Letting death in the room.

Taken by the author. Mukwonago, WI. Oct 2016.

One of the most heart-wrenching things I witness at work is people saying goodbye to their loved ones. Today I watched a husband say goodbye to his wife of 31 years, with their son also present at bedside, weeping as his mother died.

I stay in the room for all terminal extubations, along with the ICU nurse and the respiratory therapist. It's always an emotional thing to witness; I think we all find some kind of unspoken moral support in having each other present, besides the obvious practical needs to be there (RN to give meds, I provide orders/ explain things to the family/pronounce/ask for autopsy, RT weans ventilator and removes the endotracheal tube).

I stood in the room and watched the RN bolus morphine and midazolam...I watched the patient's respiratory rate. I watched her face for signs of struggle, her body for signs of stress. There were none, so we were ready to let her go. I gave the final "ok" to the RT to remove the woman's endotracheal tube, as I thought her respiratory rate and sedation level were adequate so that she would not struggle without the ventilator's assistance (pressure and oxygen). Her sats dropped to the 60s immediately once she was on room air, she developed circumoral cyanosis, and her heart rate was dropping. The medical staff all left the room so the family could alone be with her. She lived for about one hour after extubation, deeply sedated, and died without any struggle. I returned later to pronounce her death (1250) and obtain autopsy consent from her husband. He readily consented and said she would've been an organ donor, if her cancer hadn't prevented her from doing so. He asked "What will your team learn from doing an autopsy?" and I explained the top clinical questions that I thought could likely obtained only via autopsy.


In the moments before the medical team goes into a patient's room to do a terminal extubation, there's often a collective "let's do this" sobriety. As in "This is hard. But, we will do it, and we will do it well." And we do, our team always does. Unfortunately in an oncology/BMT ICU, we are all skilled at helping people die well. And at this point in my career, I'm skilled at that part of my job and proud of it. Not proud in a perverse way, but proud to be able to palliate symptoms of pain, anxiety, and breathlessness in one's last moments of life. Proud that I can help guide families through the emotional agony of watching their person die. Proud that the last images they see of their loved one are peaceful, quiet, calm, well-choreographed. Respectful. Clean. I am grateful that we have the ability to allow people to die without suffering, to serve our patients in this way, to calmly let death into the room after beating it back for so long with our various medications, procedures, life support. We spend hours trying to corral irrational forces (life and death) with rational means (science)--it's almost absurd at times.

But as we let the dying person leave the earth, as their suffering ends, the survivors' suffering begins. Their love wasn't free; now they grieve. All of this had me thinking this afternoon--about love. Whenever we love someone we do it knowing (somewhere in ourselves) that someday one of us will say goodbye to the other. It's an overwhelming thought to ponder for too long. You'd think this would hold us back sometimes, but no. We throw ourselves wholeheartedly into love--loving our partners, friends, children, pets...while knowing that it is all temporary and that this will hurt eventually. Talk about optimism! Humans crave love and connection, we cannot resist it (can we live without it?) even though we know that eventually it is 100% guaranteed to come crashing down around us. Every time.

5 months in - just breathe, just love!

5 months into being the mother of 2 little boys and I barely have time to breathe sometimes. I work as a Pediatrician but I had completely forgotten how very very very very very very (can I just type the word “very” for the rest of the post?!?) hard mothering a newborn is. Add to that some complications, a rambunctious, highly intelligent 6 ¾ year old, a husband 2 years into his tenure-track and 35-year-old bones and you have a recipe for fatigue that rivals the best of them.

5 months of cuddles. Of tears. Of such profound joy that it takes my breath away. For example, I remember the first time Zo told us how very much he loves his “baby bro” and how he’s his “best buddy”. Mothering for the second time has also been very humbling. When we found out that our little one was losing too much weight and could not exclusively breastfeed I felt like an utter failure. I KNOW how to breastfeed a baby after successfully doing it with our first and I thought if I powered through, me and Mau would get-it-done! But I had to come to terms with the fact that sometimes a mama’s body and a baby’s body just can’t power through, you just can’t will enough strength in his little low-birth-weight jaws to muster up enough energy to be a good breastfeeder. It took lots of letting go, lots of submitting to our reality. And y’all know I cry, a whole lot, so this made me weep and gnash my teeth like nothing else! But as I snuggle his now chubby little thighs, I remember the donor breast milk, the formula, the supplemental nursing system, the bottles, the reflux and I can smile. And it’s all okay even if it’s not what I envisioned.

So 5 months in, I know why my patients miss follow up appointments. Even with my father here with us almost full time I am inundated with Early Intervention, Cardiology, Ophthalmology, and other appointments. He’s perfectly and wonderfully made (took a while for me to be able to say this) but his little life requires a team for him to thrive. And thrive he is! We have all overcome so much and we have so much more to go. To all of the mamas out there in MiM land - wishing you and your babies so much love, health, and happiness. Even when mothering isn’t what you envisioned just remember that you and your baby were meant for each other. Learn all you can. Teach all you can. Be gentle with yourself and your baby.

5 months in. Inhale. Exhale. Smile. Inhale. Exhale. Smile. “The greatest thing you’ll ever learn is just to love and be loved in return” (Nat King Cole).

Learning how to self advocate for wellness and career advancement

I've recently been meditating on personal and professional development and in a lot of ways, maintenance. Part of it aligns with recently discussed concepts of wellness and work-life balance. Part of it also has to do with this intrinsic unsettled feeling I'm experiencing with work. I attended an academic conference recently which I believe was clarifying and is helping me to frame my approach.

Health

This all started with a dive into self care, specifically, trying to make sure that I was taking better care of this 41 year old body of mine. I had not been to a dentist in 15 years. Yes. You read that correctly. I had not seen a dentist since before medical school. Part of it was because I'm irrationally terrified of the dentist... part of this fear probably came from all those times my mother forced me to sit with her and hold her hand through many root canals and extractions while she squirmed, wiggled and held a vice grip on my hand. The other part of it was the silly thought, "If it ain't broke, don't fix it." The final factor was the disease of busy. I flossed. I brushed. I have a nice smile. I'm fine.

It wasn't until my little one bravely sat through the first couple of dental appointments during which we found out he had multiple cavities between all of the molars, necessitating 8 crowns, a failed attempt at in office nitrous and subsequent trip to same day oral surgery center with a pediatric anesthesiologist that I finally made an appointment. So I did it. I had a couple of cavities, needed scaling (which is a special kind or torture) and am now getting teed up for a root canal. I suppose it's not bad for 15 years. At least I'm keeping all of my teeth, for now.

Let's move on to fitness. I'd topped off the scale at 5 pounds over my full term pregnancy weight. I hated what I saw in the mirror. Inside I was happy. My outside didn't match my insides... maybe I wasn't happy. Regardless, I've spent the last year trying to make sure to make time to do tedious things like plan healthy and nutritious meals and get some exercise. I found a colleague and now friend who was an online health coach. I found a supportive environment of other busy, professional women who found time and prioritized this portion of self care and found that they ended up being happier, more patient and feeling more fulfilled all around. I found tools which were easy to implement (albeit requiring some behavior change), accountability partners and fun exercise options. I enjoyed it so much that I myself became a coach.

With everything we give to our patients, our learners and our hospitals, we absolutely must prioritize ourselves in there somewhere. Working out may not be your thing, but you have to identify what it is that recharges you and make time for it. Put it on your schedule or it will not happen. It will ebb and flow, but you've got to take care of you before you can take care of anyone else.

I still need to schedule that Pap and Mammo... I'm a work in progress.

Personal Development

Part of the company's philosophy is ensuring that you spend some time each day on your own personal development. This created an opportunity for me to read some personal development books (the former four letter "self-help" category). Below you will find the books I've gone through over the last 6 months (good grief, whoever created audiobooks is literally the best because I become narcoleptic while reading).

I've read (or listened to in audiobooks) "You are a Badass: How to Stop Doubting your Greatness and Start Living an Awesome Life" by Jen Sincero. She's not a physician, but she's been through some things and many of her struggles and insecurities resonated with me. She is also remarkably sarcastic and funny and I had many a laugh while listening to her book.

I followed that with "The Compound Effect: Jumpstart Your Income, Your Life, Your Success" written by Darren Hardy. This dude for all intents and purposes is a self made gazillionaire and did it all with hard work and discipline, specifically with small changes every day. He had an authoritarian for a father, so we have that in common. It focuses more on the business world, however if I ever consider entrepreneurship, I'll probably revisit it.

I followed that with bits and pieces of several books from Brene Brown... "Rising Strong" and "The Gifts of Imperfection," both of which hit chords with me. Let's figure out how to pick ourselves up after we fail at something because that is what bravery truly is. It takes no energy to stay down after you take a hit. Facing the day, reflecting on how you may have been responsible for whatever you've experienced is an important lesson. Reading her book is like sitting in a therapist's office, without the $200 price tag. She's a shame researcher and she hits the nail on the head when she discusses the mountains of self imposed guilt we shoulder unnecessarily. She's also witty and sarcastic from time to time.

Next was "The Subtle Art of Not Giving a F*ck" by Mark Manson. Now, if you can move past the fact that this guy is a bit like a frat boy in his use of language, there are some important lessons to be learned. Some things just don't deserve our energy. Seriously.

My latest read is "Feminist Fight Club: A Survival Manual for a Sexist Workplace" by Jessica Bennett. I came upon this book on my way to the aforementioned conference. I knew I was specifically attending a workshop designed to appeal to women interested in leadership in academic medicine. I was looking for something which would light my fire and help me think outside the box a bit. Jessica Bennett is a journalist who specifically writes about issues of gender, sexuality and culture. In her book, she highlights the research which discusses not only how institutions may unknowingly or overtly be preventing growth of their female professionals, but also behaviors we may be demonstrating which hinder our own progress.

I take each of these books with a respective grain of salt, but it's really kind of opened my eyes to some self reflection and highlighted some things I may want to work on within myself. When we spend so much of ourselves in tending to other's needs, our own needs and need for growth can get lost in the mix.

Professional development

So, I'm an academic. I teach medical students, PA students, residents, fellows, faculty. I have sought opportunities to develop my educational niche, my ability to provide feedback, teach a skill, develop a curriculum, pitch an idea to my department chair. I teach a lot of things... probably too many things, which is why I find myself feeling stale and unfulfilled here. I feel like I've spread myself so thin that I'm doing an ordinary job at all of the things for which I'd prefer to be doing an extraordinary job. I feel like an octopus juggling knives which are on fire. Is this imposter syndrome creeping in? Perhaps, but I know I could do better with my time and efforts if I peeled away from some things.

I officially mentor some and unofficially mentor others. I've not received any training per se in mentoring, save observation of folks I hope to emulate. I don't know what the steps are. I don't know what skills to hone. It's kind of like teaching, but also very different from teaching. There should be a program for mentoring the junior mentor. There probably is, but I've not yet had the bandwidth to seek out or discover it, but it is something I need. What I found most interesting in the sessions at this conference was the focus on not necessarily seeking out the most sage mentor. Sometimes peer mentors are actually better for you as you navigate different challenges in your career.

I've been at this academic gig for 6 years now. At the conference I attended, many of the female leaders commented on "cycles" and feeling unsettled after a certain amount of time doing each of the jobs they did. That hit home for me. I feel unsettled. I want to do what I'm doing differently and I need to advance my position from my current title to the next. As such, I've been meeting with my closest mentors, having heartfelt talks about what I thought I wanted when I started, what I've done and where I see it going. I see now that I've invested a tremendous amount of time and emotional capital in one path. It was my hope that by working hard and contributing, I'd be rewarded with position. Boom!!! Words from all of the books came to mind and highlighted for me that I in fact cannot do it all and I should be asking for compensation in some way for what I am doing. You will not get 100% of the things you DO NOT ask for. I must focus my efforts on those things which are most meaningful to me in my professional life. I need a new goal. I need a promotion. So, I'm going to spend the next couple of months working on my dossier, writing papers, reviewing and revising the curricula that I am responsible for and pouring the energy freed up by letting go of tasks held by one of my octopus tentacles.

It's exciting and anxiety provoking to have this new approach and challenging in that I've never before created a dossier or gone up for academic promotion. Why didn't someone tell me about all of the stuff that goes into this? Why didn't someone tell me to keep better track of all of the lectures I taught, programs I developed, mentees I invested in, meetings I attended, evaluations I received??? This wasn't part of orientation when I became faculty. It was discussed as an afterthought in my annual meetings "You should be ready for promotion in a couple of years." After reading my most recent book, I wonder if the experience is the same for my XY colleagues. Is the assumption that because I'm a single mother, I must not be interested in promotion or advancement, so I don't really need the guidance or personal investment? To adapt a quote from Jessica's book, "No one gets shit done like a mom."

I'm trying to figure out what my professional and personal mission statement is. What are my values? What do I hold dearest to me? Do my actions align with my values and my mission? How do I parlay these reflections into actions moving forward and be sure I'm looking out for my own professional interests, professional development and advancement?

Open or closed? How do you deal with emotions?

My whole life is organized into boxes. (ie, my blog name). I like to compartmentalize, keep work and home life separate, keep public me and private me separate, emotional me and getting-through-the-day me separate. Usually, this works. I can be the happy, relaxed, fun loving mom I want to be to my kids, efficient and professional at work, and contemplative when I'm by myself on a run or on my own. But recently,  I have not been able to figure out who I want to be or who I am when I'm with my husband. The problem, I think, is that I want to be all of me for the one I love and built a life with, but I'm having a hard time putting it all together in a cohesive, not unpredictable, way.

A lot of what we as physicians see daily gives us perspective, and makes us confront our own mortality. It's heavy stuff, if you let yourself think about too much. So I try to leave work at work, keep the danger stories or cool saves to share with my family, and  compartmentalize. With the kids, it is easy. But it is sometimes hard to explain to my partner the intensity of what I do and see daily. I want to share, but sometimes I can't begin to explain or unpack my feelings. I have never been an emotionally open person and keeping things inside and putting on a happy face is how I have been able to overcome a number of difficult periods in my life. It has worked for me before, but now it is creating an emotional void between me and my partner that I don't want to get any deeper. As I write this, I realize more that the problem is that since I can't try to explain, I don't. I simply shut it down. And then, eventually, pandora's box opens and all spills out.

For those of you with non physician partners or partners whose days look very different than yours, how do you balance? Any resources that you have read, or used, to help me feel more comfortable expressing myself and verbalizing my thoughts?