The Phoenix Rises Again: Fellowship Begins (TILIF #1)

Yesterday was my first shift as a pediatric critical care fellow. The last time I posted was in the midst of my pediatric residency, a three-year program meant to prepare me to either become a primary care general pediatrician or discover what type of subspecialist training I want to pursue.

I had a pretty clear understanding within a month of starting residency that I did not want to be a general pediatrician. It took longer to confirm which subspecialty I was interested in, because the one I was eying was not available to me until my second year of residency. After a couple rotations through the PICU, I was sold. This place had the most: the most interesting stories, the most extreme emotions, the most impact on families, the place where I was the most happy, and where I had the most to learn.

It's the last point that is most relevant for today. On the first day of residency, a pediatric resident is far less capable than a 4th or even 3rd year medical student because they have only done a couple rotations in their field and they are at least 6 months further removed from that experience than they were as medical students. Same goes for fellowship; I have only worked 3 months in the PICU in 3 years of residency, but now I'm a fellow who is supposed to lead a team of residents (under the supervision of an attending physician). As they say, if you already knew everything, then you wouldn't need med school/residency/fellowship/etc. It's still jarring - like starting high school: you may have been king of the campus in 8th grade, but now you're a lowly freshman.

There's a lot of critical care medicine that I do not know yet but some things that I do. I am effectively going to spend 18 of the next 36 months in the ICU and the rest doing research to add to the field, so I will have every opportunity to learn. Thankfully, some of my prior training does carry over. I know how to talk through complicated medicine with scared families. I know how to clear up and prevent miscommunication. I know how to be present for families when they need it. And I know how to throw myself at scary new situations with blind faith in the belief that I can figure it out as I go and survive to do better another day. These are the truly important things you learn in residency.

I was able to put several of these skills to work on my first shift, which helped me dampen the ever-present impostor syndrome and feel a little less useless. The hardest thing I did today is difficult to study for: I bore witness to the ritual of a brain death exam of a previously vibrant toddler.

This procedure is not really for answering a question, but rather affording an abundance of caution to the act of making official what we already firmly believe - that despite our most extreme interventions, our patient has died. It involves thoroughly testing all of the brain's most basic or primitive functions to see if any residual activity remains despite all outward appearances to the contrary. Before you can start you must have stopped any medications and fixed any abnormality that could cause the false appearance of death - such as sedatives or hypothermia. The exam culminates with an apnea test, where you turn off the ventilator that is breathing for the patient and watch for any response before checking a blood sample after 5 minutes to document that their blood hasn't been magically getting oxygen.

Watching a child not breathe for 5 minutes was rough, particularly for the parents (who can choose to be present or not). The hardest thing for me was seeing a stuffed animal fall to the floor in the shuffle of moving sheets. I had only known this patient for a few hours and only as a unconscious and unresponsive kid on a ventilator - which describes several children on the unit. But the ragged, discolored, stuffed dog ironically brought to life this child that we were in the process of declaring dead. The dog had been hugged, drooled on, dragged around, and generally loved by this child who would never play again. The stuffed dog won't someday be embarrassingly brought to a sleepover or college - not passed down to future kids. Only in that moment did I glimpse a sliver of the pain that the parents crying on the other side of the bed were going through. Managed not to cry until I got home. Little victories.

As melancholy as this experience sounds, it is such an honor to be a part of a family's story during these few days that will stay with them for the rest of their lives. If I can help them make the memories of this horrible time a little better, even if there was nothing we could do to change the physical outcome, then I'm more than willing to shed a few tears myself. I hope these situations never become mundane - these feelings never banal; they fuel my love of life, my respect for death, and my drive to make the most of the time I have. May the next three years help me continue to grow and learn from the extraordinary experiences in which I have the privilege of taking part.

TILIF: The Taussig-Bing anomaly is a version of double outlet right ventricle (DORV) congenital cardiac malformation where there is also a subpulmonary ventricular septal defect (VSD).

Tweezers are not as easy to come by here compared to my old hospital.

Time is relative. The 5 minutes before cardiac ICU rounds just flies by; the 5 minutes of a brain death apnea test last an eternity.