Bath Salts

I was visiting my cousin’s family in Texas when I remembered bath salts. In the bathroom by their guest room, the shower has a recessed shelf on the end farthest from the showerhead, a place to put shampoo, soap, or a little something decorative. The shelf held an assortment of colored bath salts in jars, arranged all nicely. As I stared at it while rinsing my hair, I kept thinking, Those are so pretty! So very pretty!

It turns out that I had forgotten about bath salts. Not forgotten to buy some or to set them out in my own apartment, but forgotten they even existed. This happens quite frequently, I’ve learned, when you go into the cave. (See http://beckymacd.blogspot.com/2011/09/spelunking.html.) Because you’re working so hard to block out all of the distractions, you end up blocking out the good stuff, too. A friend in architecture school – which sounds far more grueling than medical school – forgot about plants, that they exist and look really nice when people have them in pots around their houses.

As I showered, I resolved to pay more attention to the little things that bring me joy and revitalize my life. Of course I failed miserably for a few months. But then I asked Tay to get me a peppermint foot lotion for Christmas, a product I had eyed for years and alternately assumed I would lack the time to use and forgotten about. It now sits on the bedside table, moisturizes my skin and makes it smell pretty, and makes me happy whenever I look at it.

It’s a feel-good ending, until you consider that I have been on vacation for the past two weeks, sleeping in with no interruption from the alarm, reading ravenously, daydreaming about decorating a house or condo someday, and using peppermint foot cream to my heart’s content. The problem with realizing what you’ve been missing, and tasting some of it, is that you’re all too aware of what it is that you lose when you lose it again. Which I likely will when I resume my rotations. And I’m not looking forward to it.

Taking Space

This story begins in Paris, where I found myself one day about a month after college graduation. I had just wrapped up a trip during which I led and taught American high school students, who were now en route back to the US with another of the teachers. I was set to catch a flight to meet my parents in Rome the following day. With 24 hours in my favorite city, free of any obligations and with some money left over from my teaching salary, I had expected to be jubilant on this last day, roaming the city’s streets without a map, popping into tiny cafes and boutiques and daydreaming about the next time I would return. Instead, I found myself consumed with agitation and anxiety. I felt the need to run and escape, though I had no direction. An unpleasant incident had occurred the previous night, in which one of the teachers had made poor decisions that endangered a student, and although the situation had been resolved safely, my mind still swam with confusion, betrayal, anger, and disappointment that I had yet to process. So I stalked the streets distractedly until I realized where I needed to be, then made my way to one of two small islands situated in the Seine right near the city’s center and entered the cool cavernous sanctuary of Notre Dame.

I am not religious, and if I were, I’m pretty sure I wouldn’t be Catholic. Though I am only vaguely familiar with the faith – growing up, the little girl across the street always seemed to be wearing pretty dresses when she played in the driveway after church, from which I deduced that this must be one of the fancier denominations – I do know that organized religion is not, at this point in my life, something that appeals to me. Regardless, I felt a strong pull toward the cathedral.

I have made many visits before, each time falling more deeply in love with the stunning architecture, so I attributed the draw to this fondness and familiarity. I sat in a pew, thought hard and let my mind wander, focused on breathing and being.

***

This month, I am rotating in a partial hospital program, which is a treatment program for children who carry concurrent (and often connected) medical and psychiatric diagnoses. It is organized similarly to a school; the kids arrive and check in each morning, then return to their families for evenings and weekends. It can be very difficult, especially for kids suffering from anxiety, to always be around others and to participate in group activities and therapy. Thus, a child always has the option of “taking space.” This involves going to a separate room where he or she can remain - supervised by a staff member – until the feelings of anxiety or panic or being overwhelmed have subsided.

I’ve been thinking a lot about space and its importance in relation to different activities and even states of mind. I often get frustrated with myself for failing to integrate meditation into my life, until I look around my cute by small apartment and realize that there is no area where I would feel serene and calm (and not totally bizarre) sitting on my meditation cushion. In the living room with the TV towering over me? Nope. In the bedroom between the dresser and desk? Not so much. It’s the same reason that yoga performed on a mat spread out in front of the couch just isn’t as relaxing as that practiced in a studio with dimmed lights and soft music and a teacher and other students surrounding me. Different spaces have different distinct purposes and connotations, and while there is some overlap and fluidity, attempting to assign too many tasks to one particular space, or not having enough space in general, can be mentally and emotionally constricting. Which is probably why I am writing this in Tay’s large, bright, windowed apartment in Boston, where I only come to relax, and which feels vastly different from the spaces I use for studying and the tasks of everyday life.

When I look back, I have to laugh at myself because there have been many times in the past when I have fully - though subconsciously - appreciated the importance of space, such as when I chose to study for both steps of my board exam in Vermont. At the time I conceptualized the decision as "Vermont is a place where I am happy and not distracted," but I clearly needed to remove myself from my everyday milieu and the aura of stress that permeates the study areas at my school and even at my desk at home. I took space without even knowing that I was doing so.

In retrospect I understand that my pilgrimage to Notre Dame was not one of faith in religion but of faith in my need, although I didn’t explicitly understand it at the time, to take some space. I needed a peaceful, comforting place to hide out from the disappointments of world for a little while; to work out how I felt about what had transpired, to take a rest from the effort required to exist in the unpredictability of the the everyday, and to shore up my mental strength to re-emerge and face it again.

On Service (Part II)

And now there is another kind of going on service: beginning a new rotation at a new hospital in a new city. Suddenly there is much to learn beyond patient names and conditions; there are new corridors, new computer systems, new commutes. While I had spent four weeks at a hospital in Boston this fall, the setting outside of the hospital was familiar. I knew where to buy groceries, where to mail letters, where to jog. Since Sunday night, however, I have been living in Providence, Rhode Island, a place of which I have minimal prior knowledge and in which my already-pitiable sense of direction has gone completely askew.

After making it to the visitors’ parking lot for my first day after only one quick request for directions (from a security guard who kindly pointed out that the lot was directly in front of me), I learned that I would be parking in a remote lot with shuttle service to the hospital campus; an issue to be addressed the following day. That afternoon, determined to get out and start establishing my life here, I programmed my GPS to find the nearest Starbucks. I couldn’t find it, so I aimed for the next one on the list. No luck there. Finally, on the third try, I found the coffee shop and even a parking spot just around the block. After spending some time reading there, I plugged in the address of a yoga studio I had located online.

I found the studio, parked on the street by a meter, then realized I had used all but one of my quarters feeding the meter near Starbucks. It was 5:30, so only a short time remained during which my car would remain fair game for a ticket. Deciding that my mental and physical health were more important than a possible fee, I went inside and found the studio, whereupon I realized I had left my mat in the car. Back at the car, I spied an emptying parking lot next to the building. Perhaps I could park there and ensure there would be no ticket. I pulled into the lot, then saw the sign threatening that all unauthorized vehicles would be towed at all times. I retreated to the metered spot. Re-entering the building, I noticed a sign inside explaining that clients were in fact permitted to use that lot in the evenings after 5pm without fear of being towed. Back out to the car and into the lot I went. And then finally to yoga. And, after a few wrong turns, back home to the apartment where I am renting a room.

The following day, I set out for the new remote parking lot, having Google mapped it the evening prior. Only it turns out that I had used the Pedestrian setting, in which the direction of traffic on one-way streets is not taken into account. With the help of my hastily programmed GPS, I finally made it, then learned that the card I was supposed to use to swipe in had not yet been activated. A parking attendant kindly let me in, I parked, and then I faced the next problem: where to catch this shuttle? And once I was on it, where would it drop me off in relation to where I needed to be? These issues were sorted out by a kind stranger working near the garage and by my own vague recognition of the buildings near the hospital. (The problem with the parking pass recurred on the following day and required two trips to the Graduate Medical Education office and one to Parking Services but was eventually resolved.)

All this without even setting foot into the hospital! The Partial Hospital Program (a day program for children with concurrent medical and psychological diagnoses) is staffed by two directors, two psychologists, two psychiatrists, two pediatricians, two social workers, three teachers, and numerous nurses and therapists, as well as a host of other trainees. It is a busy, busy place, and while everyone has been extraordinarily friendly, it has been extremely daunting to figure out where I fit into the mix, let alone to try to retain each person’s name and role. Plus, no one told me when to show up, when to go home, or what exactly to do in between.

And then, just as with other services, be they with human patients or with my canine friends, small pieces started to stick. Yesterday I was encouraged to attend the pediatrics noon conference, to which I had accompanied one of the residents on the previous two days. Not that I had the faintest clue how to get from the Partial Hospital Program to the auditorium on my own.

Except that I did. I set out through the halls, hoping for the best, and suddenly saw a sign that looked familiar. Around the bend, I recognized a distinctive design along the wall that I was sure I had seen before. Several more serendipitous findings and a few hold-your-breath guesses and I had arrived at the conference.

Yesterday afternoon I went for a run. I had my cell phone with me, stuffed bulkily into my sports bra, just in case I needed a quick check of the route home. But it stayed right in my shirt the entire time, bouncing awkwardly while protecting me with its mere presence from imagined disaster.

Today, I attended a family meeting and a therapy session with a boy who I will be following. I set at least a preliminary schedule for meetings with the person leading his therapy. I arranged the weekly times when I will sit in on group therapy. I have some direction to my days.

And just yesterday, on a whim, I left the GPS in the glove compartment. I turned out of the parking garage, missed the turn I intended to take, then took the next one and figured it out from there. Slowly and with just the slightest bit of confidence, I wended my way home.

On Service (Part I)

When a physician begins a period of time – be it a week or a month or anything in between depending on the physician and the practice setting – taking care of a group of patients in the hospital (which could mean those on a certain floor of the hospital, a certain subset of that floor, or the patients scattered throughout the hospital on whose cases a subspecialty service, such as cardiology, is being consulted), it is known as “going on service.” Like any transition, this one takes time. For the first day or so, the physician must work hard to learn the ins and outs of each patient assigned to him or her, which can be exceedingly complicated given that some patients’ lengths of stay may already be measuring in weeks or months. In addition to learning the medical details, the doctor will gradually get to know the patients’ personalities and complicating factors – which ones downplay their pain, which ones have complex social situations involving certain family members who must receive daily updates while certain others most decidedly must not.

The same is true, to a lesser extent, as a medical student. When I join a service, either at the start of a new rotation or, during the longer rotations of third year, when we switched every two weeks so as to experience a variety of patients and care teams, I am confronted by a census (a list of the patients assigned to the team of one or more residents and an attending physician) that initially appears insurmountable (defining “surmounting” here as becoming familiar enough so that a face, a chief complaint, and a general hospital course become attached to each name). Rounds on the first day involve frantic scribbles of basic facts next to each: “CHF, on Lasix.” “Diabetes – endocrine consulting.” “Sickle cell – monitor for acute chest.” At the end of the day, the names on the list are only vaguely more familiar than before. Most ring a bell; few conjure up the image of a person and the gist of his or her story. By the third day, however, as we stop outside each patient’s door, I am usually somewhat startled to find facts floating into the forefront of my mind – a basic diagnosis, a general treatment plan, a face; perhaps a notable exam finding. By the end of the week, however, I generally know each patient and backstory, and have forgotten that these names ever rang foreign to my ears.

Conceived several months ago, this post was originally intended to segue into an examination of another type of service and the parallel nature of becoming accustomed to a different set of individuals. Last spring, I began volunteering at a local animal shelter, where I take homeless dogs out for walks and socialization. Once a week (though admittedly and heartbreakingly less often as I spend time doing rotations in different cities), we explore a path winding through trees, stride the length of a neighboring empty lot, or play off-leash in an enclosed dog run. The first time I consulted the list of names on the checklist where volunteers record which dogs they have walked on a particular day, it told me nothing; not which dogs were new and which still lingered, unadopted, after months; not what size collar and what thickness leash to collect from the supply area before heading out to greet a new friend; not which dogs were small and especially cute and thus likely to still get walked by others if I prioritized those who were larger or less traditionally cute.

But after only a few visits, I had learned some names and personalities. There was the pitbull who had both a collar embroidered with skulls and crossbones and a daisy-printed bandana around her neck, who regularly halted our walks to roll on her back in the grass, soliciting a belly-rub. There was the mix (part pitbull, but larger and with stripes, which Tay firmly asserted was less dog than tiger), who jumped in circles in her pen whenever I approached, and who made hilarious snorting sounds as she explored the olfactory phenomena that existed outside of the shelter. There was the tiny little chihuahua-like lady who supported herself on her stick-like front legs while squatting, so that her back legs were largely airborne whenever she peed. And there was the older, calm, loving female whose gait had an odd bobbing quality due to the large mass on her front leg but who soldiered on, forever stretching out our walks for as long as she could persuade my soft heart to allow. (Yes, ok, we can do one more lap around the path.)

Music Memory

My grandmother used to tell me how, when she arrived for her violin lessons as a child, her teacher would demand her left hand and clip her fingernails himself.

My favorite teacher loved sampling different brands of rosin [the substance that string players rub on the hair of their bows to help them grip the strings]; her favorite was Pirastro Olive. I bought a cake of it because I wanted to be like her. I will never use it up.

At the annual solo competitions throughout my youth, I scored the highest possible score every year except one. In seventh grade, I was too confident. I flew through the piece and lost points for careless mistakes. Excellent, not Outstanding. Devastation. Life went on.

Every year, my dad drove me to the solo competition, even after I had my license. He listened to me warm up, then listened outside the door during my performance for the judge. The year I auditioned for the All-State orchestra, he could see through a little window that my back broke out in hives as I played. When I came out, he told me that I had nailed it. He was right; I made it in.

When I went to my teacher's house for lessons the summer before she died, I would kick off my shoes and play barefoot. I practiced for her like I have never practiced for any other teacher in my life before or since. She pushed me toward boldness. I realize now that she wasn't just talking about music.

This is not a post about how lovely and noteworthy it was to pick up my violin this afternoon and how I wish I had time to do so more often. These things are true, but so what? This is about the flood of memories that rushed back before I had even wrestled the tuning pegs, sticky from neglect, into place. And about how there are more reasons than guilt over relinquishing skills that it took years of training to learn to pick it up and play again. And again. And again.

Spelunking

During orientation week of my first year of medical school, one of the deans spoke to us about the rigors we would face. He used the typical analogies – this is a marathon, not a sprint – to encourage us to find our own balance and make time for things like exercise and visits with family. But sometimes, he warned us, sometimes, we would need to "go into the cave and get it done."

I went into the cave in July. After finishing out third year with my surgery rotation, celebrating Tay’s and my first wedding anniversary, using my vacation week to move to a new apartment, and absorbing the news of my dad’s prostate cancer diagnosis, I had three weeks to prepare for Step 2 of the United States Medical Licensing Exam, a 9-hour, 352-question multiple-choice extravaganza of clinical knowledge and reasoning on which a passing score is required for graduation and which score can have a sizable impact on one’s residency prospects. So, after the first week of study, I packed my bags and took myself to Vermont.

Possibly more harrowing than preparing for the test was the prospect of living in near-total solitude for fifteen days. It’s quiet up there in the summertime. Other than going out for runs and walks and the occasional foray to the grocery store, I wouldn’t be interacting with anyone. It’s funny how, back in the days of bad roommates, I couldn’t wait to live on my own, was bursting at the seams to establish my own domain. Now I’ve lived with Tay for four years. I wasn’t sure how I would do with so much time and space for my wandering thoughts.

Fast-forward to the day the scores were released and Tay, knowing I would put off looking at my score for weeks if given the chance, took charge and looked at it (just like last year) and you will know that I learned a good bit of medicine up there. But I also learned a number of things about myself that feel somehow both arbitrary and important to know:

-I can change my own tire, though I might need a little help loosening the lugnuts. Apparently I paid attention to my dad’s lesson that day in the driveway more than ten years ago.

-I’m still kind of afraid of the dark, or at least of going to bed knowing I’m alone in the building. (Yes, even in Vermont.) I never thought I’d be so comforted to hear what I’m pretty sure was drunken Czech floating over from two balconies away.

-I have no idea if I’m allergic to bee stings, and suddenly this hole in my knowledge grew to seem incredibly egregious as I considered the potential consequences should I happen to be stung by a bee and happen to in fact be allergic and happen to feel my throat closing with no one nearby to call 911 or give me an emergency tracheostomy…. Witness the limitless creativity that results when I off-load my test anxiety onto every aspect of normal life.

-I might consider getting a [small, subtle, classic and classily-placed] tattoo, assuming I can decide on a design that I will love for the rest of my life and get over my fears of getting Hep C.

-Finally, the lesson with actual ramifications: Writing will always soothe me. It will always inspire joy. Even when I’m alone in my cave of concentration and solitude, balancing the desire to close the curtains against what was likely a firecracker but could be imagined as a gunshot (stop laughing) with the need to let in the comforting sounds of boisterous Eastern European revelry (apparently they did not think it sounded like a gunshot), writing will do wonders. It might be a poem - which is how I calmed myself the night before my exam - or an essay contemplating the decision to ink or not to ink. I might not initially feel that I have much to say, or that saying it deserves precedence over the ever-expanding list of other things I "should" be doing. But if I can just let myself start, or get myself to start, it will carry me through every time.

Experience

You know you’ve gotten the hang of third year, of functioning on rotations, of being a good “clerk” (that term that appears in the written descriptions of your role on each service but that you’ve never ever heard anyone actually use in reference to you), when you arrive at the hospital at 5:15am to find out which patients you’ll need to present on rounds, which will begin at 6am. You’re already planning how you will log into the electronic medical record system and quickly scan your patients’ lab values for anything abnormal or notable and copy their vital signs and I’s and O’s (in’s and out’s, which is just what it sounds like – a record of the quantity each has taken in and excreted throughout the past 24 hours) right onto the page you already snagged from each of their medical records on which to write your note (no reason to waste time and pen-strokes jotting numbers onto scrap paper first and then transcribing them into the note when by now you know exactly how far down in your note to write them, leaving enough space above to record the overnight events and the patient’s status this morning) before scurrying off to examine the patients themselves. You’re aiming for only one computer log-in this morning - it’s so irritating to have to go find a computer and watch seconds tick by as it processes your username and password for a second time after you’ve seen the patients and have realized while scribbling your notes that you forgot to pull up the report of that chest x-ray that one of them had overnight.

You punch in the first patient’s medical record and squint at the abbreviation indicating her location in the hospital. Instead of the expected series of three numbers preceded by an N or a P for the North or Potter sections where most of the surgical patients reside, next to the name you see ADMH05. Huh?

You’ll do the other patient first, you decide, scanning the chart for his history and what surgery he had so you have some clue where to focus your brief examine and pointed questions. When you finish his note, you ask a nurse which area this cryptic bed location indicates, and she tells you it’s the Hoag building. Excellent; you know just how to get there. You run down three flights of stairs to the first level, where all of the building’s sections interconnect, and head up to the 5th floor. You scan the large board across from the nursing station, but the patient’s name isn’t listed.

You check with a nurse – there’s no such patient on this floor. She gamely checks the computer, translating the location code as Potter rather than Hoag, so back downstairs and over to Potter you go. You find the right section, find the patient, and find out that the patient is hard of hearing. Trying not to rush, you remind yourself to keep the pitch of your voice low rather than high because high-pitched hearing is usually what goes first. You ask the patient how she’s doing, whether she has any pain and if she’s peeing and pooping without problems. You grab the chart and copy down the vital signs, then run back over to the North building to finish writing your notes.

At which point you realize that you don’t have the I’s and O’s for this second patient. The residents are going to want this information on rounds, which will start right at 6:00am. Which is five minutes from now. There’s no getting around it; you need the numbers. “I couldn’t find them” won’t cut it. You log back into the computer, but they’re not listed there. You hesitate for half a second, then turn and dash back downstairs, back over to the Potter building, back to the patient’s chart. You flip through the sections of the chart until you find the I’s and O’s, copy them down, then run back to the third floor of North. It’s 5:58. You have time for two more sentences of your note and one deep breath. And then it’s time for rounds, and you’re ready.