I’ve not posted in a while. It’s not that I haven’t written, It’s that my thoughts have not been really fully formed, so I’ll have things I want to talk about, but I’m not really sure how to process them or what I really want to say, so I’ll leave the post half-finished, thinking I’ll come back later. But, in the nature of terminal ADHD, I never come back to finish it.

In that spirit, please let me share with you a few of the scattered thoughts and experiences I’ve had over the last year-ish.

It’s December. This is almost halfway through my second year. I’m back in the ICU this block, only this time, as the “senior.” That means it’s my job to teach and guide the interns, show them where everything is kept, teach them how to present and how to sign out, talk about when patients need pressors, and how we choose which pressors to start with, train them how to run codes and put in central lines, and how to decide when to intubate. We are full of covid patients, just like every other hospital in the area, and we have admitted patients boarded in our ED for sometimes days on end, waiting for a bed. We have patients in our unit on ventilators, all the way from Pennsylvania and New York, because we were the closest hospital to them with ICU capability. And

Just like every other hospital in the country, we are hurting for nurses. They can make far more money as travel nurses in big hospitals in Texas and California, and our system can’t figure out that you have to incentivize them to stay, i.e. pay them what they’re worth.

Our numbers are up. When I first started at this program, we were seeing an average of 65 patients a day in our ER. Now, we are seeing an average of 100…. but we have fewer residents to go around. I’m hoping we are bringing in 6 residents this year, instead of only 5.

The learning curve has more to do with my anxiety than it has to do with any lack of skill. I have excellent procedural skills. My pharmacology knowledge is a little weak.

As a senior, I’m covering ICU nights, now. That means that I’m the only doctor on an 15-bed unit of critically ill patients. These are the patients that are on life-support, or so close that they might need to start it at any time. Some of them need to be intubated in the middle of the night. Some need to be shocked out of dangerous heart rhythms.

There’s usually backup in the hospital somewhere, but it’s not always immediately available. My supervising doc, the critical care attending goes home to sleep, and if something emergent happens, sometimes I need to make decisions first and call later.

I had a lady the other day with Covid, she had such bad scarring that she coughed and it ripped a little hole in her lung, and her lung collapsed. I had to put in a chest tube for her. I used the kind built for draining air, called a “pigtail” for the little curl at the end that keeps it from moving around too much even though the body around it moves with every breath. It feeds a wire through a needle into the chest cavity, and then you advance the tube over the wire. Well, I was putting it in and suddenly this lady starts to cough.

And cough

AND COUGH.

AND then she starts to cough up blood. My mind immediately reviews all the relevant anatomy: I’m at the wrong angle to have hit the subclavian artery or vein, I’m nowhere near deep enough to have hit the aorta or the heart with my needle, this HAS to be a laceration to her lung tissue. Maybe she coughed hard enough that the lung flopped out and slashed itself against my needle. I pull the wire out, I need to rethink this, AND MY WIRE IS SHREDDED.

You have to understand, the wire we use is a cable, it has a core of several long, semi-flexible wires held together in a wire wrap, and it has a soft, curved tip, which help it to bump up against internal structures gently and turn without penetrating them. But the wrap on this needle has unspooled, looking like a tiny, kinky, telephone cable and exposing the razor sharp tips of the stiffening core. NOW this is a different story, because my wire was MUCH deeper than my access needle and if the core was exposed, there’s a much higher likelihood of having damaged something more critical. And now, not only is her chest cavity full of air, it’s starting to fill with blood.

I call my attending, my heart pounding, and do my best to calmly explain that I need him. He lives 5 minutes from the hospital, and it shouldn’t be a problem…. but, as my luck would have it, He’s returning a thanksgiving casserole dish to his in-laws house on the East side of Cleveland. He’s at least 20 minutes away.

I know what to do. I know that the next step is inserting a surgical chest tube, a plastic hose as thick as my middle finger in between the ribs and sew it into place hooked up to suction. But the last time I put one of those into a living person, I was 17 years younger, and under mortar fire in the dusty room of a commandeered palace with a porcelain tile floor covered in cracks from the barrage of the weapons used to take it.

But the urgency is the same. DO something, or they die. No matter what else is happening right now. No matter what got fucked up about the last procedure. I can’t dwell on that or worry or stew. I have to just DO.

The “kit” lands on a chair, up from the ED, and it consists of a garbage bag full of varying sizes of tube, and several sterile packs containing a single scalpel, a pair of flesh scissors, and a large curved-nose type of forceps. No drapes, no dressings, no suture, no lidocaine, no cleansers.

I run through the unit, collecting the extra stuff I need, trying desperately to keep the list straight in my head, and when I get back, one of the Anesthesiologists is in the room. I breathe a sigh of relief, believing for one small, glorious moment, that I have backup.

“You have done this before?” His eastern European accent is thick and rich, as he looks over me and the bits and bobs I’ve haphazardly assembled.

“Yes, but it’s been awhile.” I squeak.

“Good.” He announces. “That means you’ve done more of them than me.”

I blink at him for a second. My relief implodes on me, and I can hear the tone of her pulse ox. Every third or fourth heart beat, it slides down another mournful half-step, like a music box with a worn-out spring. Her oxygen percentage has dropped to the 60’s. I realize that I’m it. I do this, or she chokes to death on her own blood and scars.

Seven harrowing minutes later, I’m tying the final knot to secure my tube into place, and I look up. My attending walks into the room, having dropped off his casserole dish, and he looks at the tube, my gloves covered in blood, and the monitor which is now happily beeping a much happier tone, (even if it still isn’t over 90%) and states simply, “See? You got this.”

I washed my hands in the privacy of the bathroom, so no-one would see them shake. I actually HAVE got this.

I sent her to the CT scanner, but no residual bits of shredded wire were found in her. It must have just cut the lung tissue.

Three hours later, her other lung popped and I had to but a breathing tube in her throat and sedate her, and then I had to put a chest tube in the other side. That time, the small tube went very smoothly.

Three hours after that, her family came back in for the morning, and I had to explain to them that despite all the interventions, she still wasn’t going to do well, and I didn’t expect her to live through the day.

When I woke up that evening to prepare for my next shift, it was to this text message.

It’s April. I want to tell you a story. Much of this story you all know fairly well, but bear with me, in case others do not.

In June of 2020, I moved across the country, a single mom of two kids, during the middle of a pandemic, to a place I didn’t know and a place I had no family or support, to start training as an ER doctor. I hunted for a house that would contain me and two kids and our dog. I fought to find childcare in the midst of widespread illness and new restrictions on business models and cleanliness, especially since I don’t work the same shift all the time. I went through orientation in all of July, and in August, I started my first block of residency, doing hospital medicine. At the end of August, my children went back to school, online, and I juggled work and childcare, and often I would get off work at 2 or 3 in the morning

I got this email yesterday.

I didn’t need to look her up. It’s not every day that a 22-year-old female comes with a chief complaint of coughing up worms.

And it’s not every day that you diagnose a 22-year old girl with cancer, and you have to tell her that they aren’t worms, they are pieces of tumor tissue that eroded into her airways, and they have those little ridges because that what shape your little airways are… and they’re bloody at the ends because that’s YOUR blood. And that the tumor looks like it’s the size of a softball sitting on top of her heart.

And you certainly don’t forget it when it happens in the first month that you’re an actual ER doctor. I’d spent so much time off-service that my first ER block wasn’t until October.

Also, I didn’t really DO anything for this girl, except to tell her the worst news of her life. Not sure I really deserve thanks for that.

It’s veteran’s day.

It’s a very strange day for me. In many ways, I do not feel qualified to be counted among the venerated. I don’t think I was ever very good at being a soldier.

But I have been recently attempting to integrate the varying identities I have possessed in my life… actually, “recently” might not be the proper term, as I think I’ve been wrestling with this process for a very long time.

I’ve done and been many different things in my life, and some of those things do not always seem to fit well with other people I have been and things I have done.

It’s a difficult space to occupy, and allow the warring aspects of my personality and identity to try to find ways to fit together without causing jarring conflict and cognitive dissonance.

I was a soldier once, but not heroic or courageous. I didn’t take orders well and I was never appropriately disciplined or organized. I told my commander once that I was not going to reenlist unless I could dye my hair blue and I merely went where I was sent and did the best I could, most of it was just fucking around on a truck, chain smoking cigarettes and occasionally shoving tampons in bullet holes or tying off a tourniquet, but much more often it was rolling my eyes and telling some guy to wear condoms next time.

I was an academic once, studying classical languages and literature, but I’m not sure I was ever dedicated or studious enough to be very good at that, either.

I was an artist once, and a business owner, and a slut, and a wife, and a mother, and a Christian, and a scientist, and a dreamer, and a cynic, and a soldier, and a writer, and a physician.

I remember an assignment we were given in middle school, to create a shirt with a design that embodied who we were…. and I remember being wholly unable to distill that chaos down into an image, being unable to choose any single identity that felt true. It’s still like that, sometimes. It feels forced, like compartmentalizing away enough of the bits of me that don’t fit cleanly into everyday life. But this means I can’t access them when I want to, unless they bleed unbidden into the most inopportune moments, just enough to make me question the validity of whatever I’m attempting to do in the moment.

So I’m trying to let those identities occupy the same space. I’m trying to allow the conflict and the dissonance and the pieces to jam up against each other in strange ways to see how they fit together. It’s not impossible, though it is uncomfortable.

I got an email from my old latin teacher, who’s a friend of mine now, and I love the way he writes. It’s thoughtful and self-reflective, and he incorporates quotes from his readings or translations and he reminds me so delightedly of the quintessential old philosopher, and I read my replies to him that are disjointed thoughts jumping from one subject to another, and I am at once both delighted and horrified by the differences and similarities I see in the ways we write to each other. He is calm and collected, drawing from a huge volume of knowledge and study, and I am jagged and flighty but also drawing from a huge (though different) body of knowledge. And our respective passion is not dissimilar.

Am I still, then, an academic? If a not particularly studious one?

I tied off a tourniquet one-handed on a lady bleeding extensively from her dialysis fistula the other day, enough to look at the wound without her hemorrhaging all over my scrubs, and the motion was burned into my memory. I can still find and load the pistol I keep in arm’s reach of my bed, and take the trigger lock off in the dark, and I can clear it without looking. I still call people “sir” and “ma’am” and I still revel in the moment of calm before the storm… the three minutes I spend in my “office” (aka the front seat of my car) just breathing and listening to music before I walk into my shift, or before I turn off the car and walk into the house or the grocery store or whatever else I am doing. The well-learned routine eases the burden of task-switching.

Am I still, then, a soldier? Have I not brought that piece of my identity along with me, even if I could not bring the confidence or sense of authority I once carried back when I was still “doc?” I want the confidence and the sense of authority.

I want to feel as though it is ok to embody those parts of self, the parts I felt were failures even at the time. I sometimes think that I grew from those failures and I am more now, and the growth means I need to shave those parts of my identity, the parts I felt were failures at the time, to be different from them.

But I can’t. I carry those with me. And if that’s true, then maybe, even if I WAS terrible at being a soldier, even if I WAS terrible at being an academic, at being a Christian, at being a scientist, and now at being a mother and a doctor . . . maybe it’s not really failing.

And maybe it’s ok to still be those things.

And maybe this makes no sense, and I am merely exploring my own disjointed emotions….but I think, now, that the exploration is worthwhile.

A bunch of other stuff happened, too. I got married in May, and there are 3 extra people flourishing in my home now. We’re still a little broken most days, but, then again, who isnt?