Jeopardy.

my situation on June 23, 2016. Literally.

jeop·ard·y

ˈjepərdē/

noun

1. danger of loss, harm, or failure.

Two weeks ago, I did something that I have never done in my entire medical career. Had I come close to it before? Yes. And is it something I probably should have done a few times in the past? Definitely.

So . . .  what was it that happened, you ask? Well, I'll tell you. Um, yeah. . . I'll tell you even though, after twenty full years of not doing this, it's pretty hard to actually confess. I. . I. . .sigh. Okay. . .I. . .I . . . I .  . whew.

I. Called. In. Sick.

*squeezes eyes closed and turns head so you won't look at me*

Yup.

It was the week of our interns' orientation in the hospital. Those first few days had gone just fine and at the end of the hustle-bustle of a particularly crazy afternoon, I popped by a casual eatery to grab a late lunch. And that part was fine, too.

Yep.

It wasn't until about an hour and a half later that I began feeling this cramping sensation in my midsection. My tumbly became rumbly and before I knew it, I was in and out of the restroom doing what the Grady elders (and my daddy) refer to as "running off." Somehow I managed to get a long enough window to get over to get the kids from their camps but admit that I sprinted from my car to the front door.

Thank goodness I did.

And you know? The running off part I could mostly deal with. I mean, I was hydrating and such and told myself that if there wasn't anything in my gut, the "running off" would eventually "run out." But then came the nausea. And then came the vomiting.

Uggh.

And so. I pretty much spent the next several hours trying to decide which end of my body to aim at the commode. I tried all those home remedies like ginger ale and the non-home remedies, too, like antiemetics and antidiarrheals. But mostly, this was something that was just going to have to run it's course. Literally.

I didn't catch a wink of sleep until about 4:30 that next morning. My alarm went off at 6am and I just sort of stared at it for a few beats before silencing it. Finally, I sat up on the end of the bed and prepared to treat the day like any other Thursday. I grabbed a t-shirt and a pair of sweats, pulled on some socks and shoes and prepared to walk Willow. And that was fine, too.

Well, I take that back. It actually would have been fine if I wasn't lightheaded from my certain dehydration and on the verge of vomiting the remains of the Canada Dry ginger ale and the electrolyte drink that I'd carefully sipped all night. After only two steps toward the door, I felt my belly churning again. But still, I grabbed the leash (and my tummy at the same time) and took Willow for what I am sure was the least gratifying dog walk ever.

You know? I didn't even think to wake Harry and ask him to take the dog out instead. Even though I knew he would have, I didn't. Then, when I came back inside, I stood staring at the medicine cabinet and trying to decide which concoction would allow me the best chance at not barfing all over a patient. Or passing out on them.

Yeah.

But somewhere in the middle of all of that, I spoke out loud even though no one but me was awake. "I  really, really feel like shit." Which, I am sure, is exactly what I said. Followed by a dry heave.

And right then and there, I had an ah hah moment. I recalled all of the times I've told countless residents that self care is essential. Even though, particularly when it has come to personal illness, I've never given my health priority over going to work.

Nope.

It dawned on me that if I were advising any of my students or residents, I would tell them to immediately contact a supervisor in order to afford that supervisor as much time as possible to cover the clinical duties. And then I'd tell them to drink, drink, drink fluids like crazy and get in bed under the covers and get some legit rest. And/or seek medical attention if it is even more serious.

But for myself? Chile please.

So with my dog at my feet wagging his tail and me hunched over the kitchen sink on one elbow out of fear of projectile vomit, I made up my mind to do the unthinkable. Yes. I decided to call in sick.

Um, because I was. Sick, that is.

Now. I tried as hard as I could to recall a time ever in my career that I'd done that but came up with nothing. And I think I came up with nothing because that adequately represents how many times I've decided to stay in my household infirmary versus crappily do my job while ill. And how many times I acknowledged that I was too unwell to work.

I blame jeopardy. Confused? Okay. Let me explain.

At nearly every residency training program, there is this back up schedule that is designed precisely for moments such as these. And you know? Nearly every residency training program calls it by the same name: JEOPARDY.

Yup.

So when one is sick, they call the chief resident or schedulers or whomever--and that individual refers to the "jeopardy schedule" and notifies some unlucky soul who, up until that moment, was basking in an awesomely easy assignment. Only to be thrust into the firing line of some essential patient care situation such as the intensive care unit, hospital service, or something else even more hellacious. And yeah, it's exactly as sucky as it sounds when you get called.

Yup.

Similar to, say, jury duty, everyone knows that the jeopardy schedule is everybody's necessary civic duty. That is, in the resident community. But, just like jury duty, it isn't one of those things anybody is particularly pumped up about getting notified about. But physician jeopardy is more complicated than that.

Totally.

When I was a resident, we had this longstanding culture of bravado when it came to toughing it out through illness on the job. And I can't say that it was because our program leadership wasn't supportive of our personal needs. It was just this thing that sort of happened, you know? Most of the time they had no idea.

Nope.

Well, I take that back. They were supportive when a person actually endorsed being ill as a reason to call off. But because they came up in the same system, I can't ever remember anyone insisting that someone leave back then. Go lie down for a few moments? Sure. But full on leave and cause another resident to be called in? Never.

Oh, and before I go further, I will say that there is always this teeny, tiny subset of individuals that call jeopardy 200% more than anyone else in their entire program. Most notable was this girl who had taken two benadryl on accident and called in because she was afraid she'd be drowsy. (Me countering her with the half life of benadryl, which she'd consumed 4 hours before, didn't seem to make a difference.)

Anyways. The vast majority of my resident colleagues worked when ill. Furthermore, there was this esprit de corps between us that caused us to rally around the sick guy and fill in the gaps. (Forget the fact that everyone was getting exposed to whatever illness the person had.)

Uhhh, yeah.

A few times stand out in particular. One was my junior year when I was taking call in the cardiac care unit (CCU.) I came down with fever, chills and a terrible headache. My neck was tight and I had some nausea and diarrhea, too. It was the summer and I had just come off of the pediatric inpatient service where kids with aseptic meningitis from enteroviruses was rampant. I even had a tell-tale viral exanthem (rash) to go with my constellation of symptoms. And you know? I was 99.9% sure that viral meningitis was exactly what was going on with me.

Maybe even surer than that.

I called one of my classmates (who was also on call) and asked him to come examine me in the nurses station which he did. "Dude. You probably got viral meninge. You gonna go to the ER and let a second month intern do a spinal tap on you?" He bit into the room temperature honey bun he was eating and laughed at his own joke.

"No way, dude. Did you see my rash?" I asked while pulling up my sleeve.

"Cool," he replied. "So what are you gonna do?"

"I think if I take some Motrin, I can make it through the night."

"Yeah, probably so."

And I am not kidding you. This is what happened. I took the call, fever, stiff neck and all.

Super stupid. Especially since it could have been something far more serious.

That same friend called me the following year (when we were both on call again) to check him out in a call room. He'd developed some shaking chills and a nasty, rattly cough rather suddenly. When I got there, he was breathing super fast. "Dude! Holy shit. You look like you're about to code."

"I feel like I'm about to code."

I listened to his lungs. "Yikes. You've got signs of consolidation. This looks like a bad pneumonia. And that history, man! You might have pneumococcus, I think."

"Hmmm. Cool. Think I can tough it out?"

"You're breathing pretty fast, bud. Let's go to the PICU nurses station and pop a pulse oximiter on you to see if you're hypoxic." Which is exactly what we did.

Guess what his oxygen saturation was? 82% (96-100% is normal.) Craziness.

Let me tell you. This guy? He looked sick-sick. It was NOT a soft call. At all. That said, I am convinced that were it not for the whole needing oxygen thing, he would have slugged it out through that call with his pneumonia.

Yup.

Would you believe that he got admitted to the hospital that very night? And you know? We were so entrenched in that culture that I can remember like yesterday cracking jokes in his room about him spreading TB to the interns and telling him that I was totally going to present him in morning report the next day.

Which he found funny, too. That is, when he wasn't nearly about to code.

Uh, yeah.

I blame this word "jeopardy." The actual definition means "danger of loss, harm or failure." I can't think of anyone who has ever wanted to be the one responsible for putting someone in that situation--that is, one involving jeopardy. Especially another overtired resident who finally, finally, finally is on a lighter work assignment.

But see, that word just underscores the culture. It sounds heinous, punitive even. And to tap into it literally puts another person in peril, if you follow the definition. And I think that's a part of the problem, frankly.

The one time I called jeopardy as a resident was when my father had a massive heart attack requiring emergency surgery. And you know what? I actually took call all night before taking a flight out, now that I think about it. We also have a jeopardy schedule (also called "jeopardy") in my current faculty position and you know what? The one time I called jeopardy with this group then was on November 15, 2012--the night my sister Deanna passed away.

Yup.

So yeah. I am reflecting on all of this and realizing that doctors who neglect themselves really aren't the best physicians at all.  Coming to work while truly ill puts patients in danger, can make things worse and it probably increases the chance of an error happening.

Now. Do I think folks should be calling off for sniffles or allergies? No. Do I think taking two benadryl should allow a rain delay at best but not a full on call off? Damn right. But do I believe that a vomiting, diarrhea-ing, teeth-chattering person should have another able physician working in their place? Definitely.

If you ask me (though no one did) the first step is changing the name. Instead of calling it "JEOPARDY" it might be better to refer to it as "FAMLY EMERGENCY/ILLNESS PATIENT CARE BACK UP." This way, those who need it will understand when it is to be called. And those who get called will feel okay with being called in.

We could even call it "FEIBU" (pronouced FAY-BOO?) for short. As a reminder that this is for FAMILY EMERGENCIES and ILLNESS when back up is needed. And that FAMILY EMERGENCIES and ILLNESS happen and aren't a sign of weakness at all. 

Mmmm hmmmm.

Oh, and the times that folks get pulled in because of human scheduling glitches NOT due to the needs of a colleague dealing with a FAMILY EMERGENCY or ILLNESS? Well. Keep right on calling those times  "jeopardy."

Ha.

So yeah. I acknowledged that I was ill and called off the other day. My colleague Stacie S. was great and made sure I didn't have to feel guilty. And my other colleague Alanna S. was super kind about picking up my slack in the resident clinic that morning. And you know? I think if my patients knew of my decision, they would have appreciated my choice to call off, too.

And so. I drank fluids and rested in my bed all day. That photo is proof that I was exactly where I was supposed to be, too. I went through a whole lot of hand sanitizer and considered going to get a bolus of IV fluids at one point. But the next morning, I felt a thousand percent better which taught me a mighty lesson.

And you know the best part? Not a single patient was harmed or put in jeopardy--thanks to my decision to first put the oxygen on myself.

Yeah.

***
Happy Sunday.

Now playing on my mental iPod. . . .

Bullies and Cool Kids.

*names changed to protect anonymity

"I wish that I could be like the cool kids. 

'Cause all the cool kids they seem to fit in

I wish that I could be like the cool kids

like the cool kids."

~ Echosmith

_____________________________________________

Medicine can be like middle school at times. Much like seventh grade, it's a combination of development, swagger, and perception. The early bloomers ascend to the top while the others settle wherever they can fit. It isn't always fair, actually. 

Someone deems a person "good" which, in the medical field, is like the equivalent of being considered "cool." Sometimes it's a faculty member or a colleague. Other times it's the nursing staff or junior group of admirers. What happens next isn't too far of a cry from junior high. Opportunities come. Shortcomings are quickly forgiven or even not noticed at all. And if a person is in the cool camp, life is good for the most part. 

Now.

In full transparency, I will share that my experience in residency was from the perspective of a person placed squarely in the cool camp. I remember when it happened, too. I was on my very first rotation as an intern and was signing out a late patient to my attending because my co-intern was in clinic. As I reached the end of my oral presentation and marched through the assessment and plan, my attending stopped, cocked his head sideways, and squinted one eye. 

"Remind me of your name again?"

"Kimberly Draper, sir." 

"And Kimberly where did you go to medical school again?"

"I went to Meharry Medical College, sir. In Nashville, Tennessee." 

He jutted out his lower lip and gave me a slow nod. Then gestured for me to carry on with the rest of my plan.  And that was that.

That attending was a key person on the faculty and a program leader. And I could tell that in that little glimmer of a second, he'd sized me up. The rest of our interactions were positive and he always seemed eager to teach me for the remaining time we had together. 

Sure. I worked hard as an intern and took pride in the lessons Meharry had taught me prior to starting residency. But I quickly began to realize that sometimes my lot in trainee life was better because of my position as one of the cool kids. Or rather, the good ones. 

As time marched on, I started to recognize a few other things, too. I started noticing that the cool kids are often privy to some conversations about the not-so-cool kids that aren't so nice. And I guess since I wasn't too cool in middle school, I've always felt a kindred tie to those who haven't been given a golden ticket. For that reason, those mean words always made me uncomfortable. But like any immature person who has found solace in the cool camp, fear of messing up a good thing can be a mighty muzzle. 

This got me thinking about an experience I had in residency. I had a co-intern who'd worked with me in the NICU during our first few months of internship. Sujata (name changed) was this very petite, soft spoken, and nervous young woman of Indian descent. She had a rather thickish accent but mostly it was her apologetic and anxious nature that drew the most attention to her. And that attention wasn't good, either.

Nope.

Sujata and I were on the same team that month and worked shoulder to shoulder on some very sick infants. In our extensive time together, I rapidly discerned that she'd been completely misunderstood. Not only was Suji highly competent, she was also smarter than anyone else working in the unit that month. That said, when the time came for her to defend her management or answer questions, with a tiny shake of her head she'd disappear into soft, mumbling apologies. It was awful.

Suji became my friend that month. Over that year, she looked out for me, too. Whenever I was on call in a unit or a tough rotation, without fail, she'd slide a tupperware dish into the resident lounge refrigerator with "Kim" written on a piece of masking tape stuck on top. Suji knew how much I loved her authentic South Asian cooking and never missed a chance to allow me to try whatever new recipes she whipped up. I appreciated that.  And mostly I appreciated her. 

But.

One day I was hanging out in the resident lounge waiting for sign out. In walks two "cool kid" senior residents, one of whom had already been chosen to serve as a chief resident the following year. Brent, the rising chief, plops down in a chair and groans loudly. 

"What's all that about?" I laughed.

"It's about the painful night I have ahead of me in the PICU." He plunged his hands into his hair and acted as if he was pulling it out. When I wrinkled my nose and looked puzzled, he clarified it for me. "Dude. Did you see who I'm covering tonight? I'm going to be up all frickin' night."

As soon as he said it, I knew who he was speaking about. He was referring to Suji. 

"Maybe she will be sort of helpful, Brent. You never know. . . she's gotten some more experience over these last few months." That's what the other senior resident said which I would have called him defending Sujata but won't since he was cackling the entire time.

Brent squinted his eyes and stared at his co-resident as if he'd just spoken the most asinine words in the world. "Dude. Did you say helpful? Sujata? Phsssssshhh. That chick is like an accessory nipple, man."

That line caused them both to explode in laughter. The other senior. while gasping to catch his breath, howled out loud. "An accessory nipple? What the hell? I don't even . . .bwah ha ha ha ha. . .wait, man. You gotta clarify on that one." He was already doubled over as he probed on this wicked one-liner partly because anyone who knew Brent knew that his quick-witted humor was unmatched--even when he was being mean. 

"Why an accessory nipple?" I asked, trying to look as genuinely perplexed as possible even though I wasn't. I knew that whatever he was getting at wasn't good. So I suppose this was my milquetoast attempt at a quasi-defense.

Brent propped his clogs on the dented up coffee table and leaned back on the chair. He was already chewing a big bite of the apple in one of his hands and nearly spat it all over the room when he added, "It's a perfect description. An accessory nipple is useless and just in the way. And most of the time embarrassing."  

And that? That was all she wrote. The laughing could no longer be contained. Brent literally fell on the floor and his co-senior began running in circles while screaming hysterically. And I just sort of sat there with this weird expression on my face which probably was some bizarre cross between uncomfortable and amused. You know, that way you look when you snicker at something terrible that you see on social media. 

But even worse was the fact that Sujata was my friend. I didn't defend her. I just sat there like someone watching a mugging in the street and feeling too scared to act.

Yeah.

On the way home I thought about the little babies that I'd seen in the newborn nursery with those extra mammary glands or accessory nipples. The parents pointing at the one, sometimes two little brownish peaks and asking if it was some sort of pimple or birth mark and me trying to explain through embryology that it was a "normal variant." Every single time, they'd look at me in horror as I tried unsuccessfully to reassure them about the random satellite teat that their sweet baby hadn't ditched in utero. Yup. Useless and just in the way. And most of the time embarrassing.  Pretty damn accurate description.

And this was the metaphor someone used to describe my friend as I sat by silently and allowed it. I'm still not certain why I didn't speak up, either. I'm ashamed of it even today.

Anyways.

I guess I am thinking about this today because I was talking to Isaiah about bullies yesterday. He asked me if anyone had ever bullied me. Quickly I told him "heck yes!",  reflecting on my awkward middle school years. Then he hit me with another question that got me thinking. "Did you ever stand by and let somebody get bullied without standing up for them?" 

He sort of pulled the wind from my chest on that one because instead of wandering back into high school or 6th grade, my mind squarely landed on Suji and residency. That "accessory nipple" line was one of many very, very mean things I heard about her without defending her. And so. I was honest. "Yeah, actually. I'm not so proud of that either." 

"Were you in 4th grade?" Isaiah pushed.

I twisted my mouth. "Honestly, son? I was a grown up. And some people who thought I was cool decided one of my friends wasn't. I was too scared of not being liked to speak up."

"As a grown up?"

"I know, right? I should have known better."

"Did your friend know that you weren't sticking up for her?"

I hate it when Isaiah's old soul rips the covers off of me. "Um. I sort of don't think so. Which I guess is the part that I've always felt bad about."

"Were you saying mean things about her, too, when she wasn't there?"

"Not so much. But sometimes I laughed."

Isaiah immediately looked disappointed in me when I said that part which sucked. "That's kind of being two-faced, mom." 

"Yeah, you're right. It wasn't cool."

"No, mom. It wasn't." It looked like he felt bad for giving me such a rough time so he added this to make me feel better. "But it's good when you think about something a long time and then realize a better thing to do. Like, now you tell us to always choose kindness."

I smiled. "Yeah. I guess you're right about that. And you know? It's good to let your kids and friends learn from what you did wrong."

"Yup!"

And with that, he ran off to build Legos. 

The part Isaiah isn't seeing is the part of me that now fights for everyone around me to feel like a cool kid--especially my medical students and resident learners. In all these years I've never shaken Brent's stinging words: "Useless and just in the way. And most of the time embarrassing." I don't ever want to feel that way nor do I ever want someone else to feel that way in my presence. Man, I don't.

Yeah.

I've not gotten it all fully figured out. And Lord knows that I still have my days where I don't advocate for folks like I should. But I'm better than I used to be. And what I know for sure is that the real secret to being a cool kid is believing that you don't need to be.

***

Happy Thursday. And hey, Suji? I'm sorry. 

Now playing on my mental iPod. . . . this. . .

and also this. . . . 

Shut up and dance.

Five days you work

One whole day to play

Come on everybody

Wear your rollerskates today

It's Saturday, Saturday

Saturday, it's Saturday

Saturday, it's Saturday

Saturday, it's Saturday

~ from De La Soul

I love being on the inpatient hospital service. The acuity of the patients, the energy of the wards, and just the dynamic of working as a part of a team just does it for me. Seriously, if it weren't for the fact that being on the hospital service also means working weekends, I'd do it year round.

Yup.

One of the best parts for us medical nerds is the fact that we get to do a lot of teaching when on the hospital service. The potential teachable moments are endless, man--especially at a place like Grady. But you know what? One thing I have learned is this: Not every moment is a teachable one. That is, in the literal sense. Sometimes the teachable moment is identifying the moments when it really isn't one.

Yup.

I know that probably didn't make sense, so let me explain. Matter of fact, why not reach back to the source of that lesson--my residency. Since I've been on a bit of a roll with my tales from the residency crypt, I may as well keep it going, right? Ha. Don't mind if I do.

The Unteachable Teachable Moment

My residency training took place before there was duty hour reform. In other words, how many hours we worked in a week or consecutively never seemed to be fully factored into anything we did. In some ways, it afforded us great experiences as learners. But a whole lot of other times all it meant was that  you were guaranteed to be in an exhausted stupor at some point. And how that stupor looked depended upon the person, the call and the location in the hospital.

Yup.

I will never forget this one morning on rounds in the Pediatric Intensive Care Unit (PICU).  I'd been up all night long without even a few moments to catch my breath. The kids on the unit were sick-sick--I'm talking tenuous and teetering on codes well into the wee hours of the morning. It didn't help that the PICU was, hands down, the most terrifying place in the entire hospital to me. Sure, I learned a lot but the intensity coupled with the nausea-inducing fear that I'd assassinate somebody's child was a lot. Yeah, man.

Well. What I remember the most was that this particular morning on rounds upon which I'm reflecting fell on a Thursday. That's significant for two reasons: The first is that my weekly continuity clinic was every Thursday afternoon. The second was that, because of the fact that this was during the pre-duty hours reform era, I was expected to go to clinic despite having been up all night long with critically ill children.

Yeah.

One of the kids I cared for that night had severe, persistent asthma. A fun afternoon with his family turned into a nightmare when he started having a refractory asthma attack. "Status asthmaticus" they call it; an ambulance whisked him straight to our emergency department who quickly shunted him upstairs to us. His lungs were so tight that he received the entire kitchen sink from the moment he arrived; he even had to have his blood oxygen levels monitored with an arterial line--which isn't an every day thing with kids. Arterial sticks hurt like hell which made my hands super shaky and nervous while attempting to stick him. On top of that, he was only eight or nine years old. God, he was just terrified. With every air hungry inhalation he took the skin over his ribs pulled tightly over his bones like some kind of relief sculpture. I also remember him crying as I stuck his wrist. All of that was right before he got intubated. It sucked, man.

For him more than me, of course, but still it sucked.

That same night, there was another child I cared for that we all knew very well in the hospital. Man, was she cute. Her cheeks always looked like that had a perfect application of blush and the strawberry blond ringlets she'd been born with looked like they'd cost her parents thousands to achieve. But beyond her natural beauty, she also had severe epilepsy. I'd admitted her before for complications of her frequent seizures--usually to the regular pediatric ward. On this night, she was down in the emergency department and the on-call pediatric resident was preparing to admit her for the same. I was called down from the PICU after she suddenly went into something called "status epilepticus"-- a condition where a seizure persists for a substantial amount of time and, in this case, doesn't respond to initial treatment.

We pushed med after med and nothing was working. The pediatric neurologist was en route and the PICU fellow was right there in the trenches, too. The nurses who weren't caring for her comforted her mother, a woman who, by now, was a friend to us all. Finally she had to be put into a medically induced coma. And let me just say that this was some shit I'd only read about on test questions--not actually participated in making happen. By morning, I was metaphorically down on all fours begging the sun to rise into a new day--which would mean a new resident on call.

Yeah.

So the way it worked was that we rounded with the ICU attending the following morning to discuss every single nitty-gritty detail of the overnight events. My attending that month was this really, really nice man who loved to teach in a Socratic style which, usually, I responded to as a resident. But on this particular morning, I wasn't really up for Dr. Quizbowl or any of what would surely be his standard litany of questions.

Now. Let me also just remind you that at 1PM, I was still expected to go and see a panel of seven patients in the clinic. Whenever this was the case, the goal always was to knock every single drop of work out so that you wouldn't have to return after clinic.

Yes. You read that right. RETURN. AFTER. CLINIC. POST. CALL.

The only way this could happen--and I do mean the ONLIEST way on this morning in particular--would be for my attending physician to focus more on the care of the patients than the quiz bowl soliloquy. And NO, I'm not saying that it's cool for things in residency to be all service related and not education related. But what I am saying is that the ground was fallow and not EVEN fertile for a whole bunch of extraneous teaching seeds to be planted. I needed this dude to get down to business. And focus on just the damn facts.

Capisce?

But he didn't. Not one bit. Dr. Quizbowl started first with a bunch of questions about the AV mismatch in asthma and I swear I don't know how, but from there he jumped off into a tangent about fetal hemoglobin and oxygen carrying capacity. Even though this child with asthma was not a doggone fetus or anyone with something warranting that as a discussion at the moment. (No, he didn't have sickle cell anemia, you medical nerds.) I did my best to answer his questions which escalated in difficulty.

Uggh.

Dr. Quizbowl liked to grill only the post call resident. Again, that was usually fine for me but this night was so bad that today it wasn't. I also couldn't keep my eyes off of the clock. I wanted nothing more than to get the plans locked in by 11:30 so that I could tie up loose ends and scoot to clinic.

But then we went to see our sweet curlyhaired girl.

First, he waxed poetic about the mechanism of status epilepticus and what happens on a physiologic and pharmacokinetic level with the anti epileptic drugs. From there he began quizzing me about the mechanism of action of some of the newer agents and then, after studying the vitals overnight, decided he'd start asking me a bunch of pathophysiology questions that I hadn't really thought of in such detail since my second year of medical school. And you know what? I didn't effing know the answers.

I didn't.

Well, I take that back. It was past 11:30 and I was already feeling nauseous from being so tired. While maybe, just maybe, with some thought I could have found some piece of the answers to his questions to at least prime his teaching, at that moment? I had nothin'. The more his mouth moved the faster the clock seemed to tick. Before I knew it, it was already 11:45.

"Why a pentobarbitol coma, Kim?" he finally asked me.

"What?" That is literally what I said in response. Because that was too vanilla a question for it to be almost lunch and too nebulous for me to even hold on to the tiniest chance of me getting any more work done.

"Pentobarbitol. Why do we use that in status epilepticus?"

"Um, to stop the seizures, sir. To quiet brain activity."

"Be more specific. Talk me through what is actually happening in a noisy brain that sees pentobarb. Why is this something we do in this situation?"

And just as he said that, the clock struck twelve noon. I promise you it seemed like it happened in Dolby stereo, too. Honestly, the whole team was shifting between their feet, but lucky for them, they weren't on the hot seat like me. Noon and he was still teaching with no end in sight. It was official. I would have to return to the PICU at 5:30 that evening to finish my work. Even though I'd been up for more than 24 hours at this point.

"Kim?"

"Sir?"

"What say you?"

My eyes began to throb with tears. As soon as my chest started heaving, I knew it was a wrap. My mouth hinged open to talk but only a squeak came out. "Status Postcall-icus," they should have called it.

"Dr. Draper?"

I wiped my hand over my face hard to try to mask the tears that were now falling straight from my eyes to the linoleum floor in big splashes. Shaking my head in embarrassment I responded. "I don't know, sir. I don't. I just. . ."

"Are you okay, honey?" The nurse on rounds with us rubbed my back and tried to console me. She looked over at Quizbowl and added, "On sign out the night nurses told me she didn't sleep a wink."

"Welcome to the PICU," my attending responded with a heartless chuckle.

And I swear to you, that was that. No further acknowledgement of my brief outburst or any such thing. We just kept it moving. Yep. That dude talked and taught for another half hour or so and finally let us go. All I ended up with was enough time to change into my clinic clothes, eat some leftover stromboli from the night before, and hoof it to clinic. And yes, at 6PM I was BACK in the PICU finishing up some notes and trying to stay awake for sign out rounds. While Dr. Quizbowl took it upon himself to make a few more teaching points to boot.

Yeah.

I know that the only thing that allowed me to drive home without face planting on my steering wheel was how resentful I felt of my attending and his irresponsible use of our time that morning. Not only did he not recognize a dangerously exhausted learner in front of him, he also ignored the fact that we needed to transfer patients out, care for new admissions and just get some damn work done. And I wasn't a lazy resident by any stretch either. I loved being taught and guided--and still do. But this day? It just wasn't a teachable moment, man. I mean, not in the way he forced it to be.

I bet you a million dollars that from eleven o'clock on, nobody heard a damn word of what he said. That I know for sure.

Let me quickly contrast this by saying that just a few months later, I was rounding on a Saturday with the chairman of the Department of Pediatrics. The service was busy and he was even busier. That said, he was an outstanding teacher and champion for children's health. And so. I remember him starting rounds that morning by simply saying this:

"It's Saturday. It's busy. And it's Saturday. A Saturday where our team isn't admitting new patients and where the ones we have are primarily stable. The teachable moment this morning is on focus and efficiency so that we can take excellent care of our patients and then leave. Y'all got that?"

And yes, he said "y'all" which he often did. That didn't mean be cursory or rush things. It meant to focus on the essential tasks at hand. It meant that this wouldn't be the day to draw algorithms on the chalk boards or sit the whole group down to review a new article. There were teams assigned to the hospital for the full day on Saturday and his point was that we needed to do our work and then allow them to take over so that we could achieve some semblance of work-life balance.

Oh. That.

Now that? That was pivotal for me. The thing I remember the most was that he was SO right about THAT being the teachable moment. The fact that this wasn't the time for him to review every study he has ever published or to recount all that is in his memory about every subject he can think about. It wasn't.

You know what else? Midway through rounds he looked at one of my post call interns and then interrupted rounds. He pointed straight at him and said, "You. Go ahead and sign out so that you can go home. You look like you're about fall under the nurses' station. Go get rest." The intern just stared at him. He looked from side to side and then repeated himself. "I mean NOW. Leave. Now. Get rest. Your work here is done today."

And yes--we, too looked conflicted when he said that, but nobody questioned the dang-on Chair. See, he was right. That intern was about to collapse on his face from exhaustion and that man had the sense to know it. Then he said to me, "Kim, the teachable moment here is knowing when somebody is on fumes.  Getting him out now means he'll be better tomorrow. Trust me. We can pitch in and finish what needs to be done."

And yes, he said "we." I loved the way he often said "the teachable moment is. . ." That put us all in the right state of mind for whatever it is we were doing. And helped us to see the teachable moment as just that.

I have never, ever forgotten those two experiences. Every single time I am attending on the wards I remember both Dr. Quizbowl and Dr. Chairman--and apply their mighty lessons to the way I manage my own teaching and team management. Yes, in medical education, we walk a fine line between balancing service and education. And, of course, our learners are there for supervised instruction, not just scut work--I get that. I do.

But.

As awesome as the music of medicine can be and as fascinating as the melodies often are, sometimes? Man, sometimes the very best thing that we can do as teaching maestros of this symphony called medicine is simply shut up and dance. . . . .

That, my friends, is sometimes one of the most powerful teachable moments of them all.

Yeah.

***
Happy Humpday. This post made me think of this post on Saturdays, balance, and why it's so important.


____________________________

Every time I round on Saturdays when my team isn't admitting, I think of Dr. Chairman and hear this song in my head. Then I say to my team, "It's Saturday." (Even though I am hearing this song in my head the whole time and feel like I have on roller-skates. Ha!)

But first, here's some proof--I sent this text to my ward team last weekend--complete with a witty emoticon. Heh heh.

Next time I'm just gonna text them this. . . . 

What kind of ISH is that?

Whenever I'm on wards, I find myself reflecting on my time as a resident. That was a pivotal time of becoming. And like one of my favorite quotes says, "Becoming is better than being." All day every day, it is.

Here's another story of just that. More will follow.

A little too black-ish

When people ask me where I'm from, I generally tell them that I'm from "the Los Angeles area." People that know nothing about the west coast pretty much leave it at that. But, as it turns out, a lot of people seem to know at least a little bit about Southern California. And so they gain clarity with questions like, "Where about in Los Angeles?" or, if they're super savvy, they'll try to throw a little shade at me by accusing me of being from those far away cities that are so far that they don't even count as Los Angelinos. Matter of fact, they even have a name for folks from those far-as-hell areas. I think they call it "the inland empire."

But I digress.

My point in saying all that was just to say that anyone who knows anything about L.A. gets it when I reveal just where in L.A. I was raised. I was raised in Inglewood. Yes, it's the suburbs. But no, it's not Kardashian-esque Calabasas or Superbad Santa Barbara. Nope. It was a place with predominantly underrepresented minorities and gangster graffiti on the sides of cinder block walls. But. For me, it was home and the place that had a hand in shaping me.

From there, I went to two historically black institutions of higher education in a row--Tuskegee and then Meharry. And in those places, I was a minority person by on the U.S. Census, but not in my life. My peers looked like me and so did my teachers. Black culture didn't have to get tucked under my shirt or packed on ice in the back of my freezer. It was the norm and simply the way of that world.

Yup.

I am not exaggerating when I tell you that I never really, truly felt what it was like to be "one of the only black people" for a sustained period of time until I started residency. I was the only African American in my class of residents, and there weren't a whole lot of faculty who looked like me either.

Nope.

People were super nice, though. Super nice. When I arrived in the hospital, it became quickly apparent to me that after all of those years as a minority in the majority, I didn't know how to assimilate. At all. The one week that I tried was so exhausting that I quickly told myself that I simply would not. Sure, I could speak standard English. And I'd been taught at Meharry how to be professional in my interactions. But what I couldn't do was behave in a way that wasn't me. I couldn't ignore things that connected me culturally to patients, colleagues, and  staff members. That just wasn't me. So I settled into something that felt right. Me being me and being cool with everyone else being everyone else.

Yup.

There was this guy who was one class ahead of me in residency. He was also black and had attended a historically black medical school just like I had. But that's pretty much where our similarities ended. He'd made a full time gig out of trying to be accepted through watering himself down. Black folks around the hospital got the virtual stiff arm from him.

When I first arrived, he'd taken it upon himself to look out for me. I can't say that I really wanted that from him since mostly it meant harsh whispers in the hallways about either what some fellow person of color was doing wrong or how each and every occurrence was a diabolical plot to take down the residents and medical students of African descent.

Uggh.

Mostly, I smiled politely while secretly ignoring him. That is until the day that I became his target.

"Hey Dr. Draper! Is this your admission? He needs orders." Sanika, the ward clerk on the hospital ward where I was working, tapped me on the shoulder while I was writing a note. I'd already been up all night admitting patients. I was scribbling down my final note when she said that. Sanika and I were always friendly and I liked her a lot. Our exchanges were usually relaxed and light. This day was no different.

"Naaaaaah, playa. I'm post call."

"Oh, my bad. You gon' do something fun?" she asked. She was patting the top and sides of her head with her hand when she said that. The blonde hair weave she wore seemed to be on it's last leg and, as every sister knows, the "weave pat" is something girls do when they don't want to mess up their weave tracks by scratching.

Duh.

"Who me? I'm probably I'm gonna fall asleep on my couch for a few hours. Then I'll wake up and go kick it with some of my friends later on." I cocked my head and chuckled as she continued tapping her head with her hand. "Dag. Is it that bad?"

"I'm getting this wig split!" Sanika laughed. "The whole shebang, girl. Cut, chemicals, all that!"

I knew right away what she meant. This was slang for going to the hair salon to get her hair done. "Do your thang, girl!" I said while giving her a high five. We both laughed out loud one last time and that was that.

A few moments later my pager went off. Cringing, I called back. I was super relieved to find that it was Albert, the guy in the class ahead of me and not a nurse on one of the floors.

"Do you have a minute?" he asked politely.

"Sure do.What's up."

"I'll just come to you,"

"Okay, Kool and the gang! I'm on the nurses station on 9B."

"Did you just say, 'Kool and the Gang?'"

"Ha ha ha . . .yup."

"Ummm. . . .okay. On that note, I'll see you in a minute."

I wasn't sure what he meant by that response, but soon I would.

A few moments later, Albert was sitting next to me with this really disappointed look on his face. He let out an exaggerated sigh as if whatever it was he had to say was going to hurt him more than it would me. Which made zero sense considering we just didn't have that kind of friendship. Like, at all.

He let out another enormously enormous sigh and this time he perched one of his elbows on a folded arm and rest his cheek in one hand. With his head cocked sideways, he squinted his eyes and finally spoke. "Kim? What's your deal?"

I'm sure I looked mad confused. Because I was. "Huh?"

"I'm just trying to figure out what your deal is. I mean. . .what is it you aspire to achieve in your residency?"

I was still lost. "Uhh. . . . get good training? Be a good doctor? Isn't that what we all want?"

When I said that part, he sighed again. I couldn't stand the way he looked at me. Like he was Mr. Miyagi but without the love and caring that went into the Karate Kid.

"You're kind of scaring me, Al. What is this about?"

"It's about the fact that you ain't in Kansas any more, Dorothy." He sort of curled his lips when he said that dropped his eyelids to half mast for emphasis.

"Say what?"

"You are a physician now. And you are no longer at Meharry. You can't be talking to Sanika about her weave appointments or kiki-ing at the nurses' station with her either."

"What the hell are you even talking about? Sanika is my buddy. What the hell is wrong with me talking to Sanika?"

"I didn't say don't talk to her. I'm saying you don't need to be all "honey chile" and "girl-fren" with her in earshot of other people. It's . . .it's just. . . "

"It's just what?"

"It sounds . . really. . .ignorant, Kim. And, well, n-word-ish."

When he said that--and let me be clear: He said the real n-word with "-ish" tacked on to it--I just sat there with my eyes widely gazing at him. I waiting for a beat to see if he would say he "juuuuuust kidding" but he didn't.

Nope.

And so. I just sort of sat there not knowing what to say. I was only a few months into my internship and the last thing I wanted to do was shoot myself in the foot from the very start. That pretty much was the end of the conversation. He'd cloaked me with a new insecurity that I hadn't quite felt before that moment. And it kind of sucked.

N-word-ish. He'd even tacked an 'r' onto the end of that n-word for emphasis. It was hard to shake. I walked around self conscious for the rest of that week. I second guessed all of my interactions with people in elevators, hallways and the cafeteria. My exchanges with Sanika were decidedly more vanilla. It wasn't a good feeling.

The following week, I was at one of my favorite classes in the gym one night after work. It was a step aerobics class and the instructor played lots of really upbeat music--a lot of which was popular urban music. Some old school song came on that I loved and to which I knew all the words. And you know? I did what I always  I started shaking my hips reciting the lyrics. Waving my hands in the air and laughing. Half of my friends in that class hadn't ever even heard that song before. But they seemed to dig it that I had heard it enough times to chant the lyrics without blinking. Like, dig it where it was fine and no big deal.

But work was different. Or was it?

Eventually I did the thing that I've always done in such situations. I called Poopdeck, my dad. Like always, I described all of the players involved. I painted a picture of Sanika with her unnatural blonde hair weave and dark brown skin, including the elaborate tattoo on her forearm with her son's name in cursive. Next I gave all the details about Albert. His preppy attire and dress pants with suspenders which he insisted we all refer to as "braces." The way he rolled his eyes when I walked up on the ward saying things like, "What you know good?" and using words like "chile."

"How are things going in terms of your job?" Poopdeck asked.

"What do you mean?"

"Your performance. What are the people that matter saying about you?"

I thought about that for a few moments. "Well. Actually, Dad, things are going well so far. I mean, I've gotten some really positive evaluations and feedback on my first rotations."

"That's good." Dad paused for a moment and then spoke again. "Do people seem uncomfortable with you being black?"

"With me being black? Uhh. . .if they do, they don't make it obvious."

"Let me be more clear. Does it seem to be an issue that you aren't ashamed of being black?"

That I'm not ashamed? Damn.

But you know? He was right. He was as right then as he is now. I'm not ashamed of who I am. I'm not. And you know what else? I don't like the idea of anyone else feeling ashamed of who they are either.

Nope.

So that's what we talked about. My father had been in corporate America for several years. Like me, he was okay with himself and proud of his heritage. But lucky for me, he'd navigated those waters long enough to know that sometimes it could be different for African Americans. And you know what? Succeeding seemed to come down to a couple of simple things, that is, according to what I gleaned from that discussion with my dad.

First, it comes down to being authentic about who you are and where you come from. But you have to do it while still leaving room for other people to feel invited to be authentic, too. If a person doesn't like who they are--that should be explored first. But if they do feel happy to be who God made them, that don't hide it divide it. Own it, man. And give others permission to own theirs, too.

It kind of reminds me of a funny thing one of my kids said several years ago:

"Yay ME doesn't mean booooo YOU." 

Yes. That. 

The other thing was pretty much the same thing he's told me over and over again for years. Be excellent. When you work hard and give your best, your differences might be received positively. He also explained that sometimes things just are totally unfair and that, without using these words, pretty much let me know that sometimes the haters are just gon' hate. The best panacea? Sustained excellence.

Yup.

And, of course, my dad also was really awesome about reminding me to appropriately walk the line between "doing me" and being unprofessional. That said, what that meant would be for me to determine.

That was a long time ago. I'm older now and have figured out that being true to myself requires a lot less memory and energy than trying to be what I think everyone else wants. I've also learned that your authenticity draws the same out of others.

Needless to say, I really frustrated Albert a whoooooole lot over the next few years. He pulled me up a few more times during my internship and hissed at me about being too black. It was interesting how worked up he would get over things that outwardly suggested blackness and how hard he'd worked to live true to the "less is more" mantra, but how much he complained behind close doors about "the man" trying to bring a brother down. It got really old after a while. Thank goodness he at least spared me that word "n-word-ish" that he'd used the first time.

That reminds me. Once I got some more time under my belt, I did things just to tick him off. I rolled my neck and talked about what I'd seen on BET the night before. Ha ha ha he hated it.

Anyways.

Here's what I know: When people don't like who they are or are harboring some self hatred, what they resent the most is someone else walking fully and boldly in the very aspect of themselves they despise. Black folks. Gay folks. All folks, man. And look--I'm not saying I have it all sorted out. But I do authorize myself to be who I am. And to not fall under some cloak of drone-like assimilation with whatever the majority is doing.

Yeah.

Albert was wrong. Not only was he wrong, he was disrespectful and hurtful. But now, instead of feeling mad at him, I feel sort of sorry for him. Some piece of me hopes that over these last few years he realized that what the world really wanted was the real him. And that him admitting to tasting chitlins or knowing the words to an old rap song. that is, if he really knew it, isn't "n-word-ish" at all.

Or any kind of -ish for that matter.

I say be who you are. Who you really are. And like my daddy said--what that means is for you to determine.

Yeah.

***
Happy Saturday. You know what? This ramble made me think of this--just in time for Black History Month.

Here is me last week after dropping off carpool. Some old Run DMC had just come on the radio and I STILL knew every single word. And you know what? I'm a girl from inner city L.A. who witnessed the birth of hip hop. Those words are in my head right along with the words to "Lift Ev'ry Voice and Sing." And you know what? Both are a part of me. And I ain't the least bit 'shamed. 

The secret weapon.

The thing about residency is that your growth isn't just related to clinical acumen. A huge portion of it is dealing with people and their personalities. And you have to do all of that while learning to keep human beings alive. As I look back on it, that was one of the most challenging aspects. But you know? Some of my best lessons came from that aspect. Lumpy interactions that helped me learn how to navigate this high stakes job in the midst of not only my own crazy--but the crazy of a bunch of other people.

I've been reflecting on a few of my experiences--and how they helped me to grow. Here is one of them. More will follow.

The One-Upper

There was this woman I trained with who was really smart and highly competent. She had an answer for damn near everything and a lot of the times she was right. And all of that was cool.

But.

She also liked to be the person who'd been to the mountain top before everyone else. She seemed to take enormous pride in superseding whatever it is you saw on call or did on your rotation with some far more sexy experience that she'd already had to trump it. And you know? It was annoying. Annoying as hell.

I've always loved medicine since starting my training. I like to think about it, talk about it, revisit things and hash them out. I like to sort out aspects of a clinical story and try to piece them together. And back then with my learning trajectory going skyward, there was always much to debrief on. The highs, the lows, the wows and the OMGs. Mostly I'd do this with my friends, which this particular woman was not. But what many folks will tell you is that residency is kind of like boot camp. Ward teams are like the folks in the barracks with you and often out of necessity you share when your lives overlap for whatever time that is.

And so. One month in my second year of residency, I was placed on the same team as the One-Upper. And I will just give you a spoiler alert and tell you that it didn't end too well.

Ugggh.

We were in the Medical Intensive Care Unit that month. That's a place where the sickest of the sick come for care and the call nights have the most action. Well, the way our schedule was set up, our call days were like two days apart--that is the One-Upper and myself. So whenever I was post call and trying to sort out my patients and their problems, she loved to position herself next to the attending and fellow like she was my boss, too. She'd stand there with folded arms, feeling all super rested from being home the night before-- in contrast to my up-all-night hotmessness and scatterbrain to boot.

One night, I'd gotten this patient who was profoundly anemic for multiple reasons. Due to her hemodynamic instability, she'd been placed in an ICU step-down bed which, at our hospital, was managed by the ICU team. For us, step-down patients were like a breath of easy, fresh air. I figured I'd tank this patient up with the blood that she needed and would have her ready for transfer out of the unit in no time.

So check it--I'd given her a blood transfusion and, much to my horror, like two hours after she received it, she developed severe respiratory distress. Like severe, severe respiratory distress. This was not a woman with a ton of medical problems before hand either. It was terrifying.

Her respiratory status was so awful that she required intubation. And her blood pressure fell even lower than it had been before. And so. We supported her breathing with the ventilator and lots of oxygen and also pumped her with some fluids. Given the time frame of the symptoms, I decided that this might be something called TRALI--transfusion related acute lung injury.

Well.

I'd only read about TRALI. This was all academic as far as I was concerned, so I simply did the best I could given the circumstances. And fortunately, by the time the morning came, my patient had taken a turn for the better.

My attending studied the nursing notes and vitals for a moment as I presented the overnight events. "Wow. So that was pretty sudden. These MAPs (mean arterial pressures) are in the basement," he said.

"Yes, sir," I replied. "We started the pressors fairly early since we didn't have much reserve. She was already on the low side to begin with."

I saw the One-Upper shifting from side to side. I knew she was about to say something so I braced myself. "What about steroids?"

I just sort of looked at her and paused for a moment. "Um. Well, mostly what I read said you start out with supportive care."

She stopped talking to me and sort of shifted toward our attending. "I don't know, boss, what do you say? I've seen some good results out of these guys when you hit 'em with a little SoluMedrol."

Oh have you?

"Eeeeehhhh, you can." He studied the chart a little more. "Mostly it's all supportive but yeah, steroids are often given."

"I'm a fan of the steroids," the One-Upper chuckled. Then she turns to the medical student rounding with us and says, "So the patient has acute respiratory distress right after you've given a blood transfusion. We already talked about transfusion related acute lung injury. What else could this be?"

The student floundered a bit and threw out a few options. I felt my face getting hot. Partly because I was tired but secondly because I was tired and this woman was irking the heck out of me.

"Taco," she said with a smarty pants grin.

"Excuse me?" the student said. I could tell that student was wondering whether or not she was speaking of Tex-Mex for lunch.

"TACO," she repeated. "As in Transfusion Associated Cardiac Overload." She looked toward me and asked another question. "Dr. Draper, did you consider a touch of Lasix just in case?"

Let me be clear on something: The One-Upper woman was my PEER. We were at the same level and in the same residency class. And today, she was pissing me all the way off. While my attending allowed it.

"In case of what?" I responded flatly. I hated that she addressed me as "Dr. Draper" like that. A lot of attending physicians would do that. But fellow residents never used such formality unless they were standing in front of a patient.

"In case it's not TRALI and it's volume overload like TACO." I could have sworn that she twisted her neck when she said that part. I glanced to my attending hoping he'd get my cue for him to shut her up. But he kept studying all the overnight event recordings and didn't say anything. When he didn't, she launched into another spiel on TACO and how this could have been that and how it is actually indistinguishable from TRALI. She even sort of nodded to me when she said that as if I was also her medical student. She started to say more and I cut her off.

"She was hypotensive." My voice was flat. Irritated.

The One-Upper paused for a moment. Then went on, "Well, Kim, you've not actually seen both conditions clinically but I have and--" she turned back to the student--"they both present with respiratory distress so they're indistinguishable." Her tone was so condescending. I tried my best to be subtle as a took  drag of air through my nostrils.

"Hypotension," I repeated, this time with what I know was an attitude.

"Mmmmm. . . . .Well, actually the blood pressure in--"

I cut her right off. "They are distinguishable. One gives you really high blood pressure and one bottoms you out."

She squinted her eyes and tapped her lip with her index finger.  "I'm trying to remember what my last patient with TACO looked like blood pressure wise."

"Hypertensive," I shot back. Then I took a clear swipe which was immature, I know. "That's how she looked. And if she didn't, your diagnosis was wrong."

"Somebody sure is post call snarky!" the One-Upper replied with a snort. Then she turned back to our student and put a hand on her shoulder. "When you really see a patient with transfusion related respiratory distress, you'll be just trying to keep them alive in anyway you can."

My face was hot. Thank goodness for melanin because I know it would have been beet red otherwise. This had been going on all month and I had been up all night. I decided to clench my jaw and just shut up. Finally my attending decided to climb from under the chart and chime in.

"Well, that's true. . . but Kim is right about the blood pressure being the hinge that swings you from one diagnosis to the other. TACO occurs because of a massive upswing in the blood pressure." He yawned and swirled the tepid coffee he'd been nursing all morning and took a little sip of it. "Looks like things are  going in the right direction for this patient. Who do we have next?"

And that was it. That is for that patient, it was. That same thing happened four or five more times on rounds. And each time, my blood boiled just a little more. By the end of rounds I immediately walked off the ward to get away from her.

Yeah.

But everyone knows that when you really, really need to escape this kind of person they somehow keep popping up in your personal space. I was writing the last of my notes in the corner of the physician team room when the One-Upper came strutting in with the medical student behind her.

"Heard you ran two codes last night. Pretty busy," she opened up in my direction.

"Yuh." I kept myself busy, nose down in the chart and hand writing feverishly. My fuse was short and I knew I needed to get away from her before I lost it. I was also totally exhausted.

"I had a guy with a horrible pulmonary hemorrhage a few calls ago. Thank goodness I was able to position him to keep him stable until the Pulm team arrived."

"Yuh."

"Did both patients make it?"

I looked up and rested my eyes on her. I knew she knew that one had expired and one hadn't. But she asked anyway. I'd had enough.

I laid my pen down in an exaggerated slap. "Why are you asking me that? Like, why?"

"I was just wondering. Sheesh."

Her pseudo-innocence was making my head hurt. "No, you weren't. You heard me debrief with the fellow and you knew that one passed away and one didn't. So what I want to know is why are you asking me this?"

She put her hand on her chest and acted like she was surprised. "I-I-I I didn't know that--"

"YES. YOU. DID." I turned to medical student. "I'm sorry for this. I'm just really tired."

She awkwardly mumbled that it was okay and then excused herself, which was probably smart. Now it was just me and the One-Upper. Before she could speak,  I just shook my head and asked that she leave me alone. But she just couldn't respect that request.

"I just don't understand why you have to be so hostile. All I asked was a question."

I closed the chart and stood up. Against my better judgement, I spoke. "Did you just say hostile?"

"I mean, yeah. I asked one thing in small talk and you got all hostile."

"No. You didn't just ask a question. In fact, you never do. You just. . . " I wiped my face with my hand, sat back down, and sighed. "You know what? Just leave me alone. Please. Just go away."

She just stood there staring at me. Like someone had frozen her or something. "This has happened to me before in med school. People feel intimidated when someone smart comes along. Usually it's men who have the issue. But I guess this time it's a fellow sister."

"What?" I whipped my head over at her and crinkled up my face. That's when I knew I needed to remove myself. Which is exactly what I did.

Yup.

I called my dad and lamented to him about her. He listened and then said, "Why is she able to take over so easily when you have the floor? You need to think about that." That was pretty much the gist of what he said. I thought about it all night and throughout the following day.

That was enough inspire a new strategy. For the rest of the month, I spent at least one hour reading on every one of my call nights. I showered, changed into clean clothes instead of scrubs and arrived as ready as I could for rounds after those overnights. Instead of looking haggard and beat down, I coached myself to be the exact opposite. I countered her one-upmanship with excellence. And man was it an awesome weapon.

Yup.

What I learned from that experience was that it didn't even matter whether or not she was being an asshole. I'd given her space to step on my toes by not being excellent. In my head, I'd convinced myself that looking broken down would translate to how hard I'd worked and gain me some kind of badge of honor. But what it did was give someone room to usurp my presence as a competent clinician and teacher.

So I guess that's what I'm reflecting on. Excellence as a secret weapon. Instead of getting angry, I bleached and starched my white coat, shined my shoes, and prepared. I looked my attending in his eye, tried to anticipate his requests, and covered my bases. It was much more empowering than all that huffing and puffing I did before.

Yup.

Eventually, she stopped trying me on on rounds. The fun of it was gone. My buttons weren't pushable thanks to the perspective my dad had given me. And look---I have no idea what's going on with any of you in your lives or on your jobs. But let me just say this: When plotting your attack, consider just focusing on being more excellent. I can't say I always get it right, but trying at it makes a huge difference. Excellence is the pièce de résistance that shuts the haters down every time.

And even when it doesn't, trying to be excellent takes up so much energy that you won't even have time to care.

Yeah.

***
Happy Saturday.

Eyes without a face.

image credit

I'm all out of hope

One more bad break could bring a fall

When I'm far from home

Don't call me on the phone

To tell me you're alone

It's easy to deceive

It's easy to tease

But hard to get release

(Les yeux sans visage)

Eyes without a face

(Les yeux sans visage)

Eyes without a face

(Les yeux sans visage)

Eyes without a face

Got no human grace

Your eyes without a face

I spend so much time

Believing all the lies

To keep the dream alive

Now it makes me sad

It makes me mad at truth

For loving what was you

~ Billy Idol

________________________________

BEEEEEP! BEEEEEEP! BEEEEEEEEEEEP!

That blood-curdling sound pierced through the air and jolted me from what felt like only ten seconds of sleep. I scrambled in the dark to figure out which of the three pagers on my nightstand it was this time. In my frantic state, I knocked two of those beepers onto the floor and, as Murphy's law always has it, one of them was the one I needed to answer.

BEEEEEP! BEEEEEEP! BEEEEEEEEEEEP!

This time it was coming from under the bed. My heart was pounding like it always did when a pager woke me out of much needed but never restful on-call sleep. After a swipe under the wire framed hospital bed, I came up with dust bunnies all over my arm and a pager in my hand. Just as it started to chime again, I silenced it and read the four numbers across the top.

"Ugggh!" I slapped my forehead and let out an exaggerated yawn. I recognized where that call was coming from. How could I not? It was coming from the ward and at this point in my residency I was very familiar with every one of those numbers. I picked up the phone and dialed back the extension. "Hey there. Peds Senior returning a page." My voice was grumbly and undeniably irritated.

"Kim?"

"This is me. What's going on?"

"Are you in the middle of something?"

This was what the second year resident covering the floor team that evening asked me. It was a few moments shy of 4 AM and I'd finally gotten the chance to slip into the call room for a few moments of rest after an exhausting night on call in the PICU (pediatric intensive care unit.)

"What's going on? Just say what it is."

I know that sounds rude but I was tired. Too tired for passive aggressive questions when all of it was leading to something that would surely require me to get out of that bed sooner than I'd intended.

"This baby who's been here for five days is getting treated for sepsis and meningitis. She lost her IV and needs four more days of IV antibiotics. She's a super tough stick, though. I tried twice, my intern, Priscilla our nurse, and even a NICU nurse tried."

"Ummm hmmm."

"Want to give it a shot?"

"Do I want to?"

"I mean, will you?"

I wiped my hand over my face in the most exasperated way ever even though I knew my co-resident couldn't see it. "How old is she?"

"Like not even two months. But a total chunker."

"I'll be at the treatment room in like three minutes. Can you please have every single thing set up?"

"Yes! Definitely!"  I could hear the relief in my colleague's voice. He was in his second year and was new at the supervisory role but me? I was almost over-the-hill as a resident by this point. In my fourth year of a combined Internal Medicine/Pediatrics residency, I'd been around long enough and taken enough calls to become savvier than my younger peers with certain procedures. It wasn't unusual to call the most senior Peds resident in the house as a back up on a failed procedure.

"Hey. . . .and no drama, either. I just want to come, do it, and leave."

Yes. That's what I actually said. And he knew exactly what I meant by that.

What did I mean by that? Well. Unfortunately, I meant that I wanted to make sure I didn't get wrapped up into the patient care or the people part. It was my request to be a technician and nothing else, the senior plumber who comes in after the sink is already pulled apart and fixes things with one tinkering then leaves the mess for the apprentice plumbers to clean up.

Yeah. Like that.

Now. I wish I could tell you that this is the part where I tell you that this never happened and that all of that was just to illustrate some kind of point I'm about to make. Nope. That happened. And not just once. It happened often.

What got me thinking about all of this was a conversation I had with one of my Small Group Gamma advisees the other day. He was deeply bothered by the way a resident depersonalized a patient during a procedure he'd been present for on his current clerkship. When he was telling me about it, it nearly brought tears to his eyes.

"How could that resident have been so callous? It was so, so disturbing, Dr. M."

That's what he said with his eyes widening in full anticipation of some really deep words of wisdom assuring him that THAT resident was a far cry from people like US and that WE could never, ever be that way. Never as in not ever.

But the problem is that I couldn't say that. I couldn't.

Residency training was a very demanding time. Although they still are, the hours back then were even longer and harder than anything I could have ever imagined. The learning curve was steep, the stakes were high, and growth took place at the speed of light. As horrible as pre-duty hours reform training was, it offered plenty of opportunities for exposure to experiences. And exposure meant repetition. And repetition is what led to mastery.

Yep.

But here's the problem with repetition: Eventually you get into a groove and your mind and hands operate without your heart. Like the two get in cahoots with one another and the emotion, the moment, the feeling of it all is sacrificed for efficiency and technical competency.

Even when you knew that these were human beings and not plumbing jobs.

It was four o' clock in the morning when I answered that page and I am almost 100% sure that I was back in the PICU reading a journal and talking to the nurses by 4:15 AM. The reason I know that is because, in my head, I wasn't a part of the care team. That IV was all business. Their business, to be exact.

So what happened? Well, I'll tell you. I walked in, washed my hands, and approached the treatment table where the nurses already had the little baby waiting. The intern knew to affix the tourniquet on the leg so that the veins would already be plump and engorged by the time I was finished putting on my gloves. That intern even knew where I wanted it placed because I'd already told the second year covering her to "save me a saphenous" -- as in the vein in the aforementioned location.

At that hour there weren't pleasantries, really. Just business. So after a few swipes with an alcohol pad, all that repetition took over. Hands like that of a robot on an assembly line. The flash of blood that came out of the angiocatheter was as predictable as I'd anticipated. And you know? I quickly flushed the catheter with a bit of saline, put one small piece of tape over it, and literally passed the baby's leg over to the intern to finish up the job.

"What about the blood draw?" the nurse holding the baby asked. The intern and second year looked around the room and rolled their eyes which told me that this was another technical thing they'd attempted and failed due to lack of repetition.

"Do you have a butterfly needle?" My voice was flat. Still all middle-of-the-night senior plumber business. The nurse handed it to me and without saying another word, I'd already reached for another limb on that poor two month old baby and plunged it deep into her wrist. Out came the blood, which I didn't even bother to stand there long enough to collect. Because my job was to get the faucet working. And once it worked, someone else could do the rest.

Yep.

So this? This is what I did more times than I can even count. Going through motions doing things to human beings as if they were faulty garbage disposals or commodes in the middle of the night. But see, they weren't. They weren't.

And let me just say that I cared. I did care for my patients just as much then as I do now. But back then I was burnt out at times and tired. I was able to compartmentalize people into the categories of "my patient" and "not my patient" and the former always got more of me than the latter. Which I now know was wrong. Very, very wrong.

This was modeled for me. I valued the senior residents and fellows who could stealthily walk in, nail a procedure and pop off their gloves less than two minutes later. These were the hospital legends to us, and I wanted nothing more than to be one of them. One of the ones who saves the day with few words and whose actions say "My work is done here" even though it never gets uttered aloud.

And there's nothing wrong with stepping in for parts of patient care. But the key is to know that there is a patient there. A human being. And once we get involved, we are involved.

I met a colleague during my visit to University of Pittsburgh named Bob A. who is a really cool senior faculty member with the kind of wisdom that you hold onto for later. He said to me during a simple chat, "Whenever someone calls the clinic or wherever and is needing help, I make sure I either help find what they are looking for or try to get them specifically to someone who can." And he went on to say that the person on the other end is a person with an issue and that, once he answers the phone, a tiny piece of that issue is now his, too. Which maybe you don't agree with at all, but I got his point. He just isn't a fan of punting things off when it wouldn't take much to be more helpful.

Kind of like it wouldn't take much to acknowledge the human being who needs the IV or the blood draw or the whatever-it-is-they-need.

So I was sad when I heard what my SG advisee said that day. Sad because I could relate to that resident who had become robotic like I had. No matter how hard I try, I can't remember what those middle-of-the-night patients looked like nor can I will myself to hear their cries. And I am certain that that baby was crying for her parents. Even at two months old she was, but her doctor--the plumber standing over her that night--didn't hear a single whimper. So I told that student about my experience as a resident and together we pondered if perhaps that house officer had reached a similar place.

"Eyes without a face," I said. My student raised his eyebrows for clarification. I went on. "We have to fight to make sure we never let the patients get to that point. Where they are eyes without faces. And it's up to the role models, you know? It's up to us to help keep that from happening."

"Hmmm," he responded quietly. I could tell he was trying to let it marinate and was curious about my choice of words.

"Eyes without a face. . . got no human grace. . your eyes without a face. . . . "

His eyebrows went even higher this time. He was confused now.

I groaned loud and laughed. "You don't know any Billy Idol?" His face fell blank. "Dude! Those are song lyrics, man. Apropos ones, too."

"Oh, okay," he laughed.

"Youngsters!" I shook my head and rolled my eyes skyward. "You probably don't even remember life pre-internet."

We both chuckled and after that prepared to leave. His face grew serious again as we walked out of the classroom.

"You made me wonder what my resident had seen from his supervisors. That's given me another perspective."

"In what we do, seeing other perspectives is everything."

"I'm learning that."

"Good," I replied, "It took me a while. I wish I'd realized it sooner. But when you know better you do better, right?"

"Definitely. I guess all you can do is what you know."

"Exactly."

And I could tell that he meant that and would be chewing on it for a while. I would, too.


One of the hardest realizations I've had to accept in being a physician is that, in a way, every patient is our patient. No matter what we think, it's true. And the minute we recognize that, it changes everything.    

At least it did for me.

You know what? I just thought of something--another perspective. Perhaps to those patients, I was the one with those terrifying eyes without a face. The one who'd gotten so tired that she'd forgotten the human grace she knew her patients deserved. Especially the ones she saw as belonging to someone else even though they were her patients all long.

Damn.

***
Happy Thursday.

Now playing on my mental iPod for the post-iPod era youngsters and the pre-MTV grown-folks. Mr. Billy Idol with the best scowl in 80's pop. Yes!