Estoy siguiendo adelante.

This past week was my scheduled week of vacation time. The plan had been to go to Costa Rica, which was an obvious definitely not. Even if I had somehow found a plane ticket to Central America... there's no way they'd have ever let me out of the airport. I mean... I'd be coming from New York; even I would have quarantined myself on arrival.

I spent the week at home in New York. First time of all residency that I had a staycation. The week flew by. I did venture out for a couple of day trips.

Kensico Dam. Minutes from the hospital, yet not previously explored.

Steep Rock Preserve in Northwestern CT.

It was good to get away for a few moments. Otherwise I studied a little, worked on some research, colored a few pictures, played the piano, wore out a pair of running shoes, purchased new pair of running shoes. In the end, vacation did it's job. The back pain I've been trying to ignore for the past month, as it was unresponsive to my attempts at medicating it, is finally gone. That's a relief! I was starting to annoy my coworkers with ponderings of possible osteoporotic stress fractures and the like.

Tomorrow morning I'll be heading back into the hospital to take my trauma team through the last block of the year. The month of June has seen me on Trauma every year for the past four years straight, and I'm very ready for this to be my last time!! Let's do it!

Much love and prayers!

Estoy leyendo labios.

Lip-reading really should be a course in medical school. Or if not it's own course, at least its own unit as part of the course "What-you-never-thought-you'd-need-to-know 101". It could be taught along with holding-it-for-13hours-straight, confidence-when-you're-completely-clueless, and how-to-find-your-patient's-nurse.

With the amount of lip-reading I've attempted over the past 6 years, you'd think I'd have gotten kind-of, maybe, semi-good at it. Nope. Still don't understand a thing. When a patient has a tracheostomy air is diverted via the opening in their neck and thus does not pass by their vocal cords rendering them unable to vibrate and a patient unable to phonate. For 99% of the cases, a tracheostomy is not permanent, and as patient's mend and heal the trach tube and/or opening is covered allowing the air to once again pass by the vocal cords and the patient to talk. However, during that in between time, between super sick in medical coma and all better again, there is a period when the patient is awake again and interactive yet not well enough to breath on their own. These are the patients that badly want to tell you their foot is twisted and needs repositioning, and you badly want to understand what is wrong and fix it, and unfortunately it just all gets lost in translation. Often times we can provide patients with paper and pen, or picture boards. Other times we rely on charades and guessing. Somehow the information is finally exchanged about the twisted foot and movement is provided until the patient nods in relief.

All of the patients my team has been able to discharge from the hospital to long term care facilities are still in that in between time. We get them down to minimal settings and then send them to vent weaning facilities where, when they are ready, they will make that final step of covering the trach and breathing 100% on their own again. We wouldn't send them if not positive they could make that last step on their own at the facility. But it means that, I have never gotten to hear my patients speak. Granted some, still lack the mental awareness to communicate, but there have been a handful which you could have a lengthy one-sided conversation trying to figure out the aches and pains of the day. One of my patient's tried to inform me about the diarrhea he had just committed. When I wasn't understanding his lips well enough, he gave me a look like, "c'mon doc, you're smarter than that" then pursed his lips and blew a low slow raspberry imitating the culprit. I got it then, I got it!

That same patient tried to give us all heart attacks that night as well. The most he could tell us was that he couldn't breathe. Unable to get any more information from him, all I had to work with was numbers. Spent hours by his bed starting with worst case scenario and as quickly as possible ruling them all out one by one. I had no intention of having to code yet another patient who is supposed to live. I think one of his nurses felt the same way. If I left his room, not 30 seconds later she'd come running out calling for something that I needed to come check or verify, etc. I'd check and it would be fine, but I caught on and just stayed in the room after awhile. That whole episode with the diarrhea happened at the end of that night, a long night. And it made me laugh. It was a laugh at myself, and inability to lip-read, but it was also a laugh of relief. If he was in a state that he could joke with me about diarrhea.... we were all good.

Much love and prayers.

Estoy corriendo.

I have discovered something while taking care of my COVID patients these past two weeks. As I have previously mentioned, the COVID patients I am taking care of are those whom have already survived the COVID storm and are in the long process of convalescence. As my colleagues continue to help those battling in the ICU, the step-down unit lends itself to a whole different front of discoveries and understandings stemming from the pandemic.

As a surgery resident in an academic medical center, one learns quickly about territory and the importance of respect of territorial boundaries. In other words, it boils down to who “owns” a patient. Is the patient a surgical patient? A medical patient? An ICU patient? And respect of those territorial boundaries involves respecting who owns the patient and makes the ultimate decisions concerning the patient. For example, vascular surgery is very frequently a consulting service on medical patients. In order to take a medical patient to the operating room “respect for the primary team” would consist of communicating the vascular plan with them and coordinating orders, etc so that the patient is appropriately pre-op’d and ready to go to the OR at the agreed upon time. Usually this consists of a chill exchange between surgery resident to medical resident… surgery resident: “hey, we are going to take patient Q to the OR tomorrow. Is it okay if I put in preop orders?”  medical resident: “sure, no problem.” Really quite painless, as long as the respect to the primary team is paid.

I have found that this ownership over COVID patients does not exist in its typical forms. Rather than a service… they are owned by the hospital. It was born out of necessity not choice. The surgical COVID team is perfect example of that.  We were the fifth team created by our hospital to manage COVID patients, not because COVID patients needed a surgeon, but because they just needed a doctor and a nurse and anyone willing and available was provided. The hospital mobilized its resources and owned its COVID admissions. Now the hospital is mobilizing again. ICU patients have been reassigned bed placement in effort to empty and close the makeshift ICUs that were created. As these patients are hospital owned rather than service owned, these movements have been administration-driven (rather than physician-driven) and the respect of territorial boundaries is non-existent. For example, I came into work the other night with a new patient name showing up on the board as pending arrival. My sign-out from my co-resident leaving for the day was that the patient was supposedly from a medical resident run ICU, and when he had reached out to them, they were unaware of any plan to transfer the patient and had no intention to create such a plan. I had wanted to leave the mystery of the new patient name at that… but alas, was wishful thinking.  Much time was spent on the phone being transferred among different people who didn’t know anything, but instead wanted to refer me to someone else. In the end, it was administration trying to consolidate patients, making more efficient use of space and personnel. Unfortunately, no one had actually communicated this plan with the patient’s current team, or future team (us), nor actually had the patient’s transfer approved. More time was then spent tracking down a physician who actually knew the patient and could sign the patient out to me allowing for a safe transfer.

I can’t say this form of hospital ownership is good or bad, as it was and is still needed to handle the COVID patients. It just lends itself to loss of individual ownership over patients when the Cardiologist works next to the Surgeon works next to the Anesthesiologist, none of them doing what they specialty trained to do.

Much Love and Prayers.

Estoy buscando agua.

My co-resident sat on the edge of the bed in the call room. Voice raised, hands wringing, and eyes darting amongst us he recounted to us step-by-step the events of that night. It wasn't supposed to happen. It was finally someone that wasn't supposed to die. And yet despite valorous efforts, another life was claimed by the virus. He wasn't taking it well. Confessed he hadn't slept since and was getting by aided with large amounts of alcohol. To make matters worse, to add insult to owned responsibility, he had been thrown under the bus by our Attending.

None of this is new in the life of a surgical resident. This is not an easy path, its not pretty and there are no flowers. Death, responsibility, blame, betrayal, we encounter it all. Deal with it all in our individual ways. But my co-resident's response and struggle with this specific event, is an illustration of what I have been trying to define since the beginning of March.

It is raw heightened and vulnerable emotion on display. It is the inability to compartmentalize fast enough and mental exhaustion brought on by the onslaught of these wildfire emotions. I still can not define it, nor can I explain it. Whether due to so many unknowns, so much change so quickly, or simply due to isolation, this is a very emotional time in the healthcare field. If you'd care to do a google search for frontline testimonies, you can quickly find videos of professionals from all over the world. They are in tears, many of them begging for care and caution.

The other day a few of us rode the elevator with one of the psychiatrists at the hospital, who slowly looked from one to the next and asked how we were. We of course brushed it off, answering a one word "good" before exiting on our floor. But I felt the earnestness and purposefulness in her tone with that simple question.  And I wondered what influx our psychiatry colleagues are seeing. PTSD? substance abuse? suicidal ideation? I don't doubt it, one bit.

Prior to 2020, the longest period I had gone without being able to attend church in person was six weeks. At which point, my bones feel dry as dry described by Ezekiel. There is a strength and nourishment from simply being surrounded by loved ones of Faith that is not provided listening from a distance. I always subconsciously knew it, but am now forced to admit how heavily I relied on those monthly trips to church. Seeing my brothers and sisters in person, their actions resembling Jesus, and being reminded of what kind of person I, myself, desire to be. It has now been about double the amount of time, and without a doubt, the longest I have gone without being able to attend church in person. And, I am finding just how quickly dry bones can catch fire. A lit match can spread like a wildfire in this environment, and before I knew it I found myself standing with unlit match in hand wanting nothing more than to strike a spark and watch the flames burn.

Don't worry. I caught myself, and laid the unlit match back down again. But it was an eyeopener for me, a realization of just how dangerous my viewpoint and reliance on church had been.  Not a bad viewpoint, just that it is dangerous to allow dry bones lie waiting for rain.  Especially when He is our  living water, and openly provides a stream in the desert and manna from heaven as needed. He allows me no excuse. This is the time, amidst these COVID wildfires, to lean on Jesus and to love those streams in the desert as it may be my future could be this isolating as well. Only God knows his purpose for me. And, when I am able to attend church again, whether next month, three months, next year... I will throw my arms back and enjoy the waterfall that is my family of Faith like never before.

Much Love and Prayers.

Estoy cuidando los del COVID.

I finished out my rotation on pediatric surgery this past weekend, leaving my kids in the capable hands of my co-resident. I was sad to leave pediatric surgery. The more I learn, the more I love taking care of the little ones. I was lucky to land in the world of peds this past rotation, as it was one of the few busy surgical services while the hospital was in the grips of COVID.

Services are slowly starting to test the waters once again, and over the next couple of weeks we expect to see elective cases start to resume. As much as we want to see it, we refrain from celebrating too soon. The cases of COVID-19 are still on the rise in Westchester and death toll now way past 1000. However, with the nice weather recently, has come a dramatic increase in trauma… as is expected. Motorcycle crashes polka-dot the Westchester motorways starting in the spring and last until the days grow short and cold again. The hospital making room for the influx of trauma combined with the elective cases, and we find ourselves playing musical beds with patients half the night while on call. Kind of feels like the good old days… like, from two months ago.

I have now transitioned to a brand new COVID unit under surgical critical care. My patients are not in the ICU, but rather they are those 20% few that have survived the COVID storm, and stabilized enough to be transferred out of the ICU.  What we saw and assumed 1-2 months ago, is now very different from what we find ourselves practicing. At one point, it appeared as if intubation was a death sentence in COVID. There was only one way out of the ICU once the COVID storm hit. But there are now those that have proved us wrong, they have hung on, for whatever reason, and survived the storm. Procedures that sounded outrageous for these patients are now practiced daily, specifically tracheostomies and bronchoscopies. They are, afterall, patients and deserve the same care and treatment as anyone else including airway care. Granted some of them have emerged on the other side having weathered the storm a bit more graciously than others, but either way, they come to us needing to be packaged up nicely with bows tied for discharge to their next level of rehabilitation.

Much Love and Prayers.