Reality

I felt a lot of genuine support and was buoyed by the reader comments after my last post. Been thinking a lot about the different things people said. I received some emails that also echoed the comments in the "thank you for being real" vein.

I think I'm feeling a little overwhelmed by the "is that really your life?" emotion when I flick to FB and see an endless stream of perfectly manicured children, lawns, engagement photos, work achievements, and exercise updates.  I look down at the jeans I've been wearing to and from work for the last three days, the stacks of review books I should be pouring over to study, and the pile of t.v dinners I've gone through over the past week for sustenance and I think, "Where am I going wrong here??"

And I don't want to use FB or my blog as a permanent venting space but I think there is a distressing lack of REALNESS in the world these days. We're not supposed to admit that we're scared, or unfulfilled or unhappy. And we are certainly not allowed to admit to failure, mistakes, bad decisions, or regrets.

There are a lot of people out there who I wouldn't want to disclose my shortcomings to, or my sadness to. But many of my blog readers are on a similar path and probably think they are alone. And to those people I want to say, "No, you are not alone.".

I had a beautiful, challenging week. I was up early and in bed late. I was able to sneak in a couple of bike rides on my wind trainer, and eat a couple of meals before 10 pm. But mostly, I was at the hospital with a full bladder and an empty stomach. I picked up a devastating diagnosis on a fit and rugged man, and held up a fresh, slippery, crying baby while grandad took photos on his SLR. I missed my boyfriend and my own bed. I bought a lottery ticket once again hoping magic would erase my student debt, freeing me to chose if medicine was still what I wanted to do instead of had to do now.

But there is no choice now but to carry on. As Winston Churchill famously said, "If you're going through hell, keep going."

Nothing Profound

I realize that the longer I postpone another update on the blog, the more pressure I feel to make it something noteworthy or profound. And so another week or two goes by and I have many little moments where I think, "I should write this down" or "I should post this little anecdote" but then it seems too small to creep back onto the web with.

So I resolved that this week I would just start with a basic hello. An update to say I haven't abandoned ship completely.

It's been a busy few months, as I am sure you all can relate to. Been going though the usual questions regarding life choices, career choices, and where I see myself in 3, 5, 10 years time. Having been on the delayed gratification, long-term goal track, it sometimes feels hard to get off it and just look at today.

I have written and erased so many posts in the last few months. Finding it harder to know who reads this blog and for what reasons. I don't want to violate my patients' privacy but I also don't want to violate my own.

In brief, I will say that I was offered a residency spot last spring in obstetrics. It was a really challenging decision making process to go through. For many reasons I did not take the seat and chose instead to apply for the additional year in enhanced surgical skills training. Which I have done, and found out today that my interview is in a couple of weeks. Which is exciting and daunting.

The GP-Surgeon route is all about faith; faith in rural medicine, future practice, and future policy makers. Faith is something that I have very little of these days. Thus, a nearly ongoing, "what am I doing, where am I going, what type of practice will I have, will I regret this decision" thought spiral of despair. I've worked so hard, so hard to get to this place and yet I am constantly berating myself for not having worked hard enough.

I know a big part of this is burnout, stress related to my family medicine boards, stress related to having to live away from home for 8 months of this year, and having to apply for provisional licences in other provinces/countries. But just because I can identify the aetiology of my distractibility it doesn't make it any easier to bear. I watched the ZdoggMD TED talk a week or so ago and it seemed to tip me over the edge on the major life dissatisfaction precipice. Now all I can think of is one of my mentors telling me a long time ago, "don't lose yourself in medicine, make sure you like the person you become at the end of it.". Well, so much for heeding that advice.

But there are enough REAL issues going on the world. No one needs to come to my blog to read a whiny rant. Real issues like ISIS, and the youth justice system, and violence towards women, soldiers getting killed on Canadian soil, ebola running rampant in West Africa, and I could go on. Hello, reality check.

Well, I will endeavour to keep writing, keep plodding, keep smiling. But for now, laundry, and then a 3 hour drive to work.

Listen

Today in clinic a Dene Elder says to me while I am listening to his heart, "If it sounds a little different, it's 'cuz it has a Native beat".

I have never laughed so hard with a stethoscope in my ears.

One of those patients that I felt an instant connection with. I stared at those deep laugh lines etched in his tan skin while he told me about his cardiology appointment. He pulled out a palm sized moleskin notebook and recited ejection fractions and names of specialists and amiodarone adjustments (which he doesn't care for, after all the reading up he's done on it). He told me that when he had his heart attack he remembered being wheeled in through the hospital doors and that when they closed behind him, many other areas of his life closed behind him too. He woke up eight days later in a cardiac intensive care unit.

He golfs, he lifts weights, he walks everyday. His intensivist told him he was a "ticking time bomb" but he pointed out to me that he was still here. I told him I was glad of that.

I wanted to cancel the rest of my afternoon and just listen. Such a vivid cast of characters in this unfolding narrative which is my life.

Last Day

Today is my last day as an R1, which officially marks the halfway point in my rural family medicine residency training. I find it amusing that I have to have my orders and prescriptions reviewed and see patients in a parallel consulting style today, but once the weekend is over, I don't. It is a magical weekend I suppose wherein all the wisdom of my R1 training will culminate and crystallize to make me safe on Monday morning in a way that was different from today. Ha!

I laugh because this is almost as ridiculous as the fact that a year from now I could go to sleep on Sunday night as a resident and wake up Monday morning as an attending (well if it weren't for the extra training I'm planning in surgery).

These days seem, like all other milestones, eerily anticlimactic. It is exciting though in some ways to feel that sense of independence slowly developing, to find myself feeling slightly more confident with certain things that were so scary and daunting a year ago (my first order as a doctor was for a chest x-ray and I remember being completely freaked out when I wrote it! How pathetic is that?!)

Maybe today to mark the occasion ALL my patients will get chest x-rays! (I'm kidding, of course.)

Onward and upward, amigos!

I See You

My first year of residency is winding down and I've been in my last rotation, internal medicine. 

I've been taking care of a patient who has given me a glimpse into how horrifically a human can hurt another, humiliate another, destroy another. I've had forms to fill out, phone calls to make, family members to meet with. All of this has provided enough busy work to keep my mind from drifting into actually processing the things I see in front of me. It has kept me from considering, for more than a fleeting moment, what my patient might possibly be going through...what the family might be going through. I feel borderline selfish even, getting upset over it, shaking my head over it, because it seems indulgent...like I am making it about me and not my patient. We're all drained, we all want to look away.

I come home, I want to talk about it yet I don't want to say a word.

The manager of the ICU sat beside me yesterday at the nursing station and said, "you are obviously passionate about your job, you obviously chose the right profession". I took it as one of the highest compliments I've received, but as she said it I nearly burst into tears. I thought about how much I hate this job sometimes and the things it shows us, about ourselves and about others. I feel weak when my work upsets me, and I feel jaded when it doesn't.

As I drove home today I felt angry about this job, I thought about what an awful line of work it can be. I watched the bobcat driver roll up and down our front yard, the heat beating down on the metal roof. Back and forth, spreading the dirt out.

My dad used to do work like that, he worked construction and road crews. As I got older I felt sorry for him, that this was his job. I continued to watch the methodical work out my front window and couldn't tell if what I felt was pity or envy.

Not Today

I do not miss my dad on Father’s Day. I miss him on all the other days. The funny days having a new puppy, the tough days struggling through nursing school, the exciting days moving to Ireland, the stressful days interviewing to come back to Canada. The boring days of car shopping, the celebratory days of graduating, the busy days of working, yes, I missed him all those days. I do not miss my dad on Father’s Day.

Skin to Skin

I meant to come home and write all about it. But of course by the time I got home my stomach was aching with hunger and I had a fridge holding wilted cilantro and questionable soy milk. So I had to make a dazed trip to the grocery store where I found myself staring at the nectarines and asking myself, "Do I really eat nectarines?" which then spiraled into an internal dialogue about the ethics of buying fruit that is shipped from a thousand miles away in order for me to have some variety in my snacks. This always happens when I am tired. I start to question everything I eat and try to convince myself that a diet of entirely chocolate and "Mary's Crackers" will suffice.

So now I am just standing there with my basket containing cheese, kale, and tuna and I am nowhere closer to having a normal dinner, showering, and writing up the day's experiences.

I did my first c-section! Let me qualify that statement. I have done all the 'steps' of a c-section in the past - but never all on one person. Usually the surgeon opens up to the uterus and then I go from there, or I open and they close. Or some other combination of events. But this one was mine from beginning to end, the reward for all my hard work, so I was told. I wanted to write it all down, remember every moment, however, many of the details are already starting to blur.

It was hard work rewarded with hard work. This was her third section which meant that the often easily identifiable tissue planes and regions become scarred down to one giant zone of adhesions. Meticulously dissecting the bladder can still result in injuring it or unknowingly cutting too low on the uterine wall. The tissue is also thinner which can be an issue when it comes to closing up, add in the friable bleeders, distorted anatomy, and the clock that is always ticking down on how long the spinal anesthesia is going to last.

My mentor was walking me through it, keeping the pressure on for time while ensuring I was being cautious yet bold. It's a weird combination. When you cut - CUT! Don't saw away taking little swipes! Go deeper...not THAT deep. 

Being new to all of this I still don't appreciate the different forces needed to cut through skin, fat, and muscle. I don't hold the cautery just right, I can't throw a fast stitch in a bleeder. I don't know when to dissect with my finger versus gauze versus a blunt end of a blade versus a blade. It's an entirely different universe suddenly, peeking out between the sterile blue drapes. I'm navigating with a mask that covers my mouth, connected to a plastic shield over my eyes.

Sweat is dotting the inside of my plastic shield and I can feel it running down my sides. The other surgeon is waiting at the dictation desk and his patient, a hernia repair, is waiting in recovery to come in. We are only a little behind schedule but the scrub nurse reminds me that the next surgery should have already started. The baby is out, I can't remember if it was a girl or boy. I can't even remember the mother's name or face. I would have never believed it if someone would have told me that I would forget the gender of the baby of my first skin to skin cesarean. But I don't. I remember green armytage forceps.

I remember being thrilled, scared, and sweaty. I remember having to change my scrubs immediately after, before going out to recovery. They were soaked from my chest down to my knees, as if someone had thrown a bucket of water at me. I remember being happy and surprised that mum and babe had an absolutely unremarkable course in hospital and that they were discharged two days later.

How could I have done that right?

May Day

Not exactly sure where April went. Well it involved a holiday to the UK, then buying a house and writing my QE1 exam. Oh, OK, that is where April (and the beginning of May) went.

Since residency started I feel that I am standing on the platform of a subway station. The days go whizzing by, past my face, at a speed that leaves everything a trailing blur. Then for a moment, the subway stops and people pour out, and pour in, bumping past me. Some linking eyes, some carrying on, some talking, some silent. I remain still and the chaos moves briefly around me, then the doors close and everything speeds up again. There are these blips of human interaction that stand out, but much of it remains a blur.

I kick myself for not writing, even just for myself, every night. I really ought to try and start doing that. Maybe that will be my mid-years resolution.

Things have been in a state of flux. I recently went through yet another soul searching time in my post-graduate training. I am gearing up to apply for my +1 year (in Canada GP's can undertake extra training in things like emergency medicine, anesthetics, surgery, obstetrics, palliative care, sports medicine, etc). I always knew I wanted to do this +1 option but I've gone around and around with what area to specialize in. I thought for a long time that it would be emergency medicine, but if I am honest I am getting to be COMPLETELY over EM. I am just tired of all the abuse that goes on in the ED, in every realm: patients abusing the system by going to emerg for non-emergent presentations, patients abusing the physicians and nurses, and then the specialists abusing us when we call to consult them. I still love a sick patient, a surgical patient, a procedure-needing patient, but that is about it. I just don't want to do it full time. A shift a week - sure! Everyday? Shoot me now.

So I thought about anesthetics. 9 months in the Big City and then 3 months in my current city. I like the procedural side of anesthetics, and I love airway management, but I am not a detail oriented, thinking person. I am a cook, not a baker, if you can appreciate the vast difference between the two personalities. I can force myself to be detail attentive but it requires a lot of mental energy. I realised that I was choosing this option more because it has greater portability and demand currently in Canada. It wasn't what I truly wanted to do in my heart of hearts.

Thus, I decided to apply for the Enhanced Surgical Skills program (ESS). It is one year of surgical training that is divided between 6 months of obstetrics and 6 months of general surgery. In the obs component you learn c-sections, essures, tubal ligations, instrumental deliveries, and other office procedures. In the general surgery component one is expected to become proficient in performing hernia repairs, appendectomies, lumps and bumps, scoping, and any other procedure you feel you ought to provide to your community (some do tonsillectomies, carpal tunnels, etc).

So now I am pumped. I have found an accepting community that will give me privileges in this scope of GP-surgeon practice. The applications are in the fall (for a July 2015 start) but I'm already trying to get as much experience as I can with these enhanced skills. It's been great, having loads of obstetrical procedures here as well as being scaffolded up on basic surgeries...all by kick-ass GP-surgeons!

It's weird feeling like things are possibly falling into place. I've had so much internal conflict and so many questions about what I ought to do with my career. I have always felt that family medicine was an uneasy fit for me since I started residency, mostly because there are many things about FM that I do not love. THIS feels like a fit, it feels like something I can hold on to and mold into what I want it to be in the future. I hope.

R&R 2014

Just wanted to say I am heading to Rural & Remote conference in Banff this coming weekend. Looks like it's going to be a fantabulous weekend of sessions for the birkenstock-and-jean-wearing-bearded-bougie-carrying-mad-skillz-canoeing-to-work-rural-physician!! I am also excited (and a little scared based on the pre-reading) for the AIME and EDE-1 courses that I am taking when the conference is over.

So if any of ye are knocking about come and say hi! I'll be the one eating ribs at the BBQ and loading up on as many pens as possible.

Gallstones

"My doctor sent me in for an ultrasound - he thinks I have gallstones because I've had this pain..." points to right upper quadrant "...for about a week".

Well I had seen the ultrasound report and yes there was a gallstone but more worrisome than that there were many other findings that suggested stage IV cancer.

There are moments that change your life forever. The event that defines 'before' and 'after'. At times, working in healthcare means being a person who straddles that precise moment in someone's life. For better or for worse.

The nice thing about obstetrics is often this is a joyous time to share with patients. The before we knew we had a son who had ten fingers and ten toes and his father's nose to after. But more often I have had to share moments that I would rather excuse myself from, altogether.

I have developed a very irritating contact dermatitis on the backs of my hands, a constantly itchy, burning rash that never completely goes away thanks to all the handwashing and O.R scrubbing I have to do. Despite my efforts with creepy mitts, vasoline, and steroid cream at night, it remains a dull roar. I have never had a nervous tic or habit until this came along. I catch myself scratching my hands now as my anxiety level climbs at work and I have to wonder sometimes if it isn't just the weather and the washing that has brought this on. I am mulling, processing, worrying about patients I saw in a way that is different now.

Now I find myself at this woman's bedside and I feel myself scratching and will myself to stop. I am nervous because this is a tight rope walk of being alarmist for possibly no reason versus alerting her to the fact that she might have an advanced, and likely fatal, disease. She has always been healthy, on no medications, no surgeries, doesn't smoke or drink, having spent her days being a farmer's wife.

My attending comes in and explains the ultrasound findings. I see the husband's face start to change under the thick brim of his baseball cap. I see the information sinking in and that moment of before and after forming. He suddenly looks very agitated and I can tell the discussion is over, he wants to go. We excuse ourselves and I hang on to the hope that this lovely lady does not have a death sentence, that the ultrasound was wrong, everything benign.

While scrubbing in for a case a few days later the general surgeon tells me that the ultrasound was not wrong and that she has very advanced disease. I look down while he tells me this. I feel the rough end of the brush against the back of my hand while the chlorhexadine soap suds roll down my arms. I picture the conversation they must have had and inaudibly shudder. She came in thinking she had gallstones and walks out knowing she metastatic cancer. The water rinses the lather off and trails into the drain at the other end of the sink. I push the swinging O.R door open with my foot and take a green sterile towel to dry my dripping, raw hands. 

Move

Today I started my 3 month rural 'family medicine' rotation. It is in a northern community which has a hospital and clinic run by advanced scope GP-anesthetist and GP-surgeons. Needless to say I am both excited and intrigued to see how this all goes. It could potentially be a community I could see myself living in. If, I am capable of completely eschewing hot yoga, dining out, drinking coffee in quaint locals, retail therapy, exotic ingredients and mountain gazing. Hmmm. Being in the hospital and clinic I am in a little bubble of "this is SO great!" until I step outside. It's a big sacrifice at the end of the day. Kick ass job in Armpitville or the opposite alternative.

While I was packing for the move I had flashbacks to all those times I would go on northern nursing contracts. Packing bedding, knives, high-quality snacks, books, towels, candles, textbooks, stacks of Yogi tea and feeling the mix of anticipation and dread at leaving whatever cozy digs I had. Hoping that my roommate and apartment wouldn't be too nuts and too ghetto, respectively.

My roommate here is fantastic. Our eyes are definitely aligned but the digs...oh the digs. A former elementary school turned into an apartment building. It means the echos of feral children and their meltdowns infiltrate as obtrusively as the constant supply of cigarette smoke. And I have to think, before medical school I had a cute little house in the mountains and an RRSP in the bank...now I have...this. 

Well at least I am back in the work bubble in not too many hours.

Goodnight.

Hello

A brief summary of things that have happened over the past few months, when I apparently stopped blogging on a regular basis.

Nov: Gen surg and ER rotation. Duncan's dear uncle in Scotland died and we had to make an emergency trip back to the UK for his funeral (which was why I was on an airplane catching a baby).

Dec: Ob/Gyn rotation. Christmas. Very little laundry or grocery shopping done. Very little sleep had.

Jan: More Ob/Gyn and then ICU. That was interesting. One of the attendings asked me if I had kids and when I said no replied with, "Ahhh, so you are alpha female on beta blockers". I mentioned this on FB which caused a very interesting little burst of outrage from my female physician friends. Incidentally I thought the comment was hilarious but then was embarrassed for NOT being offended.

Feb: More ICU then a 2 week elective in Major Trauma Centre in Alberta. My mind blown by the prospect that a) there is such thing as an interventional pulmonologist  b) they will come and do a thoracentesis on your patient in the ED if needed. Also, being in a centre that has an outpatient clinic for virtually every medical complaint known to man. Oh send them to the outpatient chest pain non cardiac clinic. Oh send them to the outpatient early pregnancy loss clinic. Oh send them to the depressed but not suicidal clinic. Oh send them to the outpatient intubation clinic. 

March: Elective in Ob/Gyn. Yep.

Now we're all caught up. Okay not really, not at all. Residency is rife with hilarious, heart warming, heart wrenching moments - many of which I would LOVE to write about. But there are a lot of things that are taking up my precious moments of free time (like watching Episodes, downloading Matt LeBlanc's ring tone and hoping that someone SOMEWHERE will recognize it). But also things like talking to my boyfriend, making soup, buying lottery tickets.

Plus, it's just been a tough year. I am questioning so many decisions on a regular basis and trying to decide which direction to go professionally. In Canada GP's can work in many different expanded scopes and I really want to pursue more training. Problem is I love bits about all the extended scopes and want to do it all (yet time marches on and the line of credit interest payments steadily rise up). So I spend a lot of time musing on GP-surgery? GP-Anesthesia? Extended obs skills? ER?

Sigh.

I would really like to get back into writing more and back to keeping a regular blog again. Not going to happen this month though as I have a licensing exam, an advanced airway course, and an ultrasound course looming. Oh and a dog who needs walking.

Maybe next month.