again.

Block 3: Kamil (pgy1), Aryeh (OMFS rotator), Kenji (pgy3)  They also did a fantastic job. They kept our whole team laughing as well. Made for a fun time taking care of our patients with these guys.

Much love and prayers!

Estoy trepando los árboles.

 As we hit halfway through September the general expression I am starting to hear is something along the lines of a desire to no longer be in the year 2020 at all. I can understand. There's been many a year I've been thankful to finally see behind me, never wishing to see the likes of again. But learning, growing and surviving through those years shape us as people and individuals. Our loves, losses, passions, regrets. They serve a purpose in our journey, and wishing to be out of that journey... we run the risk of missing out on those life-altering moments that happen upon us perhaps in the most unexpected time, place and manner. 

I have frequently questioned God on his timing. He patiently permits me to do so, knowing that with a little reassurance I'll calm down again and move on. His will, not mine. For example, I'll admit, I've asked why He's kept me in New York for so much longer than was originally expected. Why here, when I was willing and able to go anywhere? But he choose New York to bless my life, the reason for which He will reveal in His own time. In the meantime, I am thankful for those blessings, and the impact each and everyone has had on my life.

Last weekend, I left my Vascular service in the capable hands of my team, and went exploring in my backyard. Jenna Hartter, Emily Walder and Amanda Virkler joined me in New York Friday evening. Friends that I haven't seen in 6+months. Friends with whom multiple trips and plans were cancelled this year due to COVID. 

Me, Jenna, Amanda and Emily. Saturday morning, Amanda sadly had to leave us for family. But Jenna, Emily and I headed North to get lost in the Catskills. 

Peekamoose

 

Peekamoose

 

Table Mountain

 

Emily captured a handful of candid shots.

A couple of them were real winners!

 

 

 

Some pictures don't need an explanation.They make me smile looking at them and remembering our time in the Catskills.

Camping in the middle of the forrest Saturday night. All of us a combination of sweat mixed with dirt and then frosted with campfire smoke. We shared our campsite with the local deer and chipmunks who were gracious enough to allow us passage through and rest.

So many blessings in 2020. Small, disguised as insignificant, but created specially for us.

Much love and prayer.

Estoy sin palabras.

 I sat trying to dictate what I had just seen. What I had just done. And found myself at a loss for words. There was no official medical term for what I was trying to describe, so was struggling to make my explanation sound official. 

I had been on call and making my way through the list of surgeries that had to get done for the day. This particular case was booked as an Incision and Drainage of a right arm abscess. The patient himself.... not the brightest of fellows as despite strict instruction to not eat anything, had somehow gotten ahold of food. Which moved his case to the end of the line-up and brought us up to about 2am. He had a history of IV drug abuse, with concern for needle being lost in his arm, leading to infection, and bring him to our operating room. I've performed I&D's for similar situations multiple times in the past so honestly, was not quite expecting what I found. The patient had already undergone 2 I&D's on his arm at another hospital prior to coming to us. But when I took down his bandages, I found pus pouring out of his open incisions from those past I&D's. I always feel silly prepping something that is so grossly infected, but I went through the actions nonetheless and dumped on the betadine, skipping the washing part and going straight to the painting part. On exploration of the wounds, the patient's tissues literally would disintegrate between my fingers. I'd probe along the fascial planes and feel the tissues melt allowing more and more pus to escape. I keep going, opening the wounds even wider, looking for any sign of healthy tissue. I could grab chunks of muscle and it would break off in my hand, dead and disintegrating from such horrid infection. Sticking to the basics, which when dealing with such necrotizing soft tissue infection, is wide and aggressive debridement, I kept going until I stopped finding new pockets of pus and I hit tissues that pushed back. I left drains through multiple of the tunnels I had created to prevent any pockets from reforming and blasted the whole arm with pulse lavage, and lots of it. And as I packed the wounds now gaping and bleeding, I kept having to ask for another roll of packing, the defect swallowing up roll after roll.  

I am forever amazed at what our bodies are capable of bearing. What damage we are capable of bringing on ourselves. And I wonder just what pestilences I shall yet see before it ceases to amaze me. I am both thankful and fear I shall never cease to be amazed. 

Much Love and Prayers.

Estoy preparando por la próxima semana.

Already a week into Block 3 of the year. It’s going by even faster than I could have imagined! I had a brand new team start this past week. I was a touch more apprehensive than previous blocks as I had never worked with any of my team members before, and therefore wasn’t sure if I would need to alter my approach at all. Turns out, on Vascular, there’s no time to worry about your approach anyways. But for the most part they all kept up, even caught on quicker than last block. Maybe members from last block gave the incoming residents helpful pointers? Probably, but eitherway, I hadn’t needed to have worried.

As nice as it is to be busy and operating every day, I’d be lying if I said keeping up with the active schedules of all 6 of our Vascular attendings wasn’t exhausting. In the first 8 weeks (2 blocks) there was a grand total of one day, I had been able to spend some extra time with my team. And that one day, happened only because one of our attendings was on vacation that week and it was usually his operative day. It happened for the second time this past Friday! Again, because one of our attendings was on vacation and its usually his operative day. My rounds in the morning, took probably twice as long as they usually do, as I spent time with the medical students going over presentations.  I had warned them the day before to be ready, and they did a fine job. I’d wait till they finished, racking up the corrections in my head as they presented, then go back over them one by one. I was nice… at least I think I was. Told them they were doing a fantastic job, etc. Yet, for one student you could see the beads of sweat multiplying on his brow as he shuffled back and forth before me trying to get through his presentation. I should make more of an effort to have the students present more often, with practice it’ll become easier for them.

I still got to operate that day. It wasn’t Vascular, but I helped cover a case for the Thoracic team. And then, I had plans to spend time studying. But to my happy surprise, each time I walked into our chief call room, I’d find my co-chiefs Ansab and Ash, chilling and talking. So of course I had to join them. This had never happened before! Our paths cross, yes, but usually it’s while one of us is either running in or running out of the call room and consists of a Hi and Bye! So, by the end of the day, I hadn’t studied at all, but we had discussed schedules, interns, attendings, futures, struggles and methods of chiefing, and I had even gotten lunch! We all concluded that it was a very weird day, but welcome. We wouldn’t change it.

All of my Attendings are back again this week, so planning for a very full and busy week once again.

Much love and prayers.

Estoy disfrutando el verano.

Ever since moving away from Central Illinois and becoming separated geographically from everything and everyone I'd ever known, social media has been an important avenue of information for me. Partly my own fault, I make minimal effort to maintain open active communication on a regular basis. Communication not a forte of mine, believe I've mentioned that before. And partly, that's just how life happens. Out of sight. Out of mind. When someone moves away, they exit and enter spheres. These spheres I'm referring to, being the small bubbles that each individual human being walks around in, contain an entire universe individually personalized for their specific human being. Some spheres are smaller, some larger, but we all have them. Just meet someone new, watch your own sphere expand. 

Anyways, social media has helped me stay updated as my friends have grown their own spheres. It's nice to not be completely out of date when I am able to make it home for visits, or am struck by inspiration and initiate a string of texts, etc. Over the years, this same avenue of information, has provided its own fertile ground for seeds of discontent from time to time. Was much harder to stop the growth and weed immediately 10 years ago than it is today, but I'll still catch it from time to time. Summertime is one particular season that I've grown to dislike less and less over the recent years. Watching through pictures and posts as one by one friends and families get together and enjoy each other and being outside, while I am not. But inevitably comfort is always provided. For example, a few brave souls agreed to meet me for a picnic at the beach the other day. 

Due to my own stupid carelessness, I'd had recent contact with COVID positive patients without wearing the appropriate PPE. Since that time, I'd caught myself and corrected my actions of course. I confessed, and they still agreed to dare come within 6ft of me!! (Don't worry, less than 6ft and we had our masks on!) So I got to have my own summer vacation with family and friends!  It only lasted an afternoon. But it was sunny, and warm, and relaxing!

Silver Sands State Park. CT. with Emily & Kate Walder and Cheryl Ryan

Silver Sands State Park. CT. with Emily & Kate Walder and Kevin Ryan

Silver Sands State Park. CT

 

Silver Sands State Park. CT

 

Happy Summer feelings!

Much love and prayers!

Estoy ayudando a mis profesores.

 I've noticed my Attendings pushing me on the oxymoron that is the practice of medicine. They ask me, "Are you sure?" The truth... there is never anything 100% in medicine. I've seen it time and time again, there is no guarantee. I know it. They know it. They know that I know it, and I know, that they know, that I know it. So really, it's a test. After glancing at a chest xray for 5seconds, was that enough time for me to weigh the risk that I missed something, and despite that, make a decision about patient management. Yes. The answer is yes. In my opinion, indecisiveness and/or fear to make a decision due to the plethora of reasons readily available in medicine, is often the more dangerous option. For everyone involved, from the patient, to the nurse, to the family member. So practicing what I preach, when the patient, filled with bullet holes, looks at me en route to the operating room, and asks if he is going to die. I say no. No sir, not on my watch. We got you! You're going to be just fine. I don't just say it once, I say it multiple times, in many different ways. The patient needs to be on board with this plan, and if my decisiveness will help him feel that then, Yes, I am sure!

I recognize, that as a resident it is still exponentially easier for me to have this opinion, then when I will move into the position of attending and become ultimately responsible for such decisions. Hence, why I make a point to exercise my decision making practices as much as possible now before entering into that different tier of responsibility. 

On the otherhand, I also recognize that as a resident, I am allowed a certain level of leeway on my knowledge, and from time to time am still allowed to say, "I don't know." I used that unspoken margin of freedom the other day. Was working with my attending through an angiogram, and we quickly identified our patient's problem. Looking at the details of our patient's blockage, my attending made a decision based on a potential complication that he could see happening should we be successful at clearing this particular blockage. To prevent such a complication required the use of a very specific catheter, one which I have never used before myself.  I watched, rather uselessly, as my attending attempted to assemble the catheter. Unsuccessful in his attempts, I could see the gears spinning through the options in his mind. Should we just proceed without the specific catheter, it is just a possible complication afterall. No guarantee it will happen. I finally played the resident card, leaning in so only my attending could hear me (the patient was awake for the procedure), I asked if he'd like me to break scrub and youtube a video. He thought a second longer, pausing, before dropping his head and nodding. Sure enough, there is an excellent instruction video on youtube, through which we were able to identify our mistake in the catheter assembly. The procedure went by successfully, and sure enough, my attending had been right. That special catheter prevented a potentially devastating complication from happening. My attending, heartily thanked me for looking up the youtube video, his relief almost causing him to be emotional.

At the end of the day, medicine keeps me learning, keeps me humble. It is the great equalizer. Even while answering, Yes, I am sure, a part of me judges myself for such a lie. 

Much Love and Prayers.

Estoy peleando una batalla ya perdida.

 What is Vascular surgery? Easy answer is surgery on the blood vessels, the arteries and veins of the body. A seemingly invisible roadmap that runs throughout our bodies, avenues, highways and byways that allow blood, carrying oxygen, from our tiptoes to our nose. And in so doing, allows life to persistent, for as I explain to so many patients, oxygen means life, without blood there is no oxygen, so without blood there is no life. A Vascular Surgeon's job is to ensure that blood continues to perfuse all the way from those tiptoes to that nose and everywhere in between. When our own roadmap gets potholes, downed telephone wires or perhaps herds of sheep clogging the way, blood flow becomes disrupted, tissues downstream become starved of oxygen and start to die. The Vascular surgeon must fix the potholes, move the telephone poles or find and/or create a way around, and get the sheep off the road before the ischemia down-stream becomes irreversible. 

It can be incredibly rewarding to finish a case, do a pulse check and find a fat bounding pulse where there wasn't one before. It can be incredibly elegant, cleaning an artery and then patching it back together, the finest suture placed technically perfectly. It can also be defeating, mentally, emotionally and physically. 

There's a joke that a vascular surgeon really only needs a few patients to stay in business. And that's a funny joke, because it's so true. These patient's that I've been seeing over the past weeks have known my attendings for 20+ years. So many of their faces I recognize from my own past experiences on the vascular service, only last time they had more of their toes, or they still had both limbs back then, etc. 

The other week we had a new patient, not your typical vascular patient (elderly individual with multiple co-morbidities). In fact the opposite, young and relatively healthy except for her odd history of strokes and blood disorder causing hypercoagulability. She had gone to other hospitals complaining that her toe hurt multiple times and been sent home each time. By the time she got to us, not much blood was making it to her foot anymore. Over the course of two days, I spent a total of 15 hours (8hrs + 7hrs) in the OR working on her leg. We got it to her foot at one point, but it didn't last. Kept trying old tricks and new techniques, I actually learned a lot in the process, but nothing could get the blood down to her foot. Flow stopped at her ankle. At the end of those 15 hours, I sat exhausted with my attending, both of us trying to smile but it coming out more as a sad pathetic chuckle. Tough defeat to swallow. We didn't do the amputation until almost a week later. The delay wasn't a patient factor, she was mentally prepared and ready sooner than we were. It was surgeon factor.

That's the thing with Vascular surgery. It is fighting a loosing war. There may be intermittent successes, but the question is always, how long. How long will it last? Because it will eventually fail. Despite maybe two or three or even four battles fought and won, there will always come the final battle where all will be lost. 

 

Much love and prayer!

Estoy capitán de W.O.W.

W.O.W. was started my first year of residency as a prelim intern, by the female chiefs that year Irlna and Alison, 50% of our program was female that year. Women Of Westchester was designed as a support for female surgical residents and has remained in place since that first year. In the seven years since its initiation, not all years have been as successful as others, mainly due to the female chiefs of any given year. Some were more invested, and others not so much.

I see the benefit of a group like W.O.W. and have advocated for its continuance especially during those dry years when there were no female hires and female chiefs more interested in... other things.... than creating an environment of support and camaraderie.

Now W.O.W. falls into my lap, and I quickly realized that supporting W.O.W. and encouraging others to plan events is so much easier than doing the actual planning myself.

Living in a dirty study apartment where there is no more than a pair of folding chairs to sit on and every inch of table/counter space is buried under stacks of papers, articles and books filled my head with a plethora of reasons of how I could not possibly host a W.O.W. event myself.

So I had to first get over those excuses, warn everyone that we would be sitting on the floor, and then do a more thorough job of cleaning than, well, I don't really want to know since when.

Unfortunately, the day of, in the middle of scrubbing my apartment, I got a message that one of our ladies had been asked last minute to cover at the hospital. Despite trying to find an alternative option, we were unable to do so, meaning that we could not all be together. But 7 out of 8 is pretty good at least. We all sat on the floor and played games, ate food, and made plans for the year. Successful first W.O.W. meeting of the year!

Our brand-new categorical interns L to R: Thanh, Nicole and Kira

PGY2s: Alex and Sara

Sara demonstrating how to play The Mind. (A group card game where you can't talk to each other)

W.O.W. '20-'21

We were missing Ida, and took our group photo after Clara had already left. We'll have to commit to better planning of the photo taking next time.

L to R: Me, Nicole, Alex, Thanh, Kira and Sara

Much Love and prayers.