whitecoatwonder

[whitecoatwonder]

Panic

The ants march along the kitchen counter in a single file escape route from the oppressive heat outside. The normally ever-present cool and refreshing sea breeze has taken its own annual vacation this week. It leaves us here in the Central Coast of California with hot, dry, lifeless, stagnant autumn air. 

Our historic home, like most in the area, does not have air conditioning so I’m surprised the ants find any relief indoors. They do find sustenance however. They march for food, swarming any forgotten morsel or crumb. 

Each day this week, they continue their march. Day after day. We do our best to clean, but they find every bit of food around. More ants. More crumbs. Always more. We cannot keep up.

They find their way to other parts of the house too. I sit down to rest on the couch, only to find an unwelcome tickle on my arm. The vagrants hitch a ride and end up in all parts of our home. I sometimes feel them crawling on me when they are not there. A phantom ant haunting me. 

The ants invade the indoors with the heat every year around this time, but this year is different. The way they overtake and devour a dirty plate makes me feel helpless. Sometimes, I can’t help but feel like I am the plate. I am being swarmed by an oppressive, overbearing force. The ants. They start to crawl on me and soon overtake me. They cover my body, but they don’t stop there. They manage to crawl deep inside my chest, swarming heavy in my lungs. They twist my bowels into knots.

I try to breathe to bring myself out of this state of panic, but I gasp only to find the hot, smoky air from a state on fire. I try to breathe, but the air is filled with a virus that has attacked millions of lungs in this global pandemic. Is this what it feels like to not be able to breathe? Has the virus attacked me too? I cough. 

I remember the many patients I have seen recently with new anxiety and panic attacks. I now share their disease. This virus has taken over more than just our lungs. It has taken over our hearts and minds and fears as well. Isolation, mistrust, and hatred fill us. Voices of people of color cry out only to be slammed down into the unbreathable air.

None of us are truly breathing until we all can.

Breathe America! Breathe!

[whitecoatwonder]

She Who

Tickles the lake to ripples Teaches the wildflowers to dance Lifts the birds to flight Churns waves to fury Fuels the roar of wildfires Snaps trees in a twisted second Slams a door in rage Urges swollen storm clouds onward Collects nourishment for the sea Whispers through the leaves Shouts through the forests Carries newborn seed to a soft earth cradle And rejuvenates my flushed cheek with a cool kiss

Thank you to Sidney Barger for the beautiful illustration! https://www.instagram.com/sidneybarger_art/?hl=en

[whitecoatwonder]

La Doctora

Doctor never was assigned a gender but it remains masculine by the culture that surrounds it. Authoritative, decisive, interventionist. Fixing and fixing on his own agenda.

Doctora is different. She is kind, wise, health forward, and encouraging. She prioritizes prevention, family, and wellness. She commands all the respect and power that he holds, but softens with care and gentleness. She is a healer of body and soul.

This is a call to the feminine in the world. Please take your place in our health and the field of medicine.

Soy una doctora. I invite you all to be.

[whitecoatwonder]

I’m graduating and leaving our clinic in June

“I’m graduating and leaving our clinic in June.” Over and over again, in the months leading up to this transition, I break this news to my primary care patients. I have developed many meaningful relationships with patients over the past three years of training as a family medicine resident in a large, urban health center in New York City. But now, it is time to leave and move on.

The fluorescent lights in an over-air-conditioned white clinic room illuminate face after face with the same look staring back at me. Her face drops. His shoulders brace. His eyes shift. Her chronic low back pain tightens its grip. Her once improving mood slips back down. The 8-month-old bouncing and smiling on my lap quickly lunges back to mom. She senses that her mother is hurting.

They say, “That is not what I was hoping to hear.” “This always happens to me!” Or, “But we just...” it trails off and I fill in the blanks. We just connected. I just started to feel better. I finally opened up to someone about how horrible I’ve been feeling. We just starting working on my symptoms. …But I trusted you.

This is an old and deep wound that I’m scratching open: loss.

It’s an ever-healing and tender wound for me too that has been opened and again and again by a series of losses throughout my life. I still live with repercussions of the tragic and violent death of my father when I was little, the loss of my angelic mother-in-law to breast cancer, a loving grandfather to a stroke, a young and fiery uncle to a terrible car accident, and a dancing, smiling cousin to brain cancer. There are other losses too that are more expected and less disastrous, like moving away or good friends simply growing apart. Even what we call “good” changes like having kids or getting married have sent people I love further from me and left an emptiness to mourn.  The especially difficult ones make me want to never open myself up again. To never trust again. To harden and to stiffen so that I never feel that pain again.

But if I had mended those wounds so tightly they could never open again, then I would have missed out on so many more relationships and experiences that have passed through my life. Holding what is dear to us with an open hand is vulnerable and hard. But it also leaves space for beautiful and new things to happen. This is the stuff of life though: a series of losses and beginnings.

Selfishly, the thought of leaving these familiar faces, and having to learn a brand new set of medically complex, quirky, pain-ridden, suffering patients from scratch is daunting. Seeing the same patients over time adds meaning to my life and work as I experience the growth of our therapeutic relationship. Watching babies that I deliver grow up, families grow bigger, being there through tragedies, through good times and bad deepen and enrich the relationship, adding comfort and familiarity to a job that easily overwhelms.

Having to leave them makes me mad. I blame the system of medical education and I point to this as a piece of a broken medical system that leaves gaps in care and sustains glaring health disparities. If having continuity of care with one provider is something that is important to a patient who is wealthy and privately insured, they can easily obtain that. My patients cannot. They come to our clinic because there’s very few other options for their care. In dark moments, it’s easy to feel that I am abandoning people who trust me and patients who have taught me more than I could ever imagine learning.

Those are big questions that I don’t have answers to. But the existence of loss is a bit simpler and timeless. I can never protect myself and my patients from loss. Never. No matter how long I stay at the same clinic or town, no matter how tightly I cling to my loved ones. Loss will always return to us. An old, familiar, usually ugly, but sometimes bittersweet friend.

It can be sweet because the pain makes room for new growth. For new relationships and new trust. Different than before. Not perfect of course, but none of it ever was. The threat of losing it again though, will always linger.

To my beloved patients: Thank you for trusting me. I hope I have served that trust well. Thank you for the very many lessons of medicine and caregiving and life you have provided me with. I wish you a new and healing relationship with the next resident who has the privilege of taking care of you; I’m picking them out just for you. And I wish you many, many wonderful medical providers to come.

With a weak smile, my patients tell me they are excited for me and ask where I’m going, what are my next steps. “Oh, California sounds so nice, but it is so far away.”

[whitecoatwonder]

Powerless

I was fully aware that it wasn’t safe for you to be discharged like this. We all were. I got angry about it and fought it, but eventually I had to accept that sending you back to the shelter after over a month in the hospital with end stage liver disease would likely mean you would come right back to our doors.

I didn’t expect you to be okay with it, though. You seemed to easily accept that this hospital, a place of safety and healing, was no longer looking out for your best health. The administration decided they needed to make room for those more insured and more documented than you. There were no other options for places we could send you to. We tried them all. You knew your situation and the way it limited your placement options. You weren’t mad or upset, just respectfully asking questions about how to get back to the shelter and how to care for yourself once there.

I had let myself become numb to the sickness and brokenness that surrounds inpatient hospital work on all sides. I wasn’t expecting to let my guard down when you left. But I did. I was the one who was upset, not you.

I cried the whole way home. I cried because I was tired and overworked. I cried because as hard as I tried, I had run out of time to watch over you, and had no safe alternatives to offer. I cried because I was worried about you. I cried because I was going to miss seeing you in the mornings.

Every dark morning for 3 weeks you greeted me, welcoming me into my day in those early hours. You told me about your aches and pains, what was better, worse, new. You put up with my struggling Spanish and let me practice my language skills with you. And then you thanked me. Every day. Despite your abdomen being bigger and rounder than a full pregnant belly, despite your legs being so tightly swollen that the skin ulcerated, despite the pain you felt of not having anyone in the world to care for you who wasn’t being paid to do so. In those miserable mornings, I got to know you. I realized when you left that I was going to start missing you, which is something doctors aren’t supposed to feel, right?

Perhaps I miss you because of feeling powerless. When you were here, I knew that at least you were being cared for appropriately, and if I discovered that you weren’t, I could do something about it. Now that you’re gone, you’re on your own with a full and painful understanding of how alcohol destroyed your just 42-year-old body. I had to let you go wander into the harsh reality of your illness, full of poverty and isolation, without anyone in the world to help you shoulder that burden.

A very grouchy and immature patient was assigned to your bed the day after you left. He childishly whined and hollered about how the hospital food was not to his standards. And that was only the first complaint on the list. I spent half of my morning trying to convince him to stay at least until he had received the first steps of treatment and monitoring he needed. I wondered what you were doing in that same moment. Were you reaching for your old love, cerveza, or to your case worker? Were you being kicked out on the street for the daytime hours or could you stay inside? Could they give you your medications? Could you even manage to get to the shelter from the hospital with your swollen, oozing legs?

I pray you are sober and on your way toward citizenship paperwork surrounded by supportive staff at the homeless shelter. I pray your liver is healing slowly, sober day by sober day. But somehow, I doubt that, and that makes me feel even more powerless.

[whitecoatwonder]

“Thank you, Doctor”

It was a phrase I never thought I would get used to hearing, but somewhere in the six months since graduating from medical school, I had. The bustle of hospital medicine had consumed my days with its hurried pace, endless tasks, constant effort at refining teamwork communication, and the complete draining of my brain power. Those six months held thousands of interactions in which my role was the doctor. But as her words came buzzing through the speaker of the hospital phone pressed against my ear, all the bustle of work around me in our full resident workroom stood still. The chorus of fingers tapping keyboards, phone calls to specialists, and discussions about patient care with the rest of the team just stopped.

I had just told her that her mother was dying.

Her mother laid comatose two floors above me. She had been lying there for a week. Before that, she had been living at home with her aid, mostly independent as usual. Then one day, she fell and was brought in to our hospital for a workup. But since she got to our hospital floor, she progressively got more and more somnolent. Now she wouldn’t wake up at all.

We had tried everything to get her to wake up. We looked at every organ system and their interaction with each other. Our best assumption now was that her end stage liver disease was causing toxins to build up in her brain, causing an irreversible altered mental state. Usually our medicines can help pull this toxin out of the body, but for her, it just didn’t work anymore.

“But she’s going to get better, right? She’s going to be okay?” Her desperation pleaded through the phone. I told her I didn’t think she would. I told her that her mother was never going to get better.

Despite the multiple conversations and meetings we’d had with her over the past week hoping to discover her mother’s wishes for the end of her life, her daughter seemed unable to grasp that her mother might be dying, much less express any wishes her mother might have voiced about her death.

I told her that her mother was going to be moved to a higher acuity nursing unit where she would have more nursing supervision to be able to care for her needs. With sincerity and disbelief in her voice, she thanked me and hung up the call. The bustle in the room immediately came back to my consciousness and the day continued.

What she was thanking me for, I will never know. Was it honesty about her mother’s condition? I had been doing that all week and it seemed to go nowhere. I didn’t know if she understood even now. Love can create such reckless hope. Maybe it was just the simple persistent care I gave her mother when she was so ill. Or perhaps she just really appreciated the actual phone call, and the connection to her mother it provided, small as it was, while caring for her sweet babies kept her at home and away from the beeping sterile hospital.

I sure didn’t feel like thanking myself. It has been so ingrained in me that my job as a doctor is to solve problems and to connect with people at their most basic needs of health and healing. When the problem can’t be solved, and my patient isn’t going to get better, my job is to carry out the wishes of the patient for the end of their life. But for this patient, her wishes were buried inside of her sleeping mind, and none of us could access them, even by way of her daughter who could simply not accept the reality of her mother’s impending death.

So now, she sits intubated and comatose, her life prolonged by beeping machines, while her daughter holds on tightly with reckless hope for her mother. And although my job to provide medical care for my patient is unfinished, it is done.

[whitecoatwonder]

The Addict

Part I

I won’t give up easily and I never have. I spent my life fulfilling my dreams despite the odds against me. I fought through these nearly eighty years and achieved a successful career, marriage, and family.

Early in my adulthood, I decided to refuse to let my family history of slavery hold me back. With each letter of my surname, I was reminded of the torment my family suffered in this land of so-called freedom. I relentlessly fought to change this name to free myself of the oppression that once firmly held me. I eventually met success.

My perseverance was rewarded once again as I found the fulfilling career of a university professor. I have been happily married for twenty years to a supportive and loving wife. The two of us have been together through everything, good and bad the same. My faith has carried me through. I cling to this faith as hope and life.

But all too quickly, with just a few too-easy choices, I have become a victim of prejudice. I lost everything I once held dear. I regret every second of it.

Now, each day is a fight for survival. My pain has become my new companion. It settles in close on these cold nights I spend sleeplessly on the city pavement. The pain, the only friend who’s never left me, drives me to turn to street medications to quiet her screams to a whisper, a brief but sweet relief.

When you told me that my heart was severely damaged, I was unwilling to accept the idea of dying this year. I promised you that I would fight to qualify for the lifesaving surgery. I would go to every doctor’s appointment, take every medication, and implement every change in my lifestyle necessary to improve my heart health and get to this surgery. I promised to stay clean. Six months was more than enough time to prove myself to be a good candidate for surgery, I promised you. Dying this year was not something I would succumb to. This, I was sure of.

But after labeling me as a black homeless drug addict, you didn’t seem to think my hope for life was grounded in any truth. You gave up before the battle was fought. You said your hands were tied, but I glimpsed those same hands offering my much needed pain medication without hesitation to the patient one bed over. You left me in agony, lying helpless on the other side of the hospital curtain. You said my withdrawals were nonexistent because they weren’t causing an effect you could see or measure. Their reality cried out to me every minute in this house of misery and my pain tortured me relentlessly in secret.

But you don’t know what that’s like. You gave up on me. You sent me back to die on the pavement.

Part II

You were brought to the Emergency Room after being found as a semi-conscious heap on the sidewalk, unable to care for yourself. We nursed you back to life.

Through promises of sobriety spewing from your lips, the tests of your urine betrayed you. The tests were positive for four different kinds of illegal drugs you had been using. Several of these are commonly injected, often leading to many infectious diseases. One of the infections attacked a valve in your heart, leaving it broken and impeding the heart from fulfilling its full vital function.

I balanced the medications in your body to compensate for the failure of your heart function. I spoke honestly with you about the severity of your disease and its prognosis. I respected you and your decision to fight. I advocated for you. I fought for you and I hoped for you.

Despite this, you have burned all possible bridges of support to health and recovery. You have nobody to help you because you have lied to all of us, losing our trust. Your dear wife refuses to take you back. Your girlfriend also won’t house or support you. Your lifestyle of fraud extends to your devout religious experience, which you constantly defy.

Our hospital team can’t find a single piece of valid legal documentation about you. You have lied to our government and your health insurance about your age and identity for years to qualify for more services.

You are unwilling to consider becoming sober for any second of thought despite your promises. I know this, because I believed you at first. But you always unapologetically came back to using. Despite the lack of objective signs of withdrawal, you lie about withdrawal symptoms daily in order to catch a glimpse of the drugs that tie you down and continue to destroy any life that remains.

The prognosis is less than one year. You could extend your life by improving your heart health, with the chance of qualifying for a curative surgery, but this would require sobriety—your nemesis. With many bridges to help burned down all around you, it would nearly require a miracle even if your will was set to recovery and health.

Your addiction will take your life this year. And you will welcome it home with anticipation.

Part III

I can never forget you. You will always be a contradiction in my mind. You represent the poor, marginalized, and vulnerable. You represent the terminally ill. You represent addicts. But you became a selfish liar and a cheat. You cheated me while I advocated for you to the rest of the team in charge of your care.

You told me over and over that you worked tirelessly to have your name changed from the slave name it once was. But don’t you see that all that work means nothing now? You are not free. Your master is the drug and you are its slave.

I’ve been told that addicts who are not in recovery have hijacked souls controlled by their drug of choice. Was that where your soul was? Because I certainly did not interact with it. Who was I talking to all those cold 6 AM mornings? Was that you? Was that hijacked you?

I was proud that our team successfully fought for a wheeled walker for you, but it felt like a horrible goodbye present. It felt like a slap in the face. A walker wasn’t going to offer a roof over your head, keep the rain off of you, or keep you comfortable as you took your final breaths. It would only help you get to the street where your health would quickly deteriorate.

I don’t even know if you’re still alive and I have no way of finding out. And I don’t have any reason to believe that you would be. I never said goodbye. I couldn’t make myself do it. I felt that I had failed you. We failed each other.

I’ll see you again though. Addiction and homelessness are two problems that go together much too frequently for me to be able to avoid you. You might look different, but I’ll know it’s you. You will have the same blank eyes, lie about your use, blame everyone else for your problems, and you will still be a dying brother in need. All human and all hijacked. Inaccessible to me.

But I should be grateful to you for teaching me my first real lesson in addiction. It wasn’t pretty, but it was real. I have a lot more to learn, and hopefully I won’t fail you again. I want to free you. I want to free your soul.

Written about a patient experience during my 4th year of medical school.

[whitecoatwonder]

Doctored

I did it! I actually did it. I graduated with my MD on Saturday. This didn’t happen overnight. It happened slowly, with meticulous perseverance, a strong vision of my end goal, and endless loving support from my family, friends, and mentors. With that in mind, I would like to share some closing thoughts as we turn the page to my next chapter. 

First, I didn’t get here by myself. I couldn’t have done this by myself. My family and friends have prayed, encouraged, cooked, and laughed me through this. They have made sacrifices for me to be here. My mentors encouraged those attributes they saw in me as important to our profession, and they helped gently fine tune others that wouldn’t serve me well in our field. My patients vulnerably offered their health, bodies, and their lives to me in order for me to learn how to care for others. My family instilled values into my character that have allowed me to enter the profession of medicine. My work ethic, patience, compassion, attention to detail, and interpersonal skills come from those who loved me and instilled these values in me as I was forming my very first ideas about the world and my interaction with it. To all of you, you know who you are. Thank you. We made it through medical school! 

Most of my family and friends didn’t have college degrees, much less MD’s behind their names as I was growing up. I had no idea how to get to this point, but I followed a sort of calling to enter the profession of medicine. I thought it was the perfect blend of science, learning, hands-on skills, and interacting with people and caring for those who were suffering. I thought I was built for it. And just the right people came along at just the right times to show me how to approach the next steps. I will be forever grateful to these mentors and teachers. I asked them for help, a lot. And they helped me. They showed me the way. I will strive to carry their generosity forward to those who travel behind me.

I always felt that this was a big goal, but it never seemed unattainable. I think my tendency towards positivity and my unquenchable drive kind of blinded me from the hugeness of it all. Sometimes in a not so healthy way. I decided I would give my dream a good solid effort, the best effort I had. I kept the attitude that if something came up, and I was unable to move forward, I would change directions into another career path. In the meantime, though, I would be giving it my all.

I found out along the way that it wasn’t as simple as doing it or not being able to do it. I found out that the real choice was deciding how much I was willing to sacrifice. I remember a handful of major decisive moments, and lots more daily smaller ones. I didn’t always balance these choices well, and I gave up a lot to get here. I thought about not continuing on many times. But I felt that if I had the capacity and opportunity to enter this profession, then I should continue. And I kept slowly, slowly moving forward. One exam at a time, one application at a time, each step, one by one. I hoped and prayed that I would not lose myself and those I loved most dearly while making sacrifices to focus on my dream. And I don’t think I have.

Our commencement speaker at our graduation ceremony, explained how the letters “MD” not only stand for “Medical Doctor”, but also represent “Merciful and Devoted.” He encouraged us to think of these meaningful words every time we signed our names with these letters, and to remember the commitment we have made to our patients and to our profession. I plan on doing just that. I have many great examples to live up to and many patients and friends to honor with my career.

These new letters behind my name represent a great deal of responsibility that I will now carry on my shoulders. I don’t have to carry this on my own yet, but I took a giant leap forward on Saturday. I still have so much more to learn, but I have a pathway for learning it. In my next steps, I get to enter into a community of like-minded physicians at my residency program, who will help mold me into the family doctor that I will become in a land of opportunity—The Big Apple.

 Here are the words I pledged to this weekend:

First, I will do no harm.

I will honor those who taught me the art and science of medicine.

I will remember with gratitude and humility those whose illness helped me gain wisdom.

I will share my knowledge with future colleagues and all who are in want or need of it.

I will practice medicine with conscience and humility.

I will act with enduring respect for the dignity of human life.

Foremost in my mind will be compassion, respect, and impartial care for my patients.

I will hold sacred the trust of my patients and respect the secrets they confide in me.

I will not be swayed by greed, prejudice, or ego in the practice of my art.

I will do all in my power to help my patients reach physical, mental, and spiritual health.

I will strive for balance in my own life.

May I have the courage and character to hold these principles sacred from this day forward as I place myself into the service of others.

This oath I make solemnly, freely, and upon my honor.

  Thank you, thank you, thank you. I’m here. We did it. Together. Please continue encouraging your dreams and the dreams of those you love. With vision, perseverance, and support, you might accomplish more than you could dream. 

-Tamra Travers, MD

P.S. Dad and Laurie, I felt your love, hugs, and cheers on Saturday down here. I think it’s so cool that you can cheer together now! We miss you on this side, but please know your legacy is strong.

[whitecoatwonder]

I reached out to one of my mentors, Dr. Ken Brummel-Smith, for advice when I was on my very first clinical rotation in the summer of 2014. It was my Psychiatry rotation and I was feeling overwhelmed discussing complex, non-treatable problems and suffering from patients day after day. His response strongly resonated with me, and years later it became the inspiration for this piece.

 This is what he wrote:

“You are being given an amazing gift, working with people who are suffering. The most important thing you can do for them is to recognize your feelings and not run from them. Your job is to remain present, and removed, at the same time. It’s the perfect Zen experience. Look at the Tao symbol and think of that when you are feeling overwhelmed. The black is being overwhelmed. But even in that tidal wave there is a circle of hope. The white is your commitment to the patient and to yourself. There’s always a dark circle hidden in that, but the white is strong – and on top!”

Thank you, Dr. Brummel-Smith, for your wise words of encouragement! I will carry them with me throughout my career and continue to strive for this balance.

[whitecoatwonder]

Doctoring Death

Sometimes I wonder what I would be like if my career had taken a different path.

If I had not seen death in such variety. If I could not remember intricately dissecting a body that once housed life—skinning it and sawing it in half, exposing its entirety to learn about life and healing. If I had not witnessed these now-carved cadavers sawed in half right down the middle so that we might have an appreciation of their depths with a clearer view.

If I had not seen bodies crushed, seen bullet holes almost too many to count, bodies banged up from the inside out from traumatic accidents—some holding on, some already passed, and others somewhere in between. If I had not massaged a heart that was beating just minutes ago, never to find life again within its chambers. If I had not cared for a man after a bullet travel just underneath his face, missing his brain altogether and settling next to his ear—his face bloody and swollen, sitting up, talkative, shock not yet waning.

If I had not watched death form in the faces of family members while they learned the reality of the imminent passing of their loved one. If I had not talked them through the realization that they will never know their spouse, parent, or sibling as they once were—never laugh with them, hold them, or cry with them again.

If I had never told a giddy new mother about the lack of life within her womb.

If I had never seen the place of in between where bodies are held with hearts beating, blood pumping, but real life and function forever gone. They are kept alive by tubes and machines and loved ones who hold hope.

If I had not spoken with adults and young teens whose lives are filled with so much pain of many kinds that they want nothing more than to extract the life from their bodies. Many past attempts, failing even in death, they continue to hurt.

But I have seen, touched, smelled, and spoken with tragedy, death, pain and despair.

So, what now?

Now, I will thank these patients and loved ones for teaching me. For letting me ache and cry with their loss. For teaching me the significance of the lives we all still hold and the necessity to share our precious hearts with those around us. For guiding me through grief and encouraging me in my career along the way. For allowing me to observe the power of families and relationships in all their unique forms. For reminding me to love and kiss and laugh and enjoy those I love around me every day. For broadening my perspective of illness, healing, and life, so that I can better support and empower the health of the patients I will care for daily for the rest of my career.

For this, I thank you.

[whitecoatwonder]

Malignancy

I peered across her open belly filled with tumors. It was a nauseating wake-up to my groggy early Monday morning stupor. They began in her ovary but quickly invaded the surrounding tissues, matting them together in a tangled mess. She already received two rounds of chemotherapy to try to shrink their size before her surgery this morning. The chemo didn’t seem to have touched her tumors, but it did take her hair as it so often does.

Earlier in the pre-operative holding room before surgery, I found her anxiously awaiting her procedure in the hospital stretcher. Her scalp was covered by a checkered head scarf that gracefully framed her tired face. Tears that she could no longer hold inside dripped down her thin cheeks. She was nervous and scared.

Now in the operating room looking at her distorted insides, I was the one who could barely keep from letting tears fall. The usual banter that fills the operating room was smothered by thick, ominous silence. As we teased apart and untangled her insides, we found more and more areas that the cancer had claimed for its own. Thankfully, we were able to take out almost all of those ugly tissues and still leave her bowel intact. We hope more chemotherapy will take care of the microscopic cancer cells we can’t see surgically.

This five hour open surgery was the first case of my week with the gynecologic oncology service at the hospital. This week has been an invaluable learning opportunity, but it has combined my two most dreaded areas of medicine: the operating room, and cancer, into one challenging week.

I met my limit on the last day of the rotation. After an eight hour painfully tedious surgery removing a huge ovary that pre-surgically seemed hopefully benign, we found lots of cancer yet again.

The pathologist showed me the malignant cells under the microscope. They were ugly, big, and rapidly replicating. I was disappointed by the news, but honestly at the time I was mostly upset to return to the miserable operating room for another several hours of now even more thorough, tedious dissection on this late Friday afternoon. My empty stomach growled as I walked back upstairs.

The heaviness of the news didn’t hit me until we spoke with her family in the waiting room after suturing her closed. I know what it is like to be on the other side of that room hearing the devastating news about the cancer diagnosis of a loved one.

My preceptor patiently answered all of their questions and emphasized the treatment plan and hope for a good prognosis. Throughout the week, I watched him perfectly blend honesty with empathy, wisdom, and hope to ease fear and disappointment into a clear and supportive experience for his patients and their families. Combined with his surgical skills, patience, and sense of humor, he is easily one of the best doctors I have worked with.

I was able to hold back my tears in the operating room on Monday as I stood face to face with the tumors that threatened to take over the body of our frightened first patient. Today though, I desperately want to rescue our last patient of the week who is still slowly awakening from her anesthesia. I want to preserve the carefree laughter we shared in our pre-surgical cheerful ignorance. I hold hope that her playful personality will help shape her through her cancer journey into an even stronger, more resilient, and wiser woman than she was today. I thank her for helping me to accomplish the same.

[whitecoatwonder]

Delivery

This baby was making her work. Her contractions were strong, but he was still not descending. She needed to learn how to push effectively. The nurse and doctor explained, coached, encouraged, and commanded her into mustering the force necessary for this baby’s expulsion. Completely dilated with the baby doing well, she gave her full effort for a count of 10. Following the doctor’s orders, she took a deep breath and pushed again two more times before the contraction was over. Screaming with effort and pain, her determination was clear. She was going to bring her son into this world.

I could see his black curly hair covered in mucous slowly, slowly sliding towards our air-filled existence with each effortful push from his mother. He turned and slipped slowly forward, until his squishy little alien face was all that was exposed. With the doctor’s instruction, I helped guide the rest of his body out into our welcoming party. I was holding a miracle.

The emotion welled up inside of me. How can this incredible, intricate process actually work over and over, resulting in humankind?

I was amazed at how rough and animal-like the birth process seems. We spend so much time defining our humanity as sophisticatedly separate from the animal kingdom with efforts of science, culture, wealth, and success within our self-made societal walls. But we are unable to separate ourselves from this painful, bloody delivery process that ties us to the rest of the mammal world in a natural, necessary agony.

We lifted him up to his exhausted mother. Her relief and pride shone toward him with her smile. Her beautiful baby was healthy and full of life. This child has the world in front of him. His life has a thousand possible trajectories spilling out in front of him. And yet, only one life path will be chosen with every small decision placed before him. She has many years of worrying and praying about these future choices, but for now all she has is joy.

[whitecoatwonder]

Walking With An Angel

I went for a walk with an angel today. If she wasn't an angel, she was nearly one.

I don't know why I was feeling lonely, or why I drove to the other side of town for a simple walk, or why I even began walking with her at all. But the warm sun and cool breeze drew me out of my studies and into a journey with this beautiful, unforgettable angel.

She certainly was an intriguing figure. She was beautiful and worn. But her energy and smile bounced with every step. Her short, white hair hid under a floppy sun hat and her used-to-be-white Keds crunched the gravel path as she walked.

I first saw her figure from across the pond. She almost danced around that pond, tugged along by a big fluff of golden fur with a wet tongue. 

What started as a brief exchange with a smile and a pat to the fluffy friend turned into a journey around the pond and into her intimate experience of life that I could never forget. She opened her soul to me; raw and exposed, she shared it with me. 

I almost passed her by, assuming she would rather not be bothered. Or was I hoping not to be bothered on my pleasant, lonely walk around the pond? But something about her radiant smile and that curious dog named Mango captured me. And we began to walk together.

The soul sharing didn't begin right away, and I assumed we would keep it brief and distant. Surely discussing the weather, the park, Mango, and the birds we saw along the way would fill our time.

Before I realized what was happening, she was opening herself to me. She knew nothing about me on which to base her trust. I was just another stranger on a walk around the pond. But she did. And how much she gave!

She spoke of a husband who suffered from polio. A mom passed from breast cancer. A father at 36 passed on from cancer. Two brothers also fought cancer battles as young men. She included her own journey of breast cancer and "a heart that started going crazy." And then, she began to speak of her two beautiful children.

Both suffered from rare genetic syndromes, like hers, involving their hearts and hands. It makes sense that the heart and hands would develop together. Isn't it from your heart that your hands do their work? She held her beautiful hands out for me to see--all bare and exposed. Scars trailed down her arms, reaching back up toward her heart.

I imagined the embryonic struggle that I later found resulted from one mutated gene for a tiny protein vital for the development of the heart chambers and upper extremities. With no family history of the syndrome, this gene was altered specifically for her.

These scars uniting heart and hands continued to extend down to her uniquely shaped fingers, unlike any I had seen before. She held these open and wide for me to take in. These intimate extensions of her heart and life-long battlegrounds welcomed me in.

Joy sparkled in her blue eyes, and she walked on with courage as she spoke with awe of her precious babies. Together they faced struggles upon struggles. Both children were constantly in and out of hospitals, surgeries, and flights across the country for the best care. Both were misdiagnosed at first, but it seemed that both lived full lives in their short years. As I began to react with grief, she instantly expressed her gratitude for the years she had with them. She said she might not have had any time at all.

She spoke with a mother's pride in telling of their bold and courageous journeys. The oldest lived to be sixteen, and with his last wishes, he encouraged his baby sister to be all that she could be. And she honored his plea. After endless work and achievement in some of the best schools, universities, and abroad, she passed suddenly at the age of twenty due to an infection.

This family surely was blessed with so much heart that their anatomical flesh could not contain their strength. Her inner courage and boldness was so evident, and yet contrasted with her playful, dancing figure on this beautifully sunny day at the pond.

I couldn't understand why she was so open and honest with me. Why did she trust me? Why was she filled with so much joy? How could that smile not leave her face? Where did her bouncing energy come from? Why do I feel such a profound connection with her soul?

I do believe in divine encounters. And I also believe this was one. Whether she is an angel, or a beautiful woman with the soul of an angel, it makes no difference to me. I still had the honor of sharing a walk with her, and receiving her soul gift to me. I can't thank her enough.

Written during my first year of medical school.

[whitecoatwonder]

Home

“She’s the one over there with the short hair.” She pointed across the room to a small adolescent girl with choppy short brown hair not quite hanging below her ears.

“Samantha,” I called her name. She turned to face me and without expression, she rose from the table with the other kids. Baggy and worn blue jeans and a faded tie-dye hoodie hung from her slender frame. Her hospital socks carried her body toward me with small steps. One skinny arm swung by her side while her other arm was occupied holding up her pants. No belts are permitted on the locked pediatric psychiatric unit where she was being detained.

“Hi, I’m Tamra. I’m a medical student working with your doctor,” I looked down into her face and shook her hand softly for fear I would snap her delicate fingers with a firm grip. My smile was not returned. “Please follow us to the exam room. We’re just going to do a quick physical.”

The nurse swiped her badge to unlock the doors to the unit and accompanied us to the exam room. Samantha climbed up on the table and I began moving through the exam maneuvers. The silent girl hardly spoke throughout the entire encounter. Questions about her health problems or concerns were answered with head shakes or brief inexpressive responses and only the nurse found my silly comments or jokes entertaining. My patient’s thick glasses magnified the untrusting fear that peered through her eyes.

Then, it happened. In an attempt to enhance her under-responding knee reflexes, I tried an old trick. While she focused on clasping her hands together as tightly as possible, her leg relaxed so I could get a good reflex response. And it was a really good one. I laughed, moving out of the way of the flying leg, but she actually giggled! Her chaotic and crooked teeth slowly emerged as her lips pulled back like a curtain. I even saw a magnified sparkle in those eyes.

Later that day, I interviewed Sam for a psychiatric evaluation. She was reluctant at first in her answers and seemed bored. I apologized that she had to share her story yet again but thanked her and explained that by talking with me she was helping me learn. She responded very well, and quickly began opening up to me.

She shared that she was admitted here because she hit her younger brother really hard and left a mark on his leg. Her aggression toward her siblings was an ongoing, worsening problem. She was here for help. It was hard to imagine Sam getting really mad. Honestly, most of the kids on the unit look like stereotypical, troubled adolescents—depressed, angry, violent, and defiant. But Sam had an innocent look to her.

Some of the South came through her voice every now and then. Like when she said “We used to live in Putnam County,” or “I like to ride my bike and climb trees outside.” But other phrases were said differently. “My mom drinks Captain and Coke,” and “In my house, everyone is always disrespecting each other,” and “We hide when daddy gets home because you never know what he’s gonna be like.”

Her story was heart-breaking. DCF and in-home case management were already involved and aware of everything she shared with me. There was nothing more I could do. Sam had no psychiatric illness as her violent behavior was only present in one setting—home.

Despite her unstable home environment and sad story, she spilled joy all over the interview. I spent a long time talking with her and I felt like I had made a new friend. She even said at one point with her crooked teeth bursting out of her mouth again, “I’m really enjoying this actually.”

When the time came, I had to go. And I left her there, behind those heavy locked doors.

[whitecoatwonder]

The Breast Exam

The ridiculousness hit me hard as I stood in front of her while she sat at the edge of the exam table. With the top of her hospital gown pulled down, her round, dark-skinned breasts hung freely across her chest and upper abdomen.

This was my first breast exam. It was in a standardized clinic room at my medical school with a patient actor sitting topless in front of me. I felt my face getting warm, and my palms start to moisten as I felt the awkward stress rush over my body in the moment before beginning the exam.

I wasn’t expecting to feel this way. I spent most of my time preparing for this learning encounter by studying the vaginal exam. When compared to examining breasts, inserting and removing a speculum into a vagina seemed much more intimidating to me and potentially very painful for the patient. In practice, however, I have found that while the vaginal exam isn’t well within the boundaries of my comfort zone, it seems to live a good distance closer than the dreaded breast exam.

Both of these private areas are accessible to another person only through romantic intimacy, with the sole exception being the clinical exam. Patients allow health care providers access to these areas in exchange for being able to catch potentially lethal disease processes early on in a treatable phase. In order to accomplish this, we have to balance performing a complete and thorough exam with speed in getting the exam over quickly and painlessly.

The awkward tension comes on either side of the balance. If I am overly exhaustive and move too slow, I might be misunderstood as lingering on these sensitive areas in an inappropriate way. If I move too quickly and rush through the exam to get it over with, I might miss something crucial. Different providers practice in all different ranges of this balancing spectrum, depending on their style and individual patient preference.

We also have to be sensitive to the patient in their own unique, subjective health context while simultaneously caring for their private areas with professional, distanced objectivity. The vaginal exam creates the desired illusion of the distanced objectivity through two physical boundaries. First, the minimal amount of eye contact and physical distance between the provider and the patient define this detachment. Second, the drape that covers the patient’s belly and knees creates a physical workspace.

During the breast exam, however, these boundaries do not exist. We are face to face in close proximity, with the awkward tension palpably sitting in the space between her naked body and my white coat. In a panic, my gaze darts between her breasts and her eyes, trying to maintain my eye contact somewhere in the appropriate range of the spectrum between too much breasts and not enough, between performing an exhaustive exam and speedily returning to the courteous distance we would both love to own again.

I was able to pull myself together enough to stumble through my first breast exam with the standardized patient, but it wasn’t until I worked with a breast surgeon the next year that I actually began to appreciate the exam. I realized that the breast exam is an empowering, intimate, and even beautiful moment that provides an opportunity for excellent patient care and respect for the patient’s incredible vulnerability. She had walked alongside these patients for years throughout some of the most difficult and frightening moments of their lives. In return, they offered their open chested smiles filled with trust for their caring and loyal physician. Her strong relationships with her patients combined with her years of experience worked together to hold all of that awkward stress out of the room.

[whitecoatwonder]

The Hours

                                             Malignancies, neoplasms, cancers

Described in gruesome detail, page after page after page. I spend my hours studying cytogenetic markers, defective receptors and signaling pathways. The cells do not die. They are constantly replicating, constantly creating more and more and more cells that will never stop growing on their own.

       Leukemias, lymphomas, neuroblastoma, esophageal cancer, breast cancer

But all I see on these pages are the faces of warriors. Faces of children, grandparents, and friends. Playful blue eyes and flowing blonde hair on a slender frame only 8 years old, always dancing. Deep dark brown eyes of wisdom and understanding, but who know laughter well. All familiar faces of determination, courage, and tenacity. These faces that are so dear to me are formed from the medical terminology and microscopic images.

 Many conquered and now live with the agonizing memories of how the poisonous drugs slowly destroyed the cancer cells and so many of their own cells alongside, leaving their bodies ravaged and weak. Their faces are now strong with new flesh and color that radiates. The fear of recurrence or new cancers still hauntingly lingers.

 And there are some who do not live with this fear. Whose faces are memories, still pale and thin. Their physical weakness was crippling, but their soul’s strength carried the unknowable weight of death forward into the distant pages we cannot yet see.

Written during my 2nd year of medical school.

[whitecoatwonder]

Breathe

The air surrounding me is clouded and thick with the stench of negativity.

Overstressed, behind, rushing. The clock speeds faster and faster, and I am grasping for air.

The breath I try to catch is stale and thick with slimy grouch. It does not satisfy.

Suffocating, I drag myself across the hall while the screams of tummy aches and ugly coughs bombard my ears. I turn to see a flood of tears of exhaustion and fear swirling toward me. My emotions have begun their attack. I reach for the handle of the door and quickly dart inside.

When I look up, three faces are staring at me. Three beautifully round and dark faces.

The mother stares with relief. Their wait is finally over.

A child glares with fear and clutches her mother tightly in a fit of panic. Shots and pokes shake her imagination. Her thick hair hangs down low on her back in a silky black stream, but a few clumps stick to her tears on her fever flushed cheeks. She moans and clings tight to the comfort and safety housed within her mama.

A third face watches intently with curiosity. He follows my every motion with a smile of wonder. He pours wonder into the air from that smile. I gratefully breathe it in, and the sweet air fills even the depths and tiniest crevices of my lungs. My face relaxes and the corners of my mouth turn slightly upward. The curious little brother smiles back, shining his tiny teeth at me. I wrinkle my nose and cross my eyes, then unwind my face to see his face mimicking my own contortion. Laughter leaves his mouth and fills the room with its beautiful, soft sound.

I can breathe again.

Written during a short 3 week pediatric rotation in Immokalee, FL after my first year of medical school.