Category: Reflections on Life, Being Human, and Medicine

Reflections on a variety of topics. My hope is to stir your thinking and perhaps even give you things to talk about in regards to what it means to be human, about life in general, and often times on the practice of medicine.

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Being human Medicine Reflections on Life, Being Human, and Medicine

Learning, Relearning and Lessons Along the Way (In a Pre-Surge COVID Time)

https://www.amazon.ca/Rumor-War-Philip-Caputo/dp/080504695X

We are fortunate to not yet be in “the surge” of the COVID 19 pandemic. Our hospital has patients with it. The leaders expect or at least are preparing for “the surge” like other cities have experienced. We have been preparing and ramping up for it. As a part of that we have redeployment plans in place. Those of us in cardiology are now doing educational modules to brush up on our critical care skills. 

As I thought about what to write this week it seemed fitting to go back to some memories of being a student. 

ISINLAMIKAMP

For me, this was a very important lecture. If memory serves me correctly it was Dr. Vander. We were in the 2nd semester of our M2 (2nd year) of medical school. We were seated in our large lecture hall that was our dwelling place for most of the year. Our professor went up to the board at the front of the lecture hall. He wrote this on the board, “ISINLAMIKAMP.” 

We were all puzzled. 

He told us that he was going to teach us about a very common condition. He said that it often afflicts medical students. He said it commonly comes on sometime about the 2nd year of medical school and usually lasts for 15 years or longer. He reassured us that it was not terminal. We would survive it even if we didn’t like it.

He went back up to the board and wrote next to each letter:

I’m 

Stupid

I’ll

Never

Learn

All the 

Material and

I’ll

Kill 

All 

My

Patients

We all laughed a nervous laugh. We were all feeling that. None of us had the courage or perhaps the wisdom to admit that we were having those thoughts. That lecture was powerful. It made me realize that I was not alone. It helped me understand how to be a doctor.

That day I learned an important lesson.  There is so much material that it is impossible to learn and remember all of it. It is of course important to study hard and to remain as current as possible. There are some who are just so brilliant that it seems like they know everything. But oddly the ones who seem to know everything don’t always tend to be the best clinicians. More important than knowing everything is knowing that you don’t know everything.  

What do I mean? More important than knowing everything is:

  1. Knowing what you don’t know.
  2. Being honest and humble enough to admit when you don’t know.
  3. Knowing where to go or who to ask.

What’s the Worst Thing that Could Happen?

The next story is a repeated one. It happened almost every time I was on call. 

The story starts the day or night before my call. I would think about being on call and I would feel a pit in my stomach. Even just the anticipation of being on call would bring it on. It was a feeling of anxiety and dread. Was I up to the job? Would I be able to handle everything? Most of the time, I wouldn’t even know specifically what I was so worried about. 

But I would be worried.

Every time.

I learned a technique that helped me a lot. In my efforts to try to figure out what I was so worried about I would ask myself, “What is the worst thing that could happen?” 

The script went something like this:

Me 1: What is the worst thing that could happen tomorrow?

Me 2: …

Me 1: Well?

Me 2: Well – my patient could die! 

Me 1: Yes, they could.  But if they do – then that is ACLS[1]. And then you know exactly what to do.

Me 2: So, you are saying that if it gets terrible, then I am ok?

Me 1: That is exactly what I am saying. So just calm down and STOP worrying!

Oddly – that made me feel better. I would go and do what I needed to do. As a trainee there were senior residents or fellows or attendings who could help if I didn’t know what to do. And as an attending there were other attendings. The pre-call dread never matched the reality. 

I am not saying that it was never hard. It was. 

I can remember carrying my little green call book and managing 40+ patients on one of my rotations as an intern at the naval hospital. There were lots of times when I was really stressed. There were times when I wanted to throw my pager across the room. 

There were times when I got very tired. One night I really remember. I was so tired I struggled to finish writing an H&P (history and physical). I had to keep waking myself up. I was “falling out of my chair” tired. When I looked at what I had written in the patient chart I was horrified. There in the end of the H&P I had written part of a dream I had just had while asleep. I don’t know how I did that. It was really embarrassing! I got up and walked around to wake myself up. Then I had to throw out the paper and start writing all over again.

But no matter how bad it got, even at its worst, the worst thing that would happen is that the patient would code. And then it was just routine. Then I would know exactly what to do. We would follow the ACLS algorithms.

And even in the very hard times, I was working. I was moving. I was active. 

When I was in medical school I would read novels. Oddly they were like “sorbet for the brain.” In the midst of hours of studying I would treat myself with a few pages of a novel and it would refresh me so that I could go back to studying. One of the books I read was Phil Caputo’s, “A Rumor of War.”[2] The book tells his story about going to serve as an officer in the Vietnam war. 

https://www.amazon.ca/Rumor-War-Philip-Caputo/dp/080504695X

At the beginning of the book he was young, just out of college, and a brand-new military officer. He went from worrying about history and literature to worrying about dying. I could not imagine what that was like. While I was reading it, I was the same age and had just graduated college the prior year. That identification with him drew me into the book. Each page carried me with him. I came along as he arrived in Vietnam. I felt myself going when he went on his first patrol. By reading I could feel myself sitting on the helicopter heading to the drop zone. I could feel the intense anxiety and dread. I could feel him pretending to be brave for the sake of the men he was leading. He couldn’t admit it. He had to be strong. The drop zone was visible down below. As the pilot descended I could feel him asking himself if he would be able to do his job once they hit the ground. I wondered. If I was there, could I do the job? And then it happened. They hit the ground. Really without thinking they all jumped out and started charging forward shooting against enemy fire. They were just doing whatever they needed to do.

And so, it would be each time on call. The dread was the anticipation. The riding in the helicopter over the trees and then descending down to the hostile drop zone. Would I be up to the job? When we touched down on the ground would I do what was required of me? 

Then I was on call. I did the job. I handled whatever came.

In the action it was not as bad as the dread of the action.

And that was my second very important lesson: The anticipation is worse than the execution.  At its worst, it is ACLS.

The Person Who Taught Me How to Manage DKA

I was a brand-new intern. I had “MD” written on my lab coat and people called me “doctor” but I still had a lot to learn. 

I had been taught about how to manage diabetic ketoacidosis (DKA) in medical school. I had been a part of managing it several times. But as an intern it was different to be the person who was writing the orders. It was a whole series of things – the fluid – the timing of the insulin – the management of the electrolytes and the anticipation of the rapid shifts in electrolytes, etc. I was anxious when I did my first DKA admission in internship. 

And then I discovered a secret.

The nurses had managed it a gazillion times! As I was writing the admission orders, my patient’s nurse was there. She looked to make sure that I was not missing anything. Then she would conveniently page me every time I needed to make a change. “Doctor, would you like to do xyz?” “Why yes, nurse, I think I would like to do xyz! Can you take a telephone order for that?”

The truth is that the person who really taught me how to manage DKA was an RN.

This was my third important lesson: Healthcare is a team effort.

It is not the all wonderful and all knowledgeable doctor dictating everything that is done. The doctor is not like a puppeteer who has to control all the elements. It is a team. There are multiple layers of professionals. 

In safety we talk about the “swiss cheese” effect. That is the idea that for every error that reaches a patient, it is actually the result of multiple failures. Each failure could have but didn’t catch the error. It is as though you stacked a bunch of slices of swiss cheese and all the holes lined up perfectly to allow the error to pass through and get to the patient.

We talk about the swiss cheese effect, because the vast majority of the time, the swiss cheese effect works to our advantage. We end up doing the right thing because of the integrity of the entire team.  Gaps in one of our actions are compensated for by the others.

In training there are multiple layers. As a medical student there is the intern. As an intern there is a resident and the other interns. As a resident there is the attending and the other residents and the interns. 

But there were also nurses. The nurses trained me in ways that I couldn’t learn in books. There were respiratory therapists. They taught me about ventilators. The unit secretaries taught me how to handle the paperwork and what orders to write to get things done.  The pharmacists taught me about drug interactions and drug dosing and pharmacokinetics. The list goes on and on.

The point is that if we are smart we treasure the integrity of the entire team.  It doesn’t mean I don’t take ownership for my responsibility and my actions. I push myself to know as much as I can and to always always always do the right thing. But I do that in the context of being a human being. That means that I am fallible and will make mistakes. When I inevitably make a mistake, it is the integrity of the team that catches the mistake and stops it. It is easily corrected. It does no harm.

 The dangerous physician is the one who is arrogant and thinks that he has to do it on his own. The wise and safe clinician is the one who values and empowers the team. 

What about now?

I am so sorry for everything that is happening in Italy and New York and now on the southeast side of Michigan (and multiple other areas). They are living through very challenging times. 

The data suggests that it is coming to us too. We have been given the blessing of some extra time. It doesn’t seem especially fair that we get this and they didn’t. But who ever said that everything in life is fair? And who ever said that anything about this COVID 19 pandemic is fair? 

But we have been given time to prepare. It feels a little bit like we were given 2 extra weeks to study for final exams. In that studying it makes us feel anxious. Part of us just wants to put away our books and march in and demand our chance to take the exam. But wisdom tells us that these extra days are a precious commodity. Our colleagues in other areas would have loved to have had this time and more of a chance to prepare and plan.

And so, we prepare. We plan for redeployment. We brush up on clinical skills that we have not used in years. And we remember lessons we learned early in training:

  1. ISINLAMIKAMP: It is ok to not know everything. As long as you know that you don’t know and are wiling to ask.
  2. The anticipation is worse than the execution. When the time comes we can do the jobs that we are needed to do.
  3. The team: We are not going into this alone. We have a lot of talented people around us. We will be going through this together.

How about for those of you non-medical readers?

  1. ISINKEIWTKIDKWTB  (I’m Stupid, I’ll Never Know Everything I Want To Know and I Don’t Know What To Believe): We all feel like that sometimes. We don’t have to know everything. We just have to use our best judgment to find experts that we think are credible. At the moment,  smart people are telling us to stay home, wash our hands, and to slow the spread. That is enough.
  2. Sitting and doing nothing is hard. That is human and natural. I hope it helps just a little bit to know that? Anticipation is hard to handle because you can’t just “do”. Many are going to get this illness. Some of us will just go through it without problems. Some will feel awful and then recover. We may lose some people we love. That is the essence of the dread that many of us feel. I am in no way looking forward to any of that. Maybe I should be telling everyone that the frustrated feelings they have inside at the moment are not valid? Maybe I should be telling all of you to just be happy and that you have things “good” sitting safely home at the moment? But honestly I find myself feeling the “pre-call dread.” I am back to figuring out how to deal with that. Please know this: In the worst of it, human beings – you – have a deep strength. That strength comes out when you need it. Are you up to what is going to be required of you? When the doors open and the helicopter hits the ground and the bullets are flying around you, you can and will jump out and charge forward and do whatever job is required of you. You might not like it. But within you is the strength to do it.
  3. The Team: Remember that in medical education the learning comes from all directions. It is never just “top down.” Maybe in this time also we can take encouragement and support from all directions? If you have children in your life, maybe this is the time for them to teach you (to remind you) how to play? We are all in this game of life together. None of us are perfect. Fortunately, we do not have to be. Even if we are physically separated we are still going through this together. Together we are strong.

[1] ACLS = Advanced Cardiac Life Support

[2] Caputo, P. (1977) A Rumor of War. Holt and Company, Henry.

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Being human Reflections on Life, Being Human, and Medicine Reflections on the Christian Life Updates on my health

Crash Survival Training and How to Navigate Challenges in Life

Have you ever watched the movie, “An Officer and a Gentleman?” If you have, you might remember the jet crash survival simulator. While in the cockpit simulator, the officer candidates are sent down a rail at high speed into water and then flipped upside down. They have to get free of the “cockpit” and swim back to the surface.  In a dramatic scene, one of the officer candidates has a problem and nearly drowns in the trainer. He later DORs (disenrolls on request) because of that trauma.

I had to go through that training when I was in the Navy. I was in training to be a flight surgeon. This included aviation survival training.

I worried about what the jet crash survival simulator would be like. How would I do? Would I too end up having to “DOR.” It turns out the jet crash simulator was nothing compared to the challenge of the 9D5A. The 9D5A is otherwise known as the “helo dunker”.  Both simulators were required. The 9D5A was designed to simulate the crash of a helicopter into water. The jet crash simulator was mostly just something to be endured. The 9D5A however was a real challenge. 

The Training:

There are several key things to survive a crash. 

  • Believe you can survive:  The most important thing is to remain calm (not panic). This is probably the most important part of the training. The goal was to give us the confidence to not give up.  Whether you survive or fail in any situation may just depend on whether you believe you will survive or not.
  • Develop a plan: You must establish a plan in advance before everything gets confusing and stressful.  We were trained to think about reference points (landmarks in the cockpit around us) and what would be our plan to get free of the helicopter (simulator).  
  • Wait for all motion to stop: You must wait for the rolling and pitching of the trainer to stop. If the instructors saw us release and try to exit too early, it would be counted a “fail.” We would have to go through it again. In the real-life scenario, the idea was to have optimal timing for action. You don’t want to release early and be injured by the tumbling aircraft.
  • Use your reference points: Your first step was to grab a reference point (such as a window beam or brace). We needed to plan to move from one reference point to the next. This is the key to counter the confusion and disorientation of the moment. We were to never ever be without one hand on a reference point. Losing your reference point is a sure way to get hopelessly disoriented and not survive. Before we could release our safety harness (seat belts) we had to have one hand on a reference point. We would then release and move one hand to the next as we executed our plan of escape.
  • Ignore the discomfort: We needed to ignore the water going up our nose and sinuses as we were suspended from our safety harness under water. We needed to ignore the strong desire to breathe. We needed to be calm. We had plenty of air to get free in a controlled manner and swim to the surface. We had plenty of time as long as we believed that we did.
  • Swim to the surface: This was the easy part. Swim up to the surface. Know that our bodies want to float, and they would naturally pull us upward. Know that victory was coming. We should not worry or despair as we ascended.

What it was really like:

We climbed up steps to a platform to enter the 9D5A (“ helo dunker”). It was suspended 15 feet above the surface of the swimming pool. We were in full flight gear. We strapped into our seats in the trainer and then we waited. I looked at the window and the window frames and planned where my hands would go – one hand after the next – to guide me out of my seat – through the cockpit and out the window.  I waited like I was on a carnival ride for the crash. My heart pounded. The suspense was enormous. 

Suddenly the trainer dropped through the air and then hit the water. As it hit the water it rolled upside down. Down we went – until we were 15 feet underwater and hanging in our seats upside down.  As soon as we hit the water I started counting. That helped to reduce the urge to release from the trainer too soon. Once we hit the count of 10, we could be fairly certain that motion had stopped. Water rushed up my nose from being suspended upside down. My nose burned from the chlorine. I ignored it. I grabbed my reference point and then with my other hand I released the safety harness. I had to shake the shoulder straps to be free of them. There was a brief moment of panic as I worried that the harness was stuck. I then moved my hand to the next reference point. I moved hand over hand as I pulled myself out of the cockpit window. 

Once free it was disorienting to know which way was up. The feeling of panic was rising inside me. I was feeling short of breath. I HAD to get a breath soon. Was I going to drown? How could I find out which way to get to the surface? I HAD to get there soon. I could feel the pull of my body which did indeed want to float to the surface. I could see the light now above me and I swam to the surface. My lungs burned for air at the surface. It felt so good to fill my lungs and breathe deeply as I treaded water in the pool. 

Victory! I did it! 

Round Two:

We all swam to the edge of the pool.  They told us it was time to climb the platform and do it again.  Really?  Really?

This time they handed us speedo goggles that had been spray painted with black paint. We were to do the trainer again but this time we had to do it without being able to see.  We climbed into the trainer (which had been pulled back up out of the water and suspended back in position). Once again we took our positions and off we went.

This time it was easier. In spite of the blacked-out goggles, I knew that I could do this. I knew exactly what to do. But even more I knew that I was able to do it. There was no panic this time. I was building confidence.

Victory (as I broke through the surface of the water)! Again.

Back up the steps again. The third time we were to do it without the speedo goggles, but we all had to exit out the main door in the back of the helicopter.  That time there was some chaos as we had multiple men kicking and squirming to get free and all get through the same exit. By now, however, I had confidence. I knew that I had time to wait patiently for all of us to file out the door. I could hold my breath. I could just deal with the burning chlorine in my nose and sinuses. I calmly pulled from one reference point to the next to the next – pausing in some places for others to pull past me – and then eventually I was free.

The fourth time was not a surprise. We once again had the blacked-out goggles and were all going out the main exit. I remember some legs kicking into me in the darkness but all in all we were fine.

We got out of the pool as victors. We felt like we could survive anything. Later that day we were in class together. All of us were sniffing and snorting from the chlorine water that had rinsed through our nose and sinuses. But we were sitting in class as victors. We had overcome the trainer and knew that if we ended up in a crisis situation, we could survive.

The Lessons:

To this day I can remember the training but more than that I can remember the confidence it gave me. It showed me that I was capable of remaining calm, developing a plan and executing the plan. I could be a survivor.

I was impressed with the way they set up the training.  They did a great job. I looked online and it looks like they may have refined the trainer some since my day. The general principles look the same, however.

What are the biggest lessons?  They are listed above in case you didn’t catch them.

The most important one is that you are capable of a lot more than you think. You can survive if you think you can survive. You can do things as long as you remain calm and convinced that you can do them. This is not absolute of course. I cannot jump out of an airplane and fly like a bird. But when faced with a challenging but achievable task, I can push through and achieve some things that might be hard for me.  When I am called on to do something hard, I take a deep breath and walk into it and just do it.  

One of our transplant directors used to have a “Wonder Woman” poster on the back of her office door. When hard things came up, she used to say that we needed to take the “Wonder Woman” pose. Before an especially challenging meeting, we went into her office and stood with our hands on our hips like Wonder Woman. We took a deep breath. I was humble enough (and thought it was funny enough) that I too participated in the Wonder Woman pose with her. As ridiculous as it sounds, it really worked. Doing that, I felt stronger. I was ready to walk into the meeting even though it was not going to be fun. One day I had a difficult patient to see. I had to tell her things that she didn’t want to hear. We had security guards in the clinic in case she became violent. The Wonder Woman pose helped a lot. I could handle this. I was strong enough. I was capable. Now just do it.

Wait for all motion to stop. Sometimes the most important thing to do is to sit and wait. This can be very hard especially when you feel yourself hanging upside down, under water, with water going up your nose. But clearly there are times when action can do more harm than good. You have time. You are not going to drown. You just have to figure out how to keep yourself calm and not act. Know that it is temporary.   

Keep your frame of reference. Do not get disoriented or lost. There are times in life when you know clearly where you are, what is important and what principles exist to guide you. Other times life will do everything it can to disorient and confuse you. As you go into the chaos, look at those reference points. Do not let go of them. Once the motion stops grab onto one and then the next and then next. Do not let go lest you become disoriented and unable to navigate your way through the crisis.

Some days I have meetings that become chaos. Things are going in so many directions that I barely feel competent to do my job. In those moments I want to run away and hide.  But sometimes I just have to sit back in my chair and wait for the motion to calm down. I look for my reference points. What are we trying to achieve? Can we remember the key principles? Once the chaos starts to quiet, I grab one reference point and then the next. With this then I can start to navigate through to what the meeting ought to achieve. It may not be all the crazy directions that were going on in the meeting. But it could be one clear direction that leads us to the exit where we are all well and good.

Of course, my reference points in life are crucial for me. In the midst of the uncertainty of a cancer diagnosis this became more important than ever. I know who I am before my Lord and Savior. I know that regardless of whatever happens, I am His. I know that He is in control and His purposes will eventually be worked out. I know that not everything in this world goes well. But my reference points are that on a much longer and broader scale things will work out. I had to grab onto one reference point and then the next. It gave me amazing strength to go forward and not panic.

Radiation Therapy

Last year I had to have radiation therapy. To properly target the radiation, I had to do a fairly sophisticated breath hold. This involved blowing out all of my breath, then taking a partial breath and holding it while they delivered the radiation. To be very precise they use a device that measures your breathing. Getting set up they brought me into the radiation therapy room to practice. First they positioned me and marked my skin. Then they put tiny tattoos on my skin as a permanent alignment mark. I asked if they could make them an anchor or a sailboat. They laughed (Yeah, and I am sure they have never heard those jokes before!) Next was the training on the breath hold machine. They put a mouthpiece (like a scuba mouthpiece) in my mouth. They put a tight clip on my nose. They put glasses (like virtual reality glasses) on me. In those glasses I could see my breathing on a graph. Up and down and up and down the line went as I breathed. Then they would activate the device and on that breath cycle I had to lock my breathing in a narrow band. 

I tried. I failed. When I failed a loud alarm would sound. HONK. I tried again. I failed. HONK. And again. HONK.

I could feel the feelings of panic rising up inside of me. My mind started going wild. I was going to be the person who failed at radiation. I was not going to be able to get this treatment. My cancer was going to recur, and I was going to die. I was going to leave my family without a husband and a father. And it was all going to be my fault because I failed! 

It felt like I had just entered into a deadly final exam. Can you pass the test? If you don’t, then you die! Or some morbid video game. You have to guide your character through a maze. If you do it successfully you get to live. If you fail, then you die (not just in the game but in reality.)

I recognized the panicky feeling. It was one that I had felt many years before in the 9D5A. It was the feeling when the shoulder straps hung up a little bit. It was the feeling when I wasn’t sure which way was up. It was the feeling that I didn’t have enough breath left to survive.

I remembered. I remembered the feeling of victory as I got the surface and swam to the edge of the pool. I remembered sitting in the classroom and the smell of chlorine in my sinuses and feeling like we were all some of the greatest persons who had ever lived. 

I could do it. I just needed to believe that I could.

We tried again. It took several tries and then I learned the technique. For the next 5 weeks I did it over and over again and became quite expert at it. I never liked it. But I could do it. I could endure.

Now

I will confess that there have been times lately when I have felt the panicky feeling inside. It is such an odd time to be locked away from people facing an uncertain threat. I am generally very calm but there are times when I wonder if I am able to cope with everything. 

The panicky feeling is a trigger however to remember the lessons from the 9D5A.  At the moment it feels like we are strapped in and waiting for the 9D5A to drop to the water. You have been given your training. Of course, you might be nervous. You might even feel a little bit panicky. That is natural. You are going to do fine. 

Someday we will be sitting together in class with chlorine dripping out of our noses knowing that we made it through this.