Estoy aqui.

The hospital is having to adapt daily. It started with sections of ICUs, then two whole ICUs, now.... they're all COVID ICUs, and any non-COVID ICU patient is over in the ACP. And, that's just the ICUs, non-ICU COVID units have taken over entire floors.

They called in the reserves. There were two COVID teams of medicine residents, pulmonary fellows and Attendings. Then a third calling in the GI fellows for assistance. Then a fourth calling in the Cardiac fellows. Yesterday they called for a fifth team. We are that fifth team, made up of Surgical Critical Care Attendings and surgery residents. I am finishing out my week currently on Cardiac surgery and my general surgery call; will then transition to the COVID unit next week.

I'm trying to read everything on COVID as soon as it comes out. My resources primarily New England Journal of Medicine, Brigham and Women's Hospital COVID-19 Critical Care Clinical Guidelines. I have the rest of this week to learn from others; what has worked vs. what hasn't. How the lungs respond to more PEEP vs less PEEP, and on it goes. I'm not so far removed from medicine or critical care. It actually was an argument that I made in more than one personal statement back in the day. Medicine is baseline, everyone is a Physician first. As a surgeon I could then theoretically treat medical disease AND surgical disease. Not easily done in the opposite direction.

It's strange looking forward, in this, my current present reality. I don't see an end. Praying to hold onto hope and purpose and of course, Love. And if possible, to lend some to those around me as well.

Much Love.

P.S. still asymptomatic ;)

Estoy operando en el corazón.

COVID continues to take over the hospital. Overnight all non-COVID patients of two of our ICUs were moved to the pre-op area of the ACP operating suite. Ambulatory Care Pavilion, a large 7 story addition to WMC that just opened a few months ago. The area was not built to house ICU patients, but we're making due. Next steps, converting ORs to house ICU patients. Patient's sharing rooms and ventilators. And last...deciding who gets the ventilator, and who dies.

It's already proved to be so in other countries. It happened in Italy, a country with more hospital capacity per capita than us. If it happened to them, it'll happen to us. Numbers wise we broke 7000 cases in Westchester county today. Considering 1,000,000 to be the number of people in this county, means we haven't even hit 1% yet.

As the infections, and now deaths, rise around us, I've noticed my fellow co-residents getting increasingly jumpy. About masks, about the cleaning of our lounge and call rooms, about any cough no matter how small. This morning, one of my co-residents realized she couldn't smell anything and started panicking until she remembered... she was still wearing her N95 mask. For the most part we all recognize it and laugh at ourselves. My last call we had ordered food and sat in the lounge waiting for it's arrival, very pensively my chief spoke up "you know, one if us will probably die." My junior, who is jumpy at baseline, just about fell out of his seat with a startled surprise. And we were all able to laugh. I personally don't think any of us are going to die... end up on a ventilator maybe, but die no.

I myself know that I've had positive COVID exposure. Thus far, am asymptomatic, so I know what I'd be told. Wear a mask, go to work, call us back if symptomatic. So am I actually infected, probably not, but I act in the hospital as if I'm a carrier at least. Purell before and after touching anything, and always wear a mask... it makes drinking my coffee rather difficult. Upon entering the hospital there are stations to check everyone's temperature, and I find myself holding my breath until they tell me I'm good.  Perhaps, I'm a bit jumpy too. A bit upset as well, just at the idea that I could have the virus. Here I am warming the bench, saying "Put me in Coach, I'm ready!" Only to be taken out before even getting to fight? I don't like that idea.

I also had a conversation with one of our prelim residents who will be transitioning to Radiology for next year. In accordance with her interest, she had been looking over all the chest xrays and ct scans of COVID patients. She commented that by the time a patient has become symptomatic, the extent of the fibrosis within the lung is already quite severe. In five years time, 10 or 20 years time, what will be the effect of COVID on its survivors down the road. Another idea I don't like to think of as a potential reality for my future.

You know what I do like to think about? Surgery!! I got to operate on a beating heart today. It was just for a small bit, we were setting up to go on bypass, and the Attending handed me the suture. It's one of the things that I admire and respect so much about Cardiac surgeons (at least all that I have been blessed to work with), their rock-solid steady hands when working on a jumping target. It's like artwork, it's beautiful, takes my breath away and makes my fingers tingle. And I got to do it today!

Much Love.

Estoy preparando.

That calm that pervaded the hospital last week, quiet and foreboding-like, it has ended. It was indeed the calm before the storm, and the storm came to Westchester this past weekend. Seems like every which way you turn a new area is being converted to house COVID patients. Anesthesia residents are being asked to help cover medicine shifts as so many of the IM residents are out. I’m still hunkered down amongst the ranks of the reserves.

My co-PGY4s requested to have a meeting with our program director, to discuss issues in the foreseeable future. Being a potential 5 people, we thought we were safe, and maybe we were, but still went the way of virtual meeting anyways. Social distancing is beginning to emerge as the largest factor limiting the spread of COVID and protecting individuals. Although we have not joined the ranks of those WFH, my co-resident tweeted out "the new normal."

Society has changed, is changing, forever.

Much Love.

Estoy saludable.

As the COVID-19 pandemic continues to develop before our eyes; we all struggle to adapt and abide by the restrictions being invoked.

COVID-19 is not a surgical disease, and as a surgery resident, I am therefore not on the frontlines. Not yet at least, should I be called to step up in the coming weeks, that could easily change. But for now, I'm not caring for any of our cases. I am being affected in other ways.

This week, ACS/ABS called for all elective surgery cases to be cancelled for the next 6 weeks. This does not include emergency, trauma, or cancer surgeries. Cancelling elective cases will limit unnecessary inpatients leaving as much space in our hospitals for new coronavirus cases as possible. It will also limit OR personnel, anesthesia, surgical and nursing personnel required to be in the hospital on any given day. We, as a residency, have shifted to a weekend-type rounding schedule for the forseeable future. Being on my cardiac elective, I did not immediately feel the effect of this change. But throughout the week, we have worked our way through all of the inpatient cases that had been pending. Each day I found myself heading home earlier than the day before. In fact, today was the first day that I did not have any cases myself. My only job today was to remove a patient's chest tube, and once done... I left the hospital again.

Walking through the hospital, you can get an eerie sense of calm before the storm. There's no visitors, decreased ORs running, no clinics open. Our cases are tucked away in the COVID ward or behind doors in our ICUs. Today Gov. Cuomo, announced New York to be on lock-down starting this Sunday. The cities' hospitals already can't handle the cases, and as he explained, we can't increase number of ICU beds and ventilators therefore lock-down is attempting to affect which factors are in our power to alter. Time will tell. In the meantime, waiting for the overflow to start affecting us here at Westchester.

There's an incredible shortage of personal protective equipment, an issue I know is not isolated to just Westchester. We have to sign our life away to get a mask... and then don't get another one for a week. We instead are issued a brown paper bag to keep our PPE in for reuse. In Mexico, most of our PPE was reusable. Masks and gowns were sterilized and reused. I wonder how long it'll be before we have to use alternate options. In the meantime, there's a fair amount of memes being circulated. For example...

Funny. Not funny.

I am trying to keep myself motivated as possible. I have frequently desired the energy and time to be able to go for a run on a daily basis. And now.... I would rather be back operating again. They have set up drive through testing in my parking lot just behind my building. Realized what it was as I weaved through traffic cones and appreciated the rows of police cars and officers there to keep order. Not awkward at all... I adjusted my route and now run around. I am very thankful that I can still go to work, that I will still receive a paycheck. But I feel very unuseful. I'm not on the frontlines. Could be called upon if needed, but right now, I'm stuck in the reserves. I have a couple of calls this coming week, so expect to feel better being able to help in that way.

Much Love.

Estoy operando en el corazón.

I get to spend the next few weeks operating with the cardiac guys. Cardiothoracic surgery is technically not considered part of "General Surgery". I'm not sure when that happened, but we as residents no longer get to rotate on the cardiac service here at WMC, but we do on the thoracic service. There has to be some politics involved in the reasoning behind that, hence the reason that I don't question nor try to dig deeper into the reasoning. I'm content with the thoracic experience I have had thus far and am thankful I get a Cardiac rotation now. It's relatively new, and not every resident gets the opportunity. It started last year with one of my co-residents who was considering a future in cardiac surgery himself. He requested the rotation and was granted it. I was asked for this year if I would like to have a block in cardiac myself. I didn't hesitate in my answer.


Since there are no residents, the cardiac service is staffed by PAs and NPs. They have a well-oiled machine. Everyone has a job, they know their position, and they know what is expected of them. Thus far everyone has been very receptive to my presence. In general, the OR staff already knows who I am, so other than asking why I am in a Cardiac room they don't mind. The cardiac attendings also know me already and don't hesitate to teach. The PA's have been very nice, and only one has thus far been condescending. In my experience, PA's tend to be territorial. As I described, they have their specific job, and they take pride in it, or at least a good PA does. So when someone they don't know comes in and suddenly they are asked to step down the table, they can subconsciously resent that someone. Some PA's hide the resentment better than others. I've made a conscious effort to make sure everyone knows there is a time limit to my rotation.  Primarily, so that the PA's can take solace in the knowledge that my presence is short lived, and hopefully reduce any condescension to a minimum.


It's only been a few days so far, but I'm having a blast. Referring to the well-oiled machine, it is a very busy machine. I basically don't leave the OR all day, finish in one room, and then move to the next, and then the next. I haven't participated in cardiac surgery since my rotation as a student in pediatric cardiac surgery, easily the best month of my medical school career. So excited to get to participate again, just absolutely fantastic surgeries!!!


Update on coronavirus: our medical students are all banned from the ORs. First, shortage of masks due to theft. But also now, there's a shortage of masks, gowns, eye wear and hats which are all produced in China. So everything is rationed.
We had a resident out sick with the flu yesterday, he is now quarantined until he can get tested for coronavirus and due to lack of testing not sure when that will be. Call schedule rearranged until further notice. I figure, might as well work, nothing else is going on the world over!

Estoy luchando contra la política.

Coronavirus was officially labeled as a pandemic today.

Do you know what is more dangerous than a pandemic? The fear caused by a pandemic.

I came back from Anguilla and found everyone afraid. What should we do? and what will we do? Westchester, a little behind its surrounding hospitals here in New York considering its proximity to New Rochelle, finally rolled out its policies and protocols on what to do and when to do it today for us as employees of the hospital.

I have mixed feelings.

I had a patient come the other night as a bad trauma. Based on injuries, looking retrospectively, was the course unsurvivable? most likely. Was the patient already there when they even came to us? probably. What I can't justify in my head, is that we won't ever know. The patient came with a story completely unrelated to the trauma that a week prior had been to a doctor's office that might have possibly had a COVID-19 case. But no one could either confirm nor deny, and the only thing family could offer was that the patient was healthy, not even a cough. But the idea of it, caused such confusion and fear, that the fact that a patient lay in front of us needing help was placed on the back burner. The nurse assigned to the care, is honestly a very good nurse, but was exhibiting behaviour I had never seen in her before. She had an excuse of how or why she could not perform a single task to care for the patient, quoting policy after policy. As I rushed to throw in lines, she turned her back on me, commenting over her shoulder passive aggressively how I was not following protocol. As her blood pressure barely registered and we were about to loose a pulse, there wasn't time for protocol and passive aggressiveness incredibly inappropriate. In the end, my efforts futile as the blood so desperately needed sat in a cooler on the floor, the nurse refusing to let it be given, again quoting policy after policy.

Anger. I was so angry at the situation. Screaming in my head at everyone being so ridiculous, while our patient lay actively dying. I'm still angry. This is medicine in America. Policy and protocols created by non medical entities of business and insurance. Combine that with an individual's own desire for self-preservation and mix it all up with confusion and fear and you have created yourself a healthcare equation that has successfully eliminated all consideration of the actual patient.

Was our patient's injuries unsurvivable? as I said, most likely. But... could we have at least tried? attempted? anything?

When the WHO declares a virus as a pandemic, it is appropriate and necessary to respond with policy and protocol to protect the people of our communities, our countries, and of the entire world. However in so doing we can not loose reason to fear. We still must attend to the care of the sick and the need of the hurting.

Much Love.

Anguilla

There's a full moon tonight. Anguillans love the moon and were excited at the coming of the full moon. Even last night, one night before the full moon, they'd point it out and exclaim, look at it! look at it! tomorrow it'll be a full moon! tomorrow it'll be a full moon!

Typical island fashion of saying everything twice.

The current adult population of Anguilla remembers the island without electricity. My last evening on the island we spent some time at Lime Keel. John named his restaurant after the spot where they had gone fishing as boys, Lime Keel. John remembers at 20 years of age digging the holes for the poles for the electrical wires. Prior to that, the island was dark at night, save light provided by the moonbeams, and some nights those moonbeams were so bright the bush was lit up clear as day. They would have picnics by the light of the moon.

I wish I could see this full moon from Anguilla yet tonight.

 Anguilla Medical Fair staff!

 Group of the female staff at the Anguilla Medical Fair. Babara - ENT, Corrine - CTS NP, me, Marjorie - Pediatrics, Monique - Opthalmology

Flying into St. Maarten, one can still see the afteraffect of past hurricanes. Not so much destruction noticeable on Anguilla, save a random broken winding staircase, etc.

No one locks their doors or their cars on Anguilla. For good reason, there's no where for a thief to go. In addition, everyone is so welcoming. The doors are not just unlocked, they're propped open as well. Even the Four Seasons resort, lifted the gate for us as we approached. We stopped by for a look around, I definitely did not stay here

 This is where I stayed, the home of Lanville and Evette Harrigan. This is the view from their second floor balconey. Looking out towards St. Maarten.

 Backyard balconeys looking out towards St. Maarten.

Shoal Bay: So many beautiful beaches on Anguilla. The water clear blue, the air warm and clean.

Shoal Bay. From a distance Anguilla is flat and covered with bush, and much less appealing than mountainous islands such as neighboring St. Maarten or St. Bart's. It has kept Anguilla from being trampled.

 Beach umbrellas at Shoal Bay

Shoal Bay

Site of the Medical Fair was at the primary school in Island Harbour on the East End of the island. As little kids sitting in school rooms, this is their view. As you can imagine, hard to maintain attention on their studies with the ocean calling to them. Every Friday after class, they'd all swim out to Little Silly, the island there in the middle of Pelican bay.

 Another view of the bay and Little Silly from the medical fair.

 The rest of the docs were given a villa to stay in during their time on the island. It served well to double as our meeting place before and after the fair to eat and regroup.

 Crystal Sunset Villa on Sandy Hill

Fish for breakfast, lunch and dinner. On Sundays, they would get chicken, a special treat.

 And lobster, grilled. Not boiled, but properly seasoned and grilled. 

 Sandy Ground

View from Little Silly back towards the primary school (location of the medical fair).

View from Little Silly back across Pelican bay.

 Relaxing on Little Silly. 

Sunset across Pelican bay.

 Conversation under the moonlight at Lime Keel. Everyone is a brother, a cousin, and a friend. Even enemies are first and foremost friends and brothers. If there's a disagreement, it'll start with a thump on the back or a hand on the shoulder and "Man, youse got to listen to me! youse got to listen to me! She's good people. She's good people" Should any disagreement end in a busted nose, it's forgotten by the next day.

Same view from second floor balconey of the house I stayed in looking out towards St. Maarten. 

Much Love Anguilla. Much Love.

Estoy sin deseado.

My rotation on Endoscopy progressed more or less the same from day to day. I'd show up in the mornings, figure out which Attending did not have one of the GI fellows with them for the day, and approach to ask if I could work with them. All but one of the Attendings would produce a visible cue of unwant to my question. Whether it was a sigh before responding, a deflecting comment, or a shuffle and a muffled response about how they have to get done in time for a meeting, etc. etc. I ignored them all, I will most likely have to do my own scopes at some point in the future, so I was bent on learning as much as I could. I knew I was not going to come anywhere close to mastery in my four weeks, but all the more reason to learn as much as I could as my time was limited. Unfortunately, one of the Attendings got too annoyed. Which was strange in itself, as in my past whenever I've caused annoyance, it's been on account of my lack of questions. Maybe he interpreted my questions as unrealistic, as I was asking about his technique. Could he explain to me just how he had managed to reduce the loop and maneuver the flexure I had just been unable to pass?  But he stopped me, and raising his voice, informed me that my presence was a joke, and there was no way I could learn scopes in just four weeks.
long pause. 
What can a girl do?
Move on. I'll do scopes one day, and I'll be able to maneuver them completely and safely.

That being said, I'm glad the rotation is ending early for me. You get tired of that environment after awhile. I'd forgotten to give myself a day off the past couple of weeks. On these off rotations, since I am a team of one, I am not required to fill out an attestation form covering everyones schedule. But in not putting it on paper, didn't realize until after the fact that I'd forgotten to take a day. But, it actually works out better, because I'm going to take them all now instead. I'm leaving tomorrow for a medical fair in Anguilla. One of the PA's in our ICU is from Anguilla and annually puts together this medical fair for his island. He invited me to go. The only two instructions he had for me was that I had to bring my white coat and my stethoscope. The two exact items you'll never actually see me with when in the hospital. (Well, outside of the trauma bay at least, have to have the stethoscope in the trauma bay.) So they are both wrapped up and at the bottom of my backpack ready to go.

Much Love.