I am sitting in by a window on the third floor of an apartment unit in Miraflores, Peru, watching the sun struggle to rise against a gloomy morning. Outside the neighborhood is very slowly showing signs of life: cars intermittently going past, a smattering of people walking up and down the streets. We have been here two nights, and I may be correct in thinking this is a town that turns in very early for the night and does not fully wake until after nine am. Which works just fine for me, as a little peace and quiet is what I think I need at this time.

It has been a little over two months since I wrote on my website. In her book Dead and Alive, author Zadie Smith says she stopped writing diary entries after her actual writing career took off. I think I have been doing the opposite. I have no writing career to speak off, but I am proud to say I have been doing a bit of writing here and there offline, as I always do when I am processing things I am having trouble dealing with. I have also been journaling, which might explain why I have not had time to make these posts.

I am on my last vacation of intern year. I could not have planned a better time for a holiday. Last week I began my last rotation of the year, Surgical Oncology at Fox Chase Cancer center. If I am being honest, I did not feel quite myself the entire week. I felt a bit unprepared for the rotation in terms of information, but I can hardly lay fault at anyone’s feet for that. I have been having a hard last few months. The rotation prior to this one, Abdominal Organ Transplant, was by far the most emotionally challenging one of my intern year. When I came on, we had two very sick patients, recently transplanted, who required close monitoring and continued care. When I came on, they were the two patients to watch on the service. They had both been in the hospital for a long time. They had needed repeat surgeries, intensive care, multidisciplinary involvement. Halfway through my rotation it had looked almost as though they were both turning the corner. We were trying not to be too optimistic but people were breathing a little easier, there were surreptitious high fives, we were beginning to think we had gotten to a good place with them.

Then abruptly, the tide began to turn. First for the one, then for the other. I had a week on my rotation where my chief was away on vacation, and I was on service with the students. Of course there were people available to help, but it was the craziest week of my intern year. Both of these patients required multiple returns to the operating room. Their labs and hemodynamics just kept getting worse. For the one patient, we knew why. It was one of those devastating things you pray never happens, and when it does, you pray the consequences are minimal, even though the evidence-based, factual side of your brain knows there is not much that can be done. For the other, no one could figure out what was happening. Every possible eventuality was considered, anticipated and dealt with as it arose. We threw the kitchen sink at this patient, so to speak. Every treatment that could be optimized was optimized, whichever could be taken away was removed. Everything that was supposed to work was applied. Nothing worked.

One patient passed the day before I left the service, the other two days after. In the in-between time from the moment of learning of their status changes to “Do Not Resuscitate” and eventual transitions to comfort care, I continuously refreshed their profiles, hoping for a miracle, some wind of change, to swing the boat in the other direction. There was none. The last time I refreshed, they had fallen of my list, as though they were never there. I dug around the long way, and finally found them. I knew why they were off my list, but reading the death note on both patients still made my stomach hurt. For the next few days I found I had trouble eating or sleeping. I had these unpredictable, uncontrollable bursts of tears. I woke my husband up in the middle of the night with these, always having to respond “I’m fine, I’m fine, sorry, go back to sleep,” to his bewildered “What? What is it? Are you ok?”

How does one answer the question “Are you ok?” in circumstances like these? Sure, we lost patients we were hoping to cure. That hits hard, especially when we got to know the patients’ parents, siblings. I grieve these patients, but I also think of the unmeasurable grief that no doubt will assail their families. I think especially of these patients’ mothers. The one who came in every day and sat at their child’s bedside religiously, who looked for any shred of hope in every update, who held their hand and spoke to them even when they would not respond. I think of the other, who called multiple times a day asking for updates because they were themselves an invalid and could not make it up to the hospital to see their child in person. I think of these parents, having to make the heartbreaking decision to ease their children’s suffering, to accept the doctors’ conclusions that there was nothing else that could be done, that anything else would be medical futility. I think of these mothers, choosing to have their babies’ breathing tubes removed, to watch them die, slowly, peacefully with help of comfort medications, but still to watch them descend into the unknown. I think of the invalid mother, who despite her wish to be at bedside when her child passed, arrived just a little too late, as a result of her own physical challenges. If these patients’ passings affect me so, how much more for them?

I also wonder and worry about my attendings. How do they do it? To be awoken in the middle of the night, to take a patient emergently back to the operating room who only just left. One of my attendings requested that the ICU call them if there was even a whiff of something going wrong after one of the patients returned from the OR. I imagine the calls they must have gotten that night the calls they must get every night. I wonder how they wake up the next morning and head into the hospital, needing to be at their best for the next patient, to come up with better ideas for managing these ones, to deliver the terrible news to families about patients’ grim prognoses. I wonder how they cope with it.

Funny enough, this was just the worst of the events that occurred during this time. We had a patient who was doing so well the entire rotation, only to suddenly take a turn without explanation my last week. We had another for whom everyone’s breath was held from the moment they stepped into the operating room because they coded every other day, was brought back from the brink, did perfectly fine for twenty four hours or so, then tried to die again, was brought back, and the cycle continued. There were several theories as to why this was happening, but no one had a clear explanation why. And then there was the patient stuck in limbo in the hospital because we could not quite figure out who would care for them, or where they would go, once they were ready for discharge, because their needs were just too many and we were not sure they would survive without constant supervision. The only way I can describe the state of my nerves after this rotation is frayed. I was physically and emotionally spent.

So, I spent my first week on my Fox Chase rotation in bit of a haze. I felt completely on the backfoot, moving just a little slower than I ought. Thankfully this holiday was merely a few days away, and my body and spirit are all too happy to be away from the hospital and all its sad reminders for some time. So far we have slept in, walked to the local grocery store, jogged by the beach and taken in the powerful sounds of the ocean waves. Few things exist that soothe the troubled soul like the rhythm of strong waves rolling into the ocean’s edge, or striking large rocks along its banks.

Before I head off into the streets to find something to start the day off, I want to say, it has not all been gloom and doom. In no particular order:

• We went out to OKC to visit my brother-in-law and his fiancee, and met her family. It was a whirlwind visit, and we had a lovely time. I also met my husband’s Cameroonian family for the first time, and got to watch my mother-in-law reconnect with her longtime friend after almost twenty-one years
• My youngest nephew and niece were baptized, and my husband and I were asked to be godparents. This is by far the highlight of this year for me.
• I got to walk the stage with and hood my mentee on the occasion of her graduation from medschool. She is also expecting soon, so more good news is on the horizon.
• I participated in my first full liver transplant surgery procedure. The patient did very well, and was discharged home. This patient was the highlight of that particularly challenging rotation.
• One of my short pieces was published in Pulse Voices.
• We (finally!) found a place to play soccer!!! It is all the way in New Jersey, but who cares?! We found a place!! If I tell you how much my soul felt healed after that first Saturday!

My plan for the holiday is to spend it organizing, putting together our vision for our house, including our backyard, figuring out what how I want to structure my second year. I am looking forward to exploring Peru, but I am just as happy people watching the sleepy town from my balcony window as I doing at the moment. Anything that brings calm to my nerves and peace to my soul is welcome today.