A Hard time for Dreaming

Jessica Evans-Wall, HO2, UNM

A knight is sworn to valor, their heart knows only virtue, their might upholds the weak, their word speaks only truth.

These words inspired a childhood of romance, the dream of fighting for a just cause, of aiding anyone in need, of serving the ideals of equality and compassion. A long road to medicine later, and I am standing in the small makeshift resuscitation room in what used to be the Emergency Department’s psychiatric safe area, preparing to intubate a patient with worsening hypoxia from COVID-19. Some days this fight against COVID feels like the battle I always dreamt of, our noble team struggling against the odds, striving to provide the chance that patient by patient the humans most severely affected by this still novel disease have the greatest chance of hugging their children again. Some days it feels like I am a cog in the wheel of disparity in medicine by not being able to spend enough time on the phone with patients’ family members, jumping quickly to code conversations in the concern of the moment.

We know that patients of native heritage were and are disproportionately represented in the 3,400 (as of 2/8) NM COVID-19 death toll. We know that here and throughout the US, communities of color are more affected by this virus. Was I impatient using the phone interpreter with my Spanish speaking patient; did I prematurely close on a diagnosis due to the difficulty of them hearing the speaker phone? How are we as health care providers adding to this imbalance and how can we better combat it? The resident selection process at UNM is recognizing that our provider population does not mirror our patient population and is working towards helping the future move towards having more even representation of our patient demographics and backgrounds represented in our providers, working towards increasing trust through representation.

As a new resident in 2019, all of medicine sparkled with the glow of discovery. Privileged to be part of another human’s medical care, I enthusiastically dove into every case, thrilled to perform any procedure that I could then immediately go record in my logbook. I saw the sadness of hard cases but did not feel responsible or take it in to my core because of all the glitz of being a new doctor. Trying to see myself in this seemingly important role outweighed the daily grief of caring for people who are acutely or chronically ill, homeless, or struggling with addiction.

Now, halfway through my second year, a full year into this pandemic, the gold leaf has worn thin in places. The grief of pronouncing someone’s son’s death, the understanding of worsening prognosis after intubation for a patient with COVID-19, the reality of explaining what a stroke means to a person’s independence, starts to show through like crumbling plaster beneath the fancy facade. To be clear, I did not come into Emergency Medicine because I thought it would be a life of glamor, but there is a certain sparkle to your first chest tube, your first level one trauma, your first anion gap that closes with treatment. In the beginning, there is a false sense of control, a feeling that the interventions you perform directly and precisely, determine the patients’ course. We do have the ability to give people the best treatment we know how to provide, the most evidenced based, and with the most kindness. However, sometimes our best is not enough. Driven, as most of us are in medicine, helped by medical education’s focus on tests and competition, I saw these moments as failures either of myself or of my patients. It seems one of my failures was the pure focus on the interventions performed instead of the poetry of human connection which could be offered. Both are important. One is often lost with exhaustion.

In the past few months, I have been through the common ups and downs of feeling “burnt out” in residency and with the addition of this pandemic, even seasoned staff in our ED are feeling more on edge this winter. Currently in a state of burn and far from being out, fanning the spark of compassion and learning, I see a bit of a shifting vision of myself in this still very new role as a physician. So much of my sense of control has faded, and I work instead to see myself as a facilitator, attempting to provide appropriate care to patients with numerous shared decision-making discussions rounding out every shift. Our team seeks to provide the opportunity for a good outcome but can make no guarantees.

All the while, throughout this year COVID-19 looms ever near and at times I find petty thoughts slyly sneaking into my stream of consciousness, “Am I going to get COVID-19 from this patient?” This patient who threw expletives at me and threw urine at their nurse. I would rather get COVID-19 trying to resuscitate the retired firefighter or the sweet Navajo speaking grandmother, whose family sings to her over speaker phone. Horrified at my own selfishness in having such biased thoughts arise while in a position of providing medical care, I sought to ignore them, ashamed. I took an oath after all. Medical school taught me that a physician must be above reproach at all times. This feels an impossible task at times when stress is high, and sleep is low. I feel myself taking more time with the patient of color wearing a Black Lives Matter shirt in May than I do a middle-aged white male wearing a MAGA hat on January 6th. Their context exists, our context exists, we still must care for all. In caring for humans who sometimes come to the Emergency Department after making flawed choices, I recognize in myself that every action is a choice. When I have frustration with patients who are downright mean, the choice is mine to take an extra breath before entering that room, be sure my mask is fitted tightly, and offer them the same treatment options I offer their neighbor. The wall between provider and patient seems to grow more thin as I recognize the flawed human in me is not so far from the flawed human in room 12. We all learned firsthand this year the sensation of vulnerability. Now, with the vaccine on board I feel able to hold a patient’s hand who has dementia and fears being in the hospital, with less fear of getting coronavirus. With the recent cut of vulnerability still fresh I cannot help but feel more empathetic.

I have been struggling lately with the possibility that once COVID-19 is not in the forefront I will no longer have the sense of purpose, the label of “frontline worker” brings. Although the societal acknowledgement of our role fades, it has been double digit months since I sat on the floor in our living room after a long shift with tears in my eyes beside my partner who is a nurse, watching famous musicians and actors dedicate songs to us as healthcare workers.

The millennial-era-doubt creeps in now and then; Does my work matter if I am not getting recognized on social media? We live in interesting times where a cat video seems to have more clout than health care workers. And yet, how much recognition is enough? I want it to be enough that the patient I sat with and told she has a mass in her bladder, likely cancer, says “it means the world you took the time to sit with me.” I want it to be enough that the 91-year-old POA of a 66 year old patient with cerebral palsy said “thank you for taking care of my baby boy.” These are the moments I find myself clinging to in the tired times when there are not enough shelter beds for patients, and we have limited further treatment options for either the trauma arrest or the patient with chronic pain. We had a brief glimpse last spring of the warmth of community and larger social accolades for our work, but it faded quickly into political unrest and larger recognition of racial inequities ironically unmasked by this virus. Now we must look to our institutions and remember the importance of recognizing each other for the work we do.

In the beginning, the simplicity of algorithms makes medicine feel linear. You recognize a pattern of presentation and use a patterned treatment in response. Humbled by experience over this past year it seems more and more that nothing in human experience is actually linear. We linearize afterwards to attempt to comprehend the complexity of experience. Such simplifications inherently alter the thing we are attempting to understand. Love, illness, recovery from injury; these are not experienced in a straight line.

Illness and injury are humbling to witness. Human stories are not simple nor their paths straight. We as providers are flawed and raw and human; we cry and we feel frustrated or angry, we get giddy with success, and have grief with loss. All these emotions may be present in a single shift. While we must still always be mindful of how our inner emotions affect patient care, it seems more and more unreasonable for us to be taught in medical school that we must somehow be aloof to human emotion. Instead, may we use this power for good, channel it to inspire us to feel passionate about caring for ourselves, our co-workers, and our patients. Grateful I am for the band of incredible people with whom I work, who embrace me both when I am overly enthusiastic and when I have tears well up on shift. Let’s shift the paradigm of separation between patients and providers, and perhaps it will be one way we can contribute to unity in a divisive time. Let us see the human in us, in all its flawed glory, so that we can see the human in those for whom we provide care; we are they.

As the skinned knee child who dreamed of becoming a knight protector, now in worn thin scrubs and PPE for armor, I feel proud of our profession. I will continue to listen to epic music from films with dramatic representations of life whilst moving through this real life epic we are experiencing. I will continue to fist bump my fiancé on our way to a shift saying, “strength and honor.” We all tell ourselves stories to get through challenging times; why not make it one our childhood selves would be proud of. Through this year of pandemic, the more I learn of people the more I cry and the more I care.