Checkpoint - Month 7: February in Review

*Project reflections at the end

As I’m writing this, I have the oddest feeling in my stomach – and no it is not all the

Indian curry and dosas I’ve consumed over the past month. It’s the melancholy

realization of what this month’s passing symbolizes. For starters, the number 7 feels

different than any of the other monthly checkpoints I’ve captured so far. It symbolizes that

I’m no longer teetering on the halfway point but well into the second half of my Watson

year. When I left the US back in July, I had trouble picturing how I would make it to even the first month mark. Now, I’m having just the opposite problem: I’m having trouble picturing what it means to be ending this year and what my life back home will feel like in the aftermath. In a very similar vein, the end of February signals that it’s time for me to begin the long process of preparing my medical school application. It means turning a new leaf of my Watson, where I am going to learn to strike a balance between project work, travels, and “real life.” I intend not to change anything I’m doing privately: writing, exploring, learning. But it probably means I’ll have less time to share it as consistently as I have been. I’m determined to keep up with at least my checkpoints though, maybe make them into more of an amalgamation of both project and personal thoughts. 

The end of February also marks a huge milestone – the end of my extremely culturally diverse travel. I have spent the past four months living between Ghana, South Africa, and India. When I was planning this time in my Watson, I knew it would be the biggest push out of my comfort zone that I had ever endeavored to take on. The end of my time in India was always something that seemed impossible to reach, something so abstract and challenging. But here I am. And I can genuinely say I wish it wasn’t the end in many ways. While I am beyond excited to travel to New Zealand and Ireland, two bucket list destinations of mine generally, there is something so addictive about being pushed so far outside of your comfort zone. Every single day of the past 4 months has been a wildcard – what I will do, what I will eat, the architecture I will see, the cultural differences I will clumsily bump up against, adjusting to the guilt I feel as imposter resident in countries that have come to feel like a home. I can honestly say I don’t think my brain has shut off for a single second, for better or for worse. I am exhausted in the absolute best way possible. I’ve tackled challenges that would’ve previously made me curl up into a corner. I’ve seen and done more than I ever thought possible in one lifetime. My cup is so full I’ve had to exchange it for a bucket. I understand so much more now what past Watson fellows mean when they say that they come out of this year feeling invincible. For my creative writing thesis senior year, I wrote a collection of poetry. In one of the poems, I wrote “Today I ate the world and was not full.” I’m not quite sure how I was psychic enough to have written words that so accurately translate how I feel right now. I’m not at all full, I don’t think I’ll be full in 5 months, and I’m both excited to see where this hunger takes me and nervous about the restlessness it might create when I get back home.

But for the time being, I’m trying to focus singularly on what it means to be saying goodbye to India. If I could sum up one word to describe India, the word would be alive. There is the sheer amount of people, the traffic without rules, the auto-rickshaws whizzing around, shops filled with every trinket possible. But mostly, there are colors –bold colors all over clothing, people, architecture. Driving around in the Pallium vans, it’s almost impossible to tear my eyes off of the road. And while all of that is enough to give India a pulse, there is the added layer of the history. This land is an ancient land and though I can’t explain it accurately, this veil where history and the present meet gives everywhere such mystique. India has entirely captivated me.

However, even in all this constant novelty, there are familiarities from the homes I have already left. Like my time in Ghana, I find myself brushing my teeth with my water bottle, showering with my mouth shut closed, and existing in a constant state of sweat.  It makes missing the places I’ve been hurt a little less. Call it a creature comfort at this point. Another strange similarity between Ghana and India is in their beverages of choice. Why anyone who lives in the climate of India and Ghana chooses to drink hot beverages, I do not know, but they do. In Ghana, it was hot Milo – what they called their morning tea – every day. Here in India, it’s chai or “milk coffee”, served boiling in glass cups. The first time I was served (and you are served tea at least once a day), I thought my hand might fall off. A similar feeling to when my host brothers in Ghana insisted, I dug into fresh Kenkey that was still smoking and I watched them handle it in their hands and eat it with ease, while I was already blistering. To compete with that, Kerala, India has introduced me to the new idea of chugging your hot beverage. Chai is not meant to be sipped, it’s meant to be swallowed so you can be on your way. So naturally, since I am working with busy healthcare professionals at Pallium, I try to follow suit. Unfortunately for me, my tongue is in a start of constant char.

Before I left home, and even as I’ve tackled challenges in each country I’ve visited, I received the most “warnings” about solo travel in India. I would be lying if I didn’t say the constant chatter about being a Western woman in this country didn’t psych me out at all. Up until my last week and a half, I was living alone, traveling to and from the clinic by myself, and exploring when I could. This setup differed from the other places I have been where I was either living on organization premises or being hosted by locals. This true solo travel test was a bit daunting as I prepared for my arrival. On my first day here, I was a bit nervous to leave the comfort of my accommodations but I was also buoyed by all the challenges and travel I had done so far. I certainly had more confidence coming into India than I did when I first left for Africa or when I left for my Watson generally. At this point, I knew the first steps were always the hardest so I kicked myself out. Since then, I have found Kerala, with most of my time spent in Thiruvananthapuram, to be one of the most welcoming places I’ve ever been. It has gotten me thinking a lot about how we form facts from postulation, how comfortable we feel passing these “facts” along, and how dangerous that can be even when well-intended. It’s a half-baked thought at the moment but once again so applicable to so many things we are facing at home. And the cure of course is obvious but scary – you have to go find out for yourself and determine your truth. I have loved every second in this country and have felt that the city has made me come more alive just by inviting me to be a part of its rhythm.

Project Thoughts

India has taught me so much in so little time about myself, about traveling, about how many dosas I can eat in one sitting. But it’s also shown me something greater – it has shown me that I am learning “how to do it.” In India, working intimately with patients at the end of life, I have been offered an opportunity to put what I have learned so far from my journey to the test, to prove to myself I’m not taking in everything passively, but actively incorporating it into the schema of the type of doctor I want to be. First, there were the nerdy wins. On one home visit, we found the patient in an acute end-of-life stage. Her family was extremely nervous because she was making noises that indicated to them she was choking or having trouble breathing. I knew from my time around end-of-life patients thus far that what they were hearing is often referred to as the “death rattle,” the scary breathing noises someone may make as they near the end of life. However, I knew that the “death rattle” was not at all indicative of pain or choking. Instead, as our bodies slow down and we fall into a state of unconsciousness, we are not able to perform “normal” bodily maintenance. A healthy person, upon feeling saliva at the back of their throat, will clear it by coughing. A person who is near death can’t clear their throat; as a result, droplets gather and as air passes through them during breaths, it will make a gurgling and rattling noise. To ease families’ anxieties, doctors can prescribe glycopyrronium or an equivalent medication. These drugs help to decrease patients’ secretions and therefore alleviate that noise. If any breathlessness remains, at the discretion of the doctor, small doses of morphine can also be given not only to ease breathing but to make the patient more comfortable. I say all this because I was able to turn to the doctor and ask if the patient in front of us could benefit from a glycopyrronium and morphine perscription. The doctor agreed. It’s the first time I’ve truly realized how much I’ve absorbed not only in an abstract sense of the concepts but in the concrete delivery of this type of healthcare. I think I’ll forever remember that moment as the first time I stopped and said to myself “I’m doing it.”

The second “win” is much deeper and arguably more important than knowing what medications to prescribe. Recently, I had some time to sit down with one of the Pallium volunteers. We were both waiting to round on the next in-patient family and in the meantime we struck up a conversation. She wanted to hear about my fellowship and what I’ve been learning. In turn, she began sharing with me her own story. She told me she’s always been interested in death as an abstract concept but it wasn’t until her husband’s passing that she became interested in palliative care. Her husband had a sudden heart attack and was brought to the hospital where he was stabilized but in poor condition. He was in lots of pain and she tried desperately to advocate for him to his doctors but they would not hear it. One day, he had had enough and expressed to her that should he have another cardiac event, he did not wish to be resuscitated. He would go on to have another heart attack and the doctors looked to her for his decision. With all the strength she could muster, she told them no, he didn’t want extraordinary measures. These doctors dared to ask, “Just so we are clear, you are saying we should let him die right?” As she got to this part of the story, she started crying. I took her hand in my own, like I had known her my whole life and there was no age difference between us. She told me she lives with guilt every day, that’s she still unsure if she made the right choice and she blames herself for not being able to get him the pain care he desperately needed. When she was finished, I said to her something along the lines of this:

The greatest thing we can do for someone at the end of their lives is honor their wishes. We can walk beside them as they approach the end, we can hold them, we can tell them how much we love them but when we reach that point, we can’t go with them. But, we can make it possible for them to go if that’s what they choose. The love that you showed your husband by honoring his wishes is the purest form of love, an entirely unselfish form of love. In many ways, it might have been the biggest show of love you were able to give him.

I said this to her as if it were the most natural thing in the world. As if I had practiced it in the mirror a million times and landed on the right words. But truly, in that moment, the words were just there for me. We sat there for a while, myself and this otherwise stranger, holding each other and reflecting on that concept of selfless love, the type of love I hope I am strong enough to give when I need to. Neither one of us was in any rush to leave the moment and it dawned on me that I just did it, capital I-T it. The thing that I had set out to learn how to do. I had sat with someone, gathered their story, stepped into it with them, found exactly the words they needed from me, and stepped out. This year, I have spent time around so many healthcare workers as they deliver hard news or meet with families after the death of a loved one. Each one has their own “script,” their own metaphors that they use to help someone navigate the impossible. I have been amazed by every conversation and also terrified that I may never do the job justice and that I may not have the same abilities. And then so naturally, I find myself just doing it, not even thinking about it, drawing from all I have learned this year and speaking exactly what I was thinking. This is not to say it was perfect and that my work here is at all done. I have so much more to do and learn but I did feel something shift inside of me and a feeling of immense gratitude at being able to occupy that moment with her. I am on the right path.

This entire year I’ve been at odds with the term “end-of-life care.” I think it gives the impression that healthcare workers are facilitating dying. But that’s largely incorrect. Dying is a natural process; the body knows how to do it just as a woman’s body knows how to give birth. There are services of course that can facilitate dying, so-called “assisted dying” that aid in the process should someone wish to end their life before disease progression continues. But there is a reason that is distinct from end-of-life care. In end-of-life care done well, doctors ease pain, provide psychosocial comforts, manage nasty symptoms, and facilitate meaningful time between patients and their loved ones. So it’s not really about death at all.

Watching the work of the multidisciplinary team at Pallium has given me the words I have been lacking. I watched doctors find the right medications such that a patient who is nearing the end could be present and without pain; I watched nurses teach caregivers basic palliative skills so that way families would not default to hospital admissions and a patient could be at home; I watched social workers aid dying people in making financial arrangements for their families; I watched volunteers pray with patients and their voices echo throughout the halls of inpatient care. In short, what I was watching was life-affirming care. In life-affirming care, the question to ask is not “how do we make you die ‘well’” but how can we help you live better in the context of your terminal or chronic illness until death eventually comes, like it does for everyone. In life-affirming care, healthcare workers labor with love to help their patients live how they choose. So, yet again I must concede to Watson and to the cliché that my project will change. Now, I’m not so sure I’ve been studying end-of-life care at all.

Pallium India had one last gift to give me. Over this year, people have continuously asked me whether or not seeing the things I’m seeing and doing what I am doing is hard. I’ve surprised myself by strongly saying the answer is no. At first, I thought maybe I was an unfeeling psychopath but as my travels have continued, I’ve found that this is something common among most people who are working in this field. I now think that part of this is because, as we’ve just uncovered, what is being done is not end-of-life care but instead care that affirms life. But it’s also more than that. On one of my first home visits, I was paired with a young doctor and nurse, both my exact age. I watched in awe as they navigated difficult conversation after difficult conversation, handled complex cases with ease, and showed more emotional intelligence than I have seen amongst some people years older. After a particularly hard case, we were all trekking back down towards the car from the forested area where the patient’s house was located. We came across a stream and both the nurse and the doctor kicked off their shoes, held hands, and waded in, shrieking like little kids again. The moment was not only picturesquely framed by the forest and sunlight through the leaves, but made even more beautiful by what we had witnessed moments before. As we found the car once more, the doctor realized we were parked beneath a cacao tree with ripe cacao pods. We grabbed sticks and spent ten minutes trying to bat one down before we were successful. I watched excitedly, having never seen the fruit of a cacao pod, as they cracked it against a tree and split it open. We sat on the forest floor reveling in our fresh snack and the adventure that unexpectedly unfolded. I tell this story because I think it shows what the key to this year has been and will continue to be as I pursue a career in this field. The reason the doctor and nurses waded into the waters, the reason why we foolishly slapped at the cacao pods, and the reason why we laughed together after experiencing such heaviness moments before is because joy feeds resilience. I think it’s true that some people who experience so much acute emotional pain or see so much bad forget to also look for the good that follows. I’ve been lucky to follow the example of people this year who are constantly looking for joy around every corner. This year, I’ve seen hardship I could never have imagined, lived in conditions that I never dreamed I would, and sat with people in the worst moments of their lives. And still, I am more joyful than I have ever been, not psychopathically despite all I have seen but because I have been shown to never stop looking for all the good that exists just beside the bad. Dr. Rajagopal, the father of palliative care in India himself, sat across from me just a few days ago and said “Medical school will try to fill your head with so much information. It will grow and grow until it seeps down and threatens to push on your heart. Don’t let it.” So, as I say goodbye to India, I am making the promise that I will always be looking for joy.