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Intrinsic joy

When I was in high school and college, most of the activities I was doing were to obtain validation of others. I had quite an overpowering fear of death, or rather of being forgotten. I remember having this fear around my junior year of high school that one day I was going to die and no one would care. I quickly realized that theism was an easy way out of facing this angst and that was not going to be the solution for me. I needed something more tangible. For years that solution was to be greater, to have influence on the world, to be remembered. I pursued that through racing triathlons for a while. A few people noticed me and a couple people knew who I was. I was the first to cross the line at some little local races and I thought I was somebody. That was really hard. I tried so hard.

After college I became passionate about long distance open ocean kayaking. That seemed kind of cool. I decided to try to paddle the length of the Antilles, from Florida to Venezuela. I tried a dozen times and turned around before killing myself in the open ocean a few times. I ended up settling for an infinitely lesser challenge and paddled to the Dry Tortugas, a measly 50+ miles of open ocean.

During my first year of med school I learned I was a nobody. I went from getting recognition for academic accomplishments in undergrad to feeling like a total dumb dumb in med school. I was surrounded by brilliant, hard-working people. I was nothing. Ensue massive impostor syndrome. I couldn’t match these people in academics- no way. I tried to hike the Appalachian Trail unsupported faster than anyone ever had. Tore my calf. For a moment I was a badass and then I was just a smelly man on a train back home with a ridiculously sore bruised calf.

I went back to med school sometime later and accepted humility. I knew I was never going to match my peers academically. They were brilliant. I decided to pursue family medicine and at some point in residency it clicked. I wanted this job, not to be special, but because I actually liked taking care of patients. I don’t think that was my original thought but I am glad it panned out. I like the learning; I like meeting people; I like being a part of their lives in a vulnerable time.

This year I bought a boat load of plants, but not like the normal “I’m getting into houseplants”. My house looks like a jungle. But each day I think about what each of those plants needs. I water some of them, regret overwatering several others, monitoring the root rot on the succulent from my helicopter plant dad attitude. I used to think houseplants were silly, a chore rather than a pleasure. Every household task was a chore. Putting away laundry, washing dishes, cooking, watering plants. I enjoyed caring for my dogs but it was because they had some intrinsic joy from it. I absorbed their joy. Everything else was just a burden.

Last year I followed this guy Sam Barsky on instagram. He was probably one of the first people I followed. He knits sweaters and goddang you can tell he enjoys doing it. So tonight, I spent an exorbitant amount of time tending to my jungle. Over the weekend I learned a lot about solar systems and lithium iron phosphate batteries. I learned a lot about composting toilets. I realized that the most joy I’ve had in the past few years, outside of being with people I love, is engaging with tasks and learning that have absolutely no extrinsic value. I love learning medicine, I truly do. But my god I’m an addict to learning about things that will never benefit the world or bring me fame.

I’ve learned something over the last few years about those things that previously brought me joy, like being fast as butts at triathlons, or being able to kayak or hike stupid long distances. I’ve learned that I had way more fun with the planning, learning about weather patterns, nutrition density, lightweight textiles, ocean currents than I did with anything that followed. I enjoyed the adventure for sure. But there was some burden of drive to succeed that weighed on me that kind of tainted the actual trip. Since those mega epics, I’ve had some excellent adventures. I’ve summited Longs Peak in Colorado via a technical route requiring snow travel, mixed climbing, and ability to rope solo. I’ve rope soloed a pretty sizable cliff face in the Bitterroot Mountains. I learned how to ski and managed to summit a pretty imposing peak in the Mission Mountains solo after four failed attempts. I still love the adventure, but taking the burden of success out of the equation has made them so much more enjoyable.

So along the lines of finding intrinsic joy in things, and stopping caring about external validation, this is a rambling blog post about how I am learning to enjoy things because I enjoy them, not because others will enjoy them. I like writing. At some point this blog became about affiliate links, about publishing epics and gathering sponsorships. It’s not that anymore.

Just a tuesday

In medical school we were taught hope. We were taught the infinite ways we could help a patient. We learned hundreds of medications, participated in surgeries, learned modalities, and were educated on counseling and rehabilitation. A notable piece missing from this education was how frequently medicine is a helpless pursuit and even more importantly, how sometimes it has no role.

The COVID-19 pandemic has taken the fast track of this learning to a new level. As a new resident, I am learning the futility of caring for patients with covid. We’ve all experienced the counseling of a helpless physician in the past when we presented with a cold. “It is just a viral illness and will resolve with time.” That helplessness was frustrating for us and infuriating for patients. They wanted antibiotics, a nasal spray, a referral. They’re desperate; they wanted something, despite the risk of harm.

During covid, we have learned this futility to the extreme. Patients are often grasping at any possible therapy to treat this disease-rheumatic agents and anti-parasitics not exempt. Despite this, a large portion of the population declines the overwhelmingly best strategy against covid: vaccination. Treating gravely ill patients with covid, knowing that despite your best efforts, your academic curiosity, your years of training, the staff’s endless proning and cleaning, trach care, donning and doffing, is excruciating. Initially I was broken by this. I would ask myself what I missed; what did I do wrong. Should I have asked nephrology for their input sooner? Should I have put him on an insulin drip sooner? Did I miss a festering superimposed bacterial pneumonia or a pulmonary embolism? I eventually accepted it wasn’t me and accepted the futility.

In the meantime I would cycle back to clinic in the afternoons after transitioning patients to comfort care, calling their families with depressing updates, watching their kidneys fail, their oxygen requirements increase. I would go to clinic and then battle patients on the vaccination. I would tell them the stories. I would tell them I have seen too much death too early in my career. I would tell them I lose sleep knowing they are not vaccinated. Reassure them the only reason I bring it up is because I care and I am scared for them. Largely they ignored me.

I am tired of this. My empathy is strained but nowhere near gone. I feel callouses forming, humor filling the place of grief. I find frustration where there once was inspiration, cynicism where there once was hope. I still grieve, I still lose sleep, I still care deeply. I love this job more than I ever thought I would but it weighs on me more than I ever thought it would.

What it’s like to die from covid

I had an odd interaction with a patient a few weeks ago. I was encouraging him to get the vaccine, telling him it was safe and effective. I dispelled all his fallacies claiming lack of research, rushed to the market, lack of long term data, and that as a late 40s guy he was at low risk for adverse effects or death from covid. I pointed out that he deferred to experts in his everyday life, trusted driving on a brand new bridge the day it was built (did not need any long term data there), and told him of several 40 year olds I had seen who had died or maybe wish they had died from covid. His response was that he was not scared to be dead. He said, if I am dead, I will be dead, so I won’t care. He has a young daughter. I told him his daughter would care. He said she would be alright without him. I told him it is not the being dead that is so scary, it is the dying part. He said he thought he would be sedated and unaware for that whole process. That is what baffled me the most. He had literally no idea how people die from covid. I want to dispel that.

I have a unique perspective as a resident. I work in the outpatient setting, trying to get people to get vaccinated (honestly this is a ridiculous part of my job and pains me-it is like arguing with a toddler over eating their vegetables). People come into clinic with early signs of covid and test positive. I work in the emergency room where I see people starting to crump from covid. Some of them need inpatient management so they get admitted for respiratory support. I’ll see them on the hospitalist service. And I’ve helped manage their care while they’re in the ICU needing maximal ventilatory support. I’ve had pregnant moms right when they first get covid all the way through their post 28 week induction and ICU stay needing intubation with very premature baby that they can’t see in the NICU. I’ve seen patients every step of the way.

I’m new to this job but I can say, with the exception of cancer, I cannot think of any common disease that I would less rather die from than covid. I wouldn’t wish it on my worst enemy. I outlined for that patient how the process goes and I want oblivious people like him to know:

Please, please if you had a loved one die of covid or feel unsettled by this disease or death, STOP READING HERE. If you are not vaccinated, please go get vaccinated. I wish no one had to know what this process is like but if you are vaccinated and wearing masks and social distancing, please do not read on any further-you are doing the right thing and should not have to know what this process is like. This is not an easy post to write or to read.

You decline the vaccine for some ridiculous mumbo jumbo reason. You go to a college football game and someone is coughing next to you for hours. A few days later you feel really crappy, bad cough, muscle aches, fever, can’t taste anything or smell anything, and you go see your primary doctor who tests you and diagnoses you with covid. Go home, minimal, really poor symptom relief with garbage placebo over the counter meds. You just feel awful, at home, quarantined, by yourself.

Someone feeds you from the other side of the door. You see no one for days. Or if you live alone, you have to do everything for yourself while getting progressively more and more short of breath and miserable. Eventually you feel like you’re drowning, you can never get enough air and you’re exhausted. You drive yourself to the emergency room, immediately get put on oxygen with a small nasal cannula. You’ll need to be admitted to the hospital. Think about the last loved one you saw because there is a chance that you’ll never see them again.

You are admitted to the hospital, put on some desperate meds that have hardly any benefit but it’s the best we have against this relentless virus. Everyone who sees you treats you like you’re toxic waste. We’re gowned, gloved, masked, sometime with an inflatable helmet on to filter out the infectious air you’re expelling. No one wants to come in your room. If you need something, it takes a while because someone has to put on all this garb every time. You’re alone in your cold, stale room, desperate for air, reaching for every breath, all day. You cannot sleep well because when you do you get more short of breath. You feel like a kid holding their breath under water and needing to come up for air. But that sensation is inescapable now.

Eventually your breathing is so bad we put you on high flow nasal cannula, CPAP, or BiPAP. Now you have a huge uncomfortable tight mask that rubs your skin raw. It shoves air down your throat. You now feel this constant pressure of air being forced into your lungs. Every patient hates it but without it they die. A loud generator shoves this air into you 24 hours a day. You’re still alone other than the constant roar of the machine keeping you alive now. Everyone who comes in now yells at you so you can hear them over the machine.

Your breathing is still worsening. You feel exhausted and like you’re drowning. Now every day we come in and are talking to you about putting a breathing tube down your throat or transitioning you to comfort care and letting you die. Those are your options. You know the breathing tube is what you need. But here’s the dilemma: at this point it is a 50/50 chance you survive. If we intubate you, you’ll potentially never really know which side of the coin flip you landed on. You’ll spend most of the rest of your days unconscious with people managing your every bodily function. Do you stay conscious and miserable, kicking and screaming knowing that you will eventually die but at least you were there for it? Or do you let us intubate you and eventually your family will very likely have to make the difficult decision to let you die?

You’re desperate, feel like you’re dying already and you want to take your chances with living so you let us intubate you. We sedate and paralyze you and take over your breathing. You won’t be completely unaware the whole time though. You’ll remain sedated other than a daily awakening trial where we’ll wake you up and you’ll feel so miserable with the tube down your throat that you’ll try to grab it and pull it out so we rapidly re-sedate you. Now your organs are failing. We’re watching your urine output decline, a marker of kidney function in your blood worsen, your liver is taking a hit. You have a rectal tube in place for your bowel movements, a catheter in your urethra for urine, a tube down your throat for breathing, a tube down your nose and into your stomach to feed you a brown slurry from a bag, a tube in your neck into your blood to give you a constant flow of medications. You are in charge of nothing now. We roll you onto your face every couple hours to help your breathing so you lay face down, completely limp and naked half the day.

Now it goes one of two ways:

You may start doing better. We’ll start having the discussion with your family of cutting a hole through your abdomen directly into your stomach to continue feeding you and we’ll want to cut a hole in your trachea to get the tube out of your throat. We’ll do this and you will wake up, unable to talk because air doesn’t pass over your vocal cords anymore. You will feel awful. You may need dialysis for the rest of your life because your kidneys are dead. And you may need oxygen forever because your lungs will never fully heal. You don’t have the be old and frail for this to be the case. We’ve all seen this happen to people in their late 20s.

Or it could go the other way:

Things are declining, your organs are failing. You family decides it’s time to stop the fruitless efforts. We choose to make you comfortable. However, we cannot keep you sedated and let you die. We legally have to take you off any medications that may compromise your ability to survive on your own. So we take you off many of the meds, you wake up, and then we pull the tube. You gag with the discomfort and start reaching desperately for air. You are conscious and drowning from the fluid in your lungs. We give you meds to help with the pain and air hunger but you’re there with us. In early covid family was not there. It was just you and usually a single person who knows you in no way other than that they’ve cleaned the stool off of you, tended to your pressure wounds, changed your urine bag, and given you meds.

You eventually get so confused and lose consciousness, your breathing is desperate, there is so little oxygen being delivered to your tissues that your extremities turn blue. Your organs are all rapidly dying now. Your heart muscle is dying with so little oxygen. It starts beating irregularly and ineffectively, delivering even less oxygen to your body. We stand there and watch as you die. Your brain is getting so little oxygen now that you are essentially dead but your heart still beats a fluttering beat.

Then it stops.

The strange ethics of vaccination, male contraception in comparison to cancer screening

We are facing a global crisis with an absurd amount of people refusing vaccination. I have nearly hourly conversations with patients about the importance of vaccination and largely my professional advice falls on deaf ears. To be honest, I’ve probably overly entertained the ethics and decision challenges regarding vaccination and find some similarities between that and male contraception in comparison to cancer screening.

Discussing specifically the medical ethics of immunization for rare diseases, it is kind of a strange practice. In the context of covid-19 vaccination this is moot given the absurd prevalence and declining the vaccine is really just an inability to make adult decisions. Nothing else. However, in the case of rare diseases, when we choose vaccination we choose to take a therapy that may potentially in even more rare circumstances cause us harm in order to protect those around us. It is an individually and medically absurd decision, but socially is absolutely vital. Continue reading The strange ethics of vaccination, male contraception in comparison to cancer screening

The sin of the rvu

I could never have fathomed how badly residency and medicine in the US could try to beat the compassion out of me. We all went into medical school with bright eyes, touting our love and desire to help people as our primary motivation for pursuing this career. It is likely what made us special, what marketed us as exceptional beyond the grades, MCAT scores, and extracurriculars. And yet a year and half into residency I am finding persistently berated by moral injury of a desire to help people in a system that seemingly strives to make it nearly impossible to do that.

A few months ago my residency transitioned all of our appointments to 30 minute slots, a subtle but heinously impactful change from a mix of 30-45 minutes appointments prior. Independent of new patient or established, routine or presenting with a dozen chronic diseases, we have 30 minutes to meet another human being, learn what makes them who they are and why they strive for health, and make recommendations to help influence their lives. The system is set up this way because of financial incentives to decrease duration of visits while maintaining revenue, a meaningless need to reach the arbitrary number of 1650 patient encounters before the end of residency, and a need to supply care for seemingly infinite demand with extremely limited supply. Continue reading The sin of the rvu

When to hold back?

Yesterday I led a case conference regarding ambiguous care for a complex patient. It was with regards a patient with shoulder pain with a small labrum tear, multiple comorbidities, severe illness anxiety who was maxed out on medical therapy, pain refractory to physical therapy and other conservative interventions. I hesitated very much on referring her to a surgeon because I knew she would likely get a surgery of questionable benefit with possibly worse outcomes. There is gross incentive for the surgeon to still perform surgery and it’s hard to refuse a patient when they likely will just go find a surgeon who will do it. I know that was the pathway and that is what happened. And then she got worse. Continue reading When to hold back?

A moral dilemma of placebo in american healthcare

I have been caring for patients for nearly a year and a half now in residency and have come across some of the more subtly haunting realizations in American healthcare. Recently I watched a presentation by Lorimer Moseley on pain psychology which highlighted some of the variables in placebo effect. Early in my training I naively believed in the therapies I was providing. Things needed to be more clear cut and I sought evidence based medicine by tracking down randomized controlled trials or meta-analyses relentlessly. The further along I am the more I have realized that a significant portion of the things we do in medicine are either completely useless or of questionable efficacy. Because of this I realized that largely my patients were having benefit because of natural history of their disease process (aka they were going to get better independent of what I did) or due to placebo. Continue reading A moral dilemma of placebo in american healthcare

Super ultralight backpacking: What it takes to carry a 3.5 pound pack – Appalachian Trials

Check out my post that was published on Appalachian Trials on what it takes to carry a 3.5lb pack for the northern third of the Appalachian Trail.For me, super ultralight backpacking isn’t about materialism; it’s about minimalism. Whether you’re looking to chase a FKT or just enjoy tweaking gear lists, tailoring a gear list to a specific trip is an incredibly fun challenge.

Source: Super ultralight backpacking: What it takes to carry a 3.5 pound pack – Appalachian Trials

11 reasons you may want to switch to tarp camping – Appalachian Trials

Cooped up in a nylon wrapper can be disorienting and uncomfortable. Tarps can be pitched with ceilings high enough to stand under and open on all sides. For drastically less weight, they can be outright tremendous, big enough to sleep a dozen hikers, or just to give yourself a comfortable vantage of the torrential rain outside. And with a simple lean-to tarp setup, you’re open to quickly and easily pinpoint exactly what that rustling is in the distance.

Source: 11 reasons you may want to switch to tarp camping – Appalachian Trials