October 31, 2015

Melted, poured, molded

I used to think a crucible was a form of torture device; it sounded too much like crucify for comfort. But a crucible is a tool, a vessel: a contained place for malleable material so that it can be melted down and poured into a new form. It's no wonder that the word is applied to difficult situations often as a metaphor - the experience of being shaped by circumstance or events is a powerful one.

Residency is a prime example. I can actively feel how my training is changing me. My opinions are stronger; I demand evidence for almost all decisions; I make my choices based on logic and demand high standards of performance from those around me, just as I demand them from myself. My tolerance for poor work ethics or for poor ethics in general has diminished. I can be aggressive when someone crosses me; I try to limit that aggression to cases where it will accomplish something for my patient. I am less "crunchy-granola" than my idealistic former self was about birth and healthcare and patients. I trust no one; I double-check everything; I know that patients lie or hide the truth from me.

Yesterday was a particularly chaotic afternoon. I did a c-section on a woman with twins - exciting in and of itself! and surgery finished around sign-out. I was hoping to simply fill out the paperwork documenting the surgery itself, put in her orders, and go home. Unfortunately, she was not doing well immediately after surgery. Her heart was racing, and she continued to bleed. I couldn't leave - this was my patient and the on call team was only three people, one of whom had been called to another emergency. I had to activate the "Exsanguination Protocol," which is what our hospital calls the massive transfusion protocol used when a trauma or otherwise patient needs large quantities of blood products. It was only the second time I've ever done such a thing; it was the first time the patient truly needed that quantity of blood.

She needed to go back to the OR. We took her back to see if we could remove the clots keeping her uterus from clamping down. We did, but she continued to bleed, and decided to open her up again to try and surgically control the bleeding. The attending called for a hysterectomy tray and the senior resident went to scrub with her.

I left the OR at this point: only the intern was watching labor and delivery. Granted, there were only 3 patients on the board, but it's still early in the year. I realized that while the senior was in the OR, it was up to me to manage the unit and to corral the chaos into order. For the first time, I thought that maybe being a senior resident next year wouldn't be so bad. Somewhere in the midst of all of this I became aware that I was actually enjoying myself. The adrenaline coursed in my veins. There was the thrill of making decisions on my own, the need to stop worrying about decisions and simply do what needs doing. A part of me was excited and surprised that yes, I did know what to do. The labor patient could keep laboring. The patient who was completely dilated should start to push. We were going to keep on delivering babies, because babies don't stop for other people's emergencies.

I got home at 9:30pm. Just documenting all of the chaos that had happened with my first patient had taken forty-five minutes or so. I came home and sat motionless on my couch, dumbfounded by the day. Pizza delivery took twenty minutes and I was just barely starting to come out of my shell-shocked state. I inhaled a few slices and fell asleep on the couch, watching TV. I woke up sweaty and with a crooked neck, and went to lie down in bed. My mind was racing: what had thrilled me hours earlier was now replaying like a trauma. The rapid and changing status for the hemorrhaging patient had imprinted itself on my mind, and I kept reliving the things that had happened. The delivery that I did on my own - no backup available, attending scrubbed in the OR, just myself and the nurse and the patient - was no small thrill before, but now I remembered the flash of terror as I gowned up. The brief run-through of shoulder dystocia maneuvers; the realization that it was just me who was going to be at this delivery; the fear mixed with confidence that this could actually be done and I could actually do this by myself; these moments linger in my memory, looping around every few minutes when I lull myself into a sense of calm.

It took almost an hour for me to fall asleep again in the middle of the night. I woke up alert but aware that I had tossed and turned, my body mimicking the unrest of my mind.

This is not my final self. I retain the essence of my personality - I hope - but I will not emerge from residency unscathed. This is a time of tempering, molding, hardening - of turning iron into steel.