Oops, it’s been a while since I’ve written on here (or written in general). Starting a new job amidst the pediatric “triple-demic” has been both exhilarating and consuming. I took a few months of very intentional break time between the end of residency and the start of my first attending job. As with nearly all things in medicine, I had to plan this out a year in advance. I was lucky enough to be able to do it.
I tried to stop myself from making plans for the break, beyond some amount of studying for the boards. When I have time, I tend to want to fill it. But I knew that residency and parenting had taken a lot of structured time, and having some unstructured time was the change I needed. I resisted structure for as long as I could. After a while, the initial thrill of sleeping in (till 7:30am when the kids woke up) and going to the gym or on walks or coffee shop adventures in the middle of the day, whenever I wanted, wore off. I missed the structure of work! I missed seeing patients. I used to get stressed about friends or family texting me medical questions because I didn’t feel I had the time, in residency, to respond adequately. Now, when I got these texts, I was eager to activate that part of my brain again.
I did end up creating some structure and putting some of my writing goals down on paper and in words to friends (plus this newsletter). I ended up working a lot on a story idea I had. I spent a lot of time at the same time every day at the same coffee shop, carefully chosen for its good coffee but also not being a place where I would have to run into people I knew and explain what I was doing.
“I’m working on some writing.”
“What are you writing about?”
“I don’t know.”
Every time I felt guilty for paying for childcare while I going to sit in a coffee shop and write, I remind myself that even Barack Obama 6 weeks after his wedding to Michelle went on a solo writing retreat to Bali to write his first book, at the incredible annoyance of his wife (it made it into Becoming). I am not Barack (or Michelle) and there are many reasons why I will not be leaving Philadelphia for 1.5 months, but it’s a good reminder that even masters of rhetoric need intentional time and space to write and create. People think writing just flows, but often, it lurches.
In any case, writing in a coffee shop is still very solitary, and yet if I were to go with a friend, or my husband, it’s too distracting. I love writing a bit at a time. I don’t love writing as my main goal all the time, or every day. (And don’t even get my started on editing).
But having the opportunity away from medicine, to miss medicine again, to want to go back—that was important. And being a more present parent, partner, and friend—that was something I finally felt I could do, with more control over my time again.
And now, I cherish being able to see patients in clinic. I love seeing everyone from newborns to 21-year-olds on college break. But I haven’t had a chance to write in a few months, and now, again, I miss the writing time.
So I realized at least for me, the secret is not long breaks, it is figuring out the incorporation of writing into my routine as a parent and doctor. Not all of one, not all of the other. A little of each.
And that’s my 2022 into 2023 resolution!
I’m curious—What does it mean to you to take a break?
And if you feel comfortable - share your new year’s resolution(s), if any!
Ok, and if you read this far…as promised up top, here is a snippet of the fiction I’ve been writing. Any thoughts on it are welcome. But what’s a writing sample without some caveats? CAVEATS: 1) I read this again and my immediate first thought is wow, it is bad, and I still haven’t incorporated the wonderful suggestions from my writers’ group so…so I want you to know there are some edits coming its way 2) PICU friends, please correct any ECMO stuff that I got wrong, eep!, 3) No, the character is not based off me!
“Well?”
Kavita looked up to find the team staring at her. It was 8:07am, and Dr. Kim was standing at the head of the group ready to round on the pediatric ICU patients, tapping her foot expectantly.
Kavita put away her phone hastily. Her computer had logged her out of the patient charts so she fumbled as she logged back on, feeling everyone’s eyes on her. Dr. Kim let out a steady hiss of frustration as Kavita navigated to the patient’s chart. It was Henry, a 3-year-old on ECMO for a horrific pneumonia. Henry’s mom appeared at Dr. Kim’s elbow to join rounds, as Dr. Kim said:
“Residents always complain that rounds end late, but guess why they start late?”
Kavita’s faced reddened and she bit back an apology.
One of the things Kavita was working on in therapy was to not say sorry just because people were trying to make you feel bad, even if you hadn’t done anything wrong. Kavita had been ready at 8am, she told herself, and it was Dr. Kim who was late, and then caught her unawares.
Saying sorry always felt like the only out in these situations. Instead Kavita pivoted to face Henry’s mom.
“Good morning, we are about to talk about Henry. How was his night?” She had asked the question making a second of eye contact with Henry’s mom, but then immediately looked down at her computer.
Henry’s mom looked a little confused at the number of people there.
The thing about family-centered rounds, Kavita always felt, is it’s really hard for anyone, let alone families facing a health crisis, to speak to a large group of people. Most people don’t enjoy public speaking. And the families are always confused about who to address, and who is listening; half the time, some of the residents and pharmacist will be clacking away on their computer, and the nurse will get interrupted by a phone call, and sometimes the attending is off to the side.
Henry’s mom’s eyes wandered a little amongst the faces and settled on Dr. Kim, who was right next to her. “You know, I don’t even know how to answer that question. I know we’re paralyzing him so he can be on this…” she waved her hands “...ECMO thing. At one point he wasn’t paralyzed enough, he was moving, so they had to give him more meds. I don’t know what that means, if he was in pain or something?”
Dr. Kim could have jumped in, but instead she broke eye contact with Henry’s mom and then looked expectantly at Kavita. Kavita appreciated this–attendings usually interrupted without even realizing it, because they were the ones patients often ended up directing their questions at.
The problem here was that Kavita was still feeling bamboozled by the technology of the ICU, maybe just as much as Henry’s mom. For example, ECMO. Henry was the first kid she’d seen on it. ECMO stood for Extracorporeal Membrane Oxygenation, and was colloquially the “heart-lung machine.” You had to be “cannulated” for it–basically, a bunch of general surgeons show up, you get sedated and paralyzed by the ICU docs if you aren’t already (you usually already are, because you’re intubated), and the surgeons stick tubes directly into your major vessels–either the aorta, the IVC, or both. Henry had VV-ECMO, veno-venous ECMO, meaning the cannula was only in his venous system. When Kavita saw Henry get cannulated for ECMO she felt her stomach flop over several times, but she pushed it down. The last thing she wanted was to faint when someone was literally on the verge of death. It would be even worse than fainting during her surgery clerkship while holding a retractor, which was a thing that had happened. Yes.
The purpose of the tubes, or cannulas, in the major vessels was so that the blood could be pumped from the right side of the heart to a “lung” on the outside—”extracorporeal”—running through an oxygenating membrane and then returning through another cannula so the oxygenated blood could go to the rest of the body. Kavita would find herself mesmerized sometimes by the transit of blood, the once-clear tubes now thick with plum going to the machine, and in a brighter crimson leaving. The color change that oxygen lent the blood as it clung to hemoglobin. The vision of it hopping off as blood flowed through the body, dropping oxygen off at its hungry tissues.
To get ECMO you had to have an ECMO technician sitting at bedside at ALL times, because if the blood clotted, or a cannula got dislodged, or the machine failed, well–death. And to prevent those things from happening, and for the patient’s comfort, you needed the patient fully sedated and paralyzed. Not moving, and hopefully not feeling, not remembering.
The key word, Kavita felt, was “hopefully.” She had heard stories of patients, mostly adult patients, recounting how they remembered their intubation or cannulation. It was why we didn’t hesitate to increase sedation, increase paralyzation.
“You know, it’s a good question, why did he move? It’s hard to say what he was feeling, but we know he stopped moving after a little more paralyzation and sedation. I’ll talk a little more about this in my plan.”
She paused to let Henry’s mom say anything, but she didn’t.
Dr. Kim: “Why don’t you go ahead, Kavita.”
Kavita cleared her throat.
“Henry is a 3 year old with a previous history notable for asthma, presenting with 3 days of fever and URI symptoms, leading to severe hypoxia and hypercarbia, found to have pneumonia and now stable on ECMO. We already went through the interval events; numbers?”
She looked at the nurse who started to rattle off the vital signs, the ECMO tech who rattled off the ECMO numbers like “sweep,” and watched Henry’s mom’s eyes glaze over.
“Physical exam unchanged” Kavita said once the nurse was done. “Still focal crackles in left lower lobe. Good cap refill. Plan: for the ECMO–”
“Wait–” Dr. Kim cut her off, not unkindly. “Assessment?”
Kavita forgot! She had to say whether Henry was worsening, stable, or improving. This was the part that Henry’s mom actually cared about. “Henry is stable on ECMO.”
“I would say that he’s actually improving,” Dr. Kim said gently. “Stable labs. Pulling better breaths on the vent. Less resistance in the circuit. Him moving might actually be a good sign. Though of course, we want to keep him optimally sedated and paralyzed until he can come off.”
Henry’s mom face brightened.
Dr. Kim could see Kavita had no idea what to say next so she took over, outlining the changes she would make, tweaking the lasix dose so Henry could offload some fluid from his lungs, leading the team in a discussion of proning, rotating him to lie on his stomach for part of the day to open up his lungs and improve perfusion.
Kavita was grateful but also embarrassed. She should have prepared more. ECMO just still seemed so…foreign to her. The pediatric ICU still all seemed so foreign to her. What was “better” when things were all bad? But the doctors and nurses here were good at projecting, thinking what would happen 4, 5 days down the line. Kavita could barely project to the end of rounds.
In fact one of Kavita’s strategies for keeping her toes on the edge of the pool of her depressed thoughts without actually plunging in was staying in the moment, not jumping or thinking ahead. If she stayed immobile, inert, things would not change. Projecting ahead required hope and she had pitiful amounts of it.
As they walked to the next patient, Kavita leading the pack pushing her computer on wheels, Dr. Kim caught up to her.
“Hi there Ka-veet-a,” she said, drawing out the second syllable, with a hard T. “Am I saying that right?”
“It’s Ka-veeth-a,” the “ka” is the emphasis and it’s a “th” sound.” This is what Kavita said when people asked, otherwise she didn’t bother correcting them.
“Kaaaa-veeth-a?”
Dr. Kim had drawn out the first syllable almost comically, but Kavita could tell she didn’t mean it that way. She was trying.
“Mm-hmm.”
“I just…wanted to let you know I didn’t mean to be terse with you this morning. I was stressed coming from a morning meeting, I was late, and I…wasn’t my best self.”
Kavita was flabbergasted. She wasn’t used to attendings being this vulnerable with her.
“Oh, that’s totally fine. I didn’t mind at all.” She said automatically. That wasn’t true, or maybe it was partially true. Kavita and her co-residents would joke that they were so burned out they were like used matches. A strike couldn’t ignite them, positively or negatively, anymore. This was unexpected, though. There was a small sliver of warmth that reached her, just the tiniest bit.
“I was a resident too, once. I know it’s hard. But you’re going to learn every day and at the end of residency you’re going to know so much. Plus, attending life is so much better. You’ll be there in a few years, before you know it.”
Kavita forced a smile. A few years! What if she wanted her life to get better now?