Comment in Response to 'Glimpse into the Arctic'

I posted the Globe and Mail article on my FB page and received some insightful and interesting comments as a result.

One comment was from a phenomenal Nurse Practitioner, Dana, whom I worked with years ago in Victoria--one of the nurses who inspired me to adventure North in the first place. I should really do a series of posts just on her because lordy the woman was not only one of the smartest people I've had the pleasure to work with, but also one of the most hilarious. Pretty sure if she and my friend Janet worked in the same ED the universe would spin off its axis and all disease would finally be stamped out for good. In all seriousness though, she has truly seen the spectrum of health services in this country and I am more than happy to provide a platform for her to shout from.

I asked for permission to post her comments here and she granted it. See below. 

Then the clincher to this whole thing in my career is I started going to Northern Manitoba....it makes Nunavut look good.

I recently went to a place called Wasagamac (look at the youtube video that says "Housing Crisis in Wasagamac") Anyway a population of about 2000. 2 working nurses and an NIC that is strictly admin. 85% of the population IDDM out of control, approx 40-50 born per year. Usually 15-20 residents per shanty, most have no source of heat, incredibly sick babies (with 2 nurses), tons of pathology in these kids, several with mickey tubes for feed, tons of rickets, no access except by boat so no medivacs at night, of course addiction and violence out of control, no RCMP detachment, the closest is in Garden Hill and only water accessible in day light hours. 

The price of a cucumber in January was 7.12. 

I had PTSD when I got out. I had treated a baby daily for RSV, grunting resps, RR of 80 blah blah. Unable to get her out. NIC states she is not the sickest, has been like that since birth and we will continue to treat her in community. I call Wpg, the ER doc screams at me that Health Sciences in not on contract anymore due to non payment from Northern Medical (a government agency that doesn't pay bills promptly) so they will not accept anymore medivacs until the bills are paid....Yells and rants at me on the phone and tells me it sucks to be me cause he isn't accepting. medivacs will not come without an accepting physician....

The GP that I am suppose to call says "ya thats the way it is just do your best." It is so unbelievable and I am so throughly disgusted I cancelled my next contract and am NEVER returning north, especially to Manitoba. 

Anyway watch the video if you have a moment and spread the word. Health Canada made me sign an agreement that I would not discuss conditions...huh? I came out of there after 15 years of northern nursing with PTSD and total exhaustion....on call constantly and worked 24/7 pretty much. Pay check for 2 weeks was over 10,000 net, so not worth it and just all wrong...And politicians want to talk about 2 tier health??????


We work with the sickest population both mentally and physically with no resources or diagnositcs and make a responsible diagnosis then arrange for appropriate treatment? An impossible job. These folks are at great risk. Hell no one even expects any advanced practice or experience anymore.

How can this be Canada? I have been from Beaver Creek (Yukon and most westerly community in Canada), to Cape Spear NFLD (most easterly) to Grise Fjiord all in one year as well as everywhere in between. I have been doing outpost in all 3 territories and Man. since 1995. It is appalling and gets worse every year. I have seen things that keep me awake at night. The problem is the situation gets worse and worse and worse...

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I recommend watching the short documentary she mentions. I would say 'unbelievable' but I have seen similar situations in the North and sadly it is much too believable. I wish I could say what some solutions might be to all of this, but I have no idea where to even start, except to bring some attention and awareness to what is happening in these communities. The realities these people are living should not be acceptable to Canadians. 

Glimpse into the Arctic

Many of you who read this blog know that I spent 2 years doing contracts as an outpost nurse in the Canadian Arctic. I often find it hard to put into words many of the experiences that I had there, or what it was that kept pulling me back. The work was very challenging, mostly well outside my knowledge base and comfort zone (as a nurse who had only been working for a year and a half). But clinical learning curves are steep and dizzying, and soon I found myself missing the autonomy and excitement that the North held for me, especially when I returned to urban ED's where I was not at all involved in determining how a patient would be managed.

Recently a very good article was written in the Globe and Mail about Nunavut. If any of you have ever wondered about the realities of the Canadian Arctic and the Inuit people, I highly recommend reading this piece. It will certainly give some insight into the world that I spent some time in, and the struggles we, in turn, faced as health care providers*.

Cape Dorset (the town heavily featured in the article) was my first Northern contract and I can tell you, it was a profound culture shock. Unsettling too, living in a place which produced such beautiful and unique art...as well as brutal and horrific violence. Many of those mentioned in the article are people I remember, and it deeply saddens me to read about the dangerous unraveling in that town. It is not hard to imagine, when you read the statistics on Nunavut, why MSF equated my Northern work to "3rd world experience".

A flood of memories came back to me as I read the article. I saw first-hand the results of the violence and poverty during those days as a homecare nurse.  I saw the threadbare existence of one of my elder and infirm patients whose son would leave only bruises and cuts on the old man's balding head as evidence of his visits. Not only on my patients, I would see the reality of the violent community even on the faces of our staff, like the interpreter I worked with, who showed up one Monday morning with two black eyes.

There was the young girl, who stole her grandfather's pain medication so she could sell it on the street, a girl I naively thought was so sweet for picking up his prescription. Paulassie had severe rheumatoid arthritis, and despite his condition remained a renowned soapstone carver. During homecare visits I would often find him in his back porch (when temperatures were well below -30) painstakingly working on a sculpture, many of them destined for high-end galleries in Montreal, Ottawa, or Vancouver. Through the interpreter he'd tell me stories about his early years living in igloos and animal hide tents, hunting and fishing with his father. As a young man he was a guide, often taking the early doctors and nurses by dogsled to the scattered settlements when Inuks needed emergency treatment. Wild stories about blood transfusions in tents, from staff to patients when births resulted in hemorrhages, or tales about those that survived hunting injuries only because the air was so cold it froze the blood before they could bleed to death.

He promised to carve me a little stone nurse on my next visit. Sadly, he died before my next contract there, and I often wish I had asked to buy one of his smaller carvings as a reminder of this man and all that he represented.

So many more moments came to me from those days in Cape Dorset, staring from my office window across the glare of the searing white tundra, seeing the reasons for the hopelessness which permeated the health center sometimes; the ongoing TB outbreak, the domestic violence, the malnourished children, the alcoholism, the young pregnancies, the deplorable housing situations, the lack of meaningful employment for local residents.

Yet that isn't the full picture, and I suppose I'd have to sit typing for a long time to accurately try and convey the beauty in those tiny hamlets, scattered across the North, connected only by airplanes. The mirth that has remained despite the hardships, the strength of the women and men trying to better their communities, the natural talents of many print-makers, carvers, and story tellers. The ability that some still have to survive on a landscape that would kill most us in a few days.

Drum dancer during Nunavut Day celebrations.

I am going to go back there someday, when all these USMLE questions and elective requirements are a part of my history. For now though, I have to pretend to see the importance of learning about G-coupled proteins and which enzymes convert pyruvate to oxaloacetate.
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*Of course, I would be remiss to write a post about the North and not mention my favorite book written about the place, Consumption, by Kevin Patterson.

You Know You Are in the Arctic When...

So picture Saskatchewan. Now go straight up, through Nunavut. Over all the rocks and trees and tundra. Over the caribou, lichen, streams, and ravens. Drop off the top of Canada's mainland, cross the frigid waters that will turn you to ice in minutes, then stiffly climb onto the shores of Victoria Island. There you are. In Cambridge Bay.

Imagine a flat, white, landscape. Depending on the day that white will be cut in half on the horizon with blue-bird sky that surrounds you 180 degrees or with a matching shade of blowing white which makes you feel like you are in one of those snow globes someone is shaking vigorously.

Welcome to the North.

It has been cold up here. Not just "oh I think I'll wear a coat today" cold but more like "oh, I think I have to bring my blowdryer and an extension cord to work today so I can de-ice my lock when I get home" cold.

My walk to work is approximately 5 mins (or 1.5 Lucinda Williams songs I've discovered). And in that time all kinds of fun and interesting things can happen to you when it is -50 with the windchill.

Things like:
-your face freezing to the inside of your coat from the moisture in your breath. As if you licked the entire front of your face then stuck it to the side of a metal door.
-your eyelashes freezing shut
-a trail of snotcicles (icicles made of snot) clinging to your upper lip
-a pain, burning, immobility of movement in the fingers which leads you to believe that your fingers are actually freezing. It is not just an expression any more.
-your earphone cord seizing up to a taught, brittle, wire instead of the normally flexible plastic handing loosely by your side.
-tendrils of hair coated by breath moisture turning into wisps of ice hair framing your face, which then melts and plasters to your forehead imediately after stepping indoors.

It's fun. It's something different all the time.  Today it is only -37 with the windchill so people are outside snow kiting in the bay to celebrate the chinook like change in weather.

Got to love those hearty northeners, hey?

Seriously

That was one helluva strange night. It was like the ED axis was spinning just slightly off kilter. Whatever the chief complaint was,  it had nothing to do with what was actually bothering them.

Chief complaint: shoulder pain
Actual problem: Baker cyst x 3 months causing leg stiffness which resulted in a fall which resulted in the shoulder pain which resulted in exasperation over Baker cyst, which resulted in ED visit despite impending surgical consult for removal of cyst very soon.

Chief complaint: shoulder dislocation (2 weeks ago)
Actual problem: scabies (and alcohol abuse)

Chief complaint: dizziness
Actual problem: desire for expedited nursing home placement

And it went on like that.

I had the husband of an IV ABX dental abscess refuse to look at me and just kept repeating over and over again, "I want to speak to the doctor". He wasn't quite getting the concept that there was NO doctor in the department at the time and at 0100h NO doctor is going to come in from a warm bed or give orders on a patient unless the NURSE makes it happen.


Then there was the completely obtunded teen that drank himself into a bedwetting stupor.  He awoke from the depths of a Silent Sam induced coma to drag himself to the ED patient washroom. He then pissed all over the floor, wall, sink and escaped out the other entrance to the bathroom. When mom arrived to pick him up a few minutes later I went to get him out of the bathroom only to find a trail of urine footprints out the other side. I did some frantic searching through the few unlocked doors on the main floor and into the basement, worried that I might find him head first down a stairwell or something. Then saw that the pissy-prints went out the front door. I offered to call the police to help find him but mom was fairly certain that he'd just wander to a friends house and pass out there for the night.

Needless to say I was more than relieved when she called to say that he'd stumbled home. Heart attack by me averted.

There was more, but I think I'll give those ones some time and space. It is a small town after all.

Needed That

Had a wonderful night with three hilarious nurse-friends from the hospital. We had planned to go to a movie tonight after dinner at Rae's but in the end we sat and ate a lovely feast of fresh summer salads, enjoyed delicious beverages, stared at the ocean, and told stories.

I thought about how our conversation rolled along the whole perspective of life--from defining when life starts to what it feels like to watch a prolonged death. We laughed so very very hard at stories about the quirky people that populate our lives in and out of the emergency department--from the overly energetic nurse that falls asleep watching Inception, to the practical jokes we play on some of the docs, to the names we've been called during the night shift by drunken patients.

In these exchanges I hear sadness, frustration, humor, humility, love--every raw emotion possible.  I think about how many times those emotions have washed over us in the hospital. When those stories start rolling one really develops an appreciation for what we see in those buffed MRSA coated corridors.

It was better than any movie we could have watched. It was just what I needed.

Failed Resus

So glad he called it early.

It was an unwitnessed arrest of grandpa, the 8 year old called 911 because mom was out on a run.

Seeing people quietly in shock is more disturbing than watching people grieve loudly and dramatically.

It wasn't a messy code, like they usually are. It was just very apparent from the start that our efforts were in vain. We tried but, as the name implies, asystole is a hard rhythm to come out of.

We had a medical student start with us today, I went in the resus room after we'd all cleared out and found him in there with the patients daughter, a hand on her shoulder. I was impressed. We worked most of the day together but I didn't tell him that I was a medical student as well. He's actually a legit student, where as I am kind of more like a hospital crashing renegade medical student.

On the other side of the equation I did get to witness a birth yesterday, and I was happy to feel tears in my eyes when the baby finally emerged. I like getting an unexpected jab of emotion at work, it makes me feel less like an ED-Bot who works unflappably at putting out tiny fires all day but gets no major satisfaction out of a lot of it.  The doc I was with said I can catch the next one. I have since been creeping the maternity admissions.

And now...I need to cook dinner and let my shoulders relax.

Adventures in Air Travel

I believe that each time I get on a plane that my luggage will be delayed, lost or destroyed (or all of the above).

I believe that a blizzard, freezing rain, hurricane winds, a power outage, a malfunctioning video screen, ice on the plane, snow on the tarmac, an abandoned suitcase, an ash cloud, a frozen propeller, damage due to impact with a pick-up truck, a non-starting engine, or a bird will hamper my flight plans.

I believe all of this because in the last 3 years all of those events have occurred. Yep. Every single one of them. Today one of my old favorites which I haven't experienced in a long time thwarted my itinerary: marine fog. Oh marine fog, why do you choose to not burn off the mornings I want in, and roll in early on the days that I want out?

So we landed in another town and had to take a bus the rest of the way. I wasn't too fussed about it all since I had ample battery power on all my distraction devices and an orange.  But Holy Butter-Icing Batman was the heavily tattooed gent in the tracksuit ever hopping up and down about a cake that he had carried on board.

He actually was swearing at the agent on the tarmac about the fact that there was no refrigerator on the bus. Apparently he was going to have a very effing angry client. Like it was her fault.

[Insert chain smoking and pacing here.]

---

Anyway, the bonus was running into a long-lost housemate, B.B, from 10 years ago at the Vancouver airport, then discovering that she and her husband (boyfriend when I last saw them) were coming here as well for a fishing holiday. They also had an 8 week bambino in tow. She was very cute and well behaved, just how I like bambinos. The last time I saw B.B. I was in nursing school and WOW have I changed since then. It was a pretty dark time in my life to be honest. I hope that she was able to see how much of a 180 degree spin things have taken since then.

When they asked what I was up to I just said, "I am in medical school in Ireland, just home working for the summer". Which is the most direct answer I have ever given about my state of affairs--I usually dance around things by saying, "yeah, I am working for the summer...no I am not living in BC anymore...no I am living in Ireland....yeah I am there living not visiting...oh, yes I am a student....er well actually I am in medical school....yeah...it's pretty good..." etc.

Then I felt weird about how I said what I was doing. Did it sound showy? Or braggy? That is why I hate throwing out the MD school thing like that. But then I sound cagey and evasive. Falsely humble or something.

Ah well, I am working on tactful directness.

---

It was a wonderful few days with K.B. We just relaxed and cooked, drank wine and talked, walked. A great break in the middle of my contract. I am feeling good heading back to work tomorrow. My soul has been watered. It is exactly 4 weeks from today until I am in Ireland again!

My excitement is certainly growing. Mostly because I cannot WAIT to see Tobie who I've had in my clutches for only a week since May 17th. It has been really tough being apart for most of the summer. He's off to Ireland in 4 days, doing a course in Spain for a couple of weeks, and then setting up our "Nest" in Ireland for my arrival. I am also looking forward to seeing my good friends who are in Ireland and various North American locations (yes you too George!) It's strange being so tightly compacted in a ball of stress with a core group of people and then being tossed apart for the summer.

Off to the store to get stocked up for the next round of 'Living in the Hospital, 2010'.

The Current Digs

Starting to settle into my hospital provided housing. Been working like a dog (a happy dog but a dog nonetheless) for the past 13 days. Since my arrival I have been at the hospital every day, either leaving in the morning or showing up in the evening. Or both.

On my first morning I looked up from my tea and saw a bald eagle swooping out my window. Voila.

Can you spot the three bald eagles?

This place is certainly a step up from many hovels I've been assigned to in my adventures as a travelling nurse. Quirky, woody, borderline funky, and creaky. But a killer view and for two more days it's just me here (a rare treat in this game where cramming as many people as possible into staff housing is paramount).

Can't you just see John Travolta lounging in a white sequin onesie on that couch?

Something about this kitchen gives me the urge to prepare a jello salad. With tiny marshmallows.

Does anyone else think, "John Denver" when they see my bedroom?

Even on the ugly days, it sure is pretty. 

My picture perfect picture window. 

Cartoon and OR Theme

The recent post by Doctor Grumpy reminded me of this clip my friend Aaron sent me a couple of weeks ago. It is particularly pertinent given my recent activities.

Rae (fellow emerg RN) and I gave each other report in these voices today and drove everyone insane. Does make hand-off much more entertaining mind you...

Enjoy!

ER vs OR

So for a long time I always thought that if I ever became a doctor I'd work in emergency medicine*. It was dynamic and interesting, there were sphincter tightening moments and breezy presentations. Another bonus was that quirky personalities seemed drawn to that type of medicine. Hello, ABB finally fits in somewhere in healthcare.

I know I am going through the usual blush that medical students undergo with each specialty that trots in front of them during medical school. Yes, I was in a real anesthetist kick for the past year, but with more of a critical care/ED/pain specialty intention than an OR intention.

In the past week I've spent some time in the OR, shadowing a general surgeon and an orthopod. And holy mother of scalpels--I am in love.


Things I love about the OR/surgery:

-it's clean, sterile in fact!
-at the end of a 12h shift you don't feel the need to scrub yourself with lye and chlorhexidine in an attempt to get rid of the dirt that just wont wash off...
-patients are cooperative and unable to yell profanities at you/spit at you/bite you
-it is totally hands on, hello procedure-ville
-you get to look at imagining, see people in your office, consult in the ED
-nice variety (see above)
-you get to wear a mask and a cap (so really it doesn't matter what you look like at work)
-patients need to go through the medical systems sieve to get to you

Things I do not love about the OR/surgery:

-you could seriously eff someone up if you make a mistake (yes that can happen in the ED as well but somehow it seems much worse to botch a cholecystectomy and have a patient end up on the transplant list than to miss an occult fracture in emergency, or fail to intubate a difficult airway...)
-you have to stand still for hours on end and crick yourself into crazy positions to get the job done sometimes
-cautery smoke stinks
-apparently the hours stink too, though the surgeons here have *sweet* hours
-less patient interaction (though that means less of the nasty aspects of patient interaction)
-when you leave work there are still patients in the hospital under your care

The quest continues. Funny thing is my friends/colleagues seem very divided on the matter. I guess it is all part of the great med/surg divide. When I say that I am loving surgery, half the camp starts frothing at the mouth whilst going into a slow-motion dive toward me yelling 'noooooooooooooooo'
and the other half says, 'Yeah! Do it! You've totally got the personality for surgery and would be so good at it.'

Time will tell.

*I have been working in emerg for about 7 years now. Maybe it is the 7 year itch. 

Fun in the OR

Got to scrub in today for three neck surgeries and one ortho repair of a fractured ankle.

The Albinoblackbear tastes surgery and LIKES it!!

Oh dear.

More on that later. Right now I am heading back (after a quick meal and 20min nap) to work a 12h night shift. Gonna be a long long night.

And... *drum roll please*

I PASSED FIRST YEAR! Woooohhoooooo!

(It is pass/fail so I am assuming "P" is for "passed").

Back in the Saddle

Yesterday was my first shift back in the ED after 10 months away. I received a genuinely warm welcome from all of the staff which made the first day seem all buttery and smooth.

I have been chuckling at all the things I have forgotten (how to turn off alarm monitors) and all of the tweaks I am noticing to my practice (ridiculously long patient histories). Also, now I have these urges to perform unnecessary assessments on patients. For example, I suddenly feel the urge to palpate everyone's lymph nodes (and name them off while doing so). I also want to locate apical beats, listen for carotid bruits, and attempt to elicit reflexes.

It had been pleasing to be back in direct patient contact land--for the most part--until I had to be at the other end of a call bell belonging to a *very* curmudgeonly old man who spend most of the afternoon yelling at me and shitting in various locations in the ED. One clogged hopper and sweaty procedure in the patient bathroom later I was ready to throw in the towel on the old nursing gig. The doc I was working with took that moment to remind me of my recent spiel on how I "loved being back at the bedside again". It was well played.

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I had an ICU patient this morning who was an elderly woman, not doing so well post-op. It was decided that she'd be switched to palliative, as her pre-op wishes were DNR. Yesterday she was very fidgety, puling at her ART lines and central lines, so had to be put in restraints. Thus my first order of business today (once the status had changed) was get all those invasive lines out and take off the restraints. She looked so much more comfortable and settled once all the tubes and wires and drains were removed.

I heard later that she'd passed away after being transferred upstairs. It gave me a small moment of thankfulness that I'd been able to make that passage a little more comfortable. Those feelings always make me think "...hmm...palliative care? Maybe."

I do feel accomplishment for both letting patients go peacefully as well as traumatically bringing them back to life.

Tomorrow I am going to be a medical student. I am following one of the surgeons in the OR, his exact words as I left today, "don't worry, we won't let you burn anything important tomorrow". Gotta love the twisted hospital humor. Looking forward to the day. Fingers crossed I won't get the spins and water brash like I usually do when I step under the lights with a mask on.

Interweb Machine Connection Again

Hello Blog-land.

How I have missed you so.

It has been a wonderful whirlwind, travelling from the vibrant Gatineau area to the familiar prairies of Alberta. Too short of a holiday with Tobie and too many people to see out West. I had to compromise for quality not quantity.

Now I am in my new digs in Northern BC. Staring at the ocean from my wood and brick bungalow, decorated with circa 1970's teal couches and ivory appliances.

My luggage, however, is in Nanaimo, BC.

I realized that things were not good when I was waiting for my connecting flight out of Vancouver and noticed my baggage tags were marked with the wrong last name to the wrong destination. The initial flight customer service agent threw out my bag tags and told me there was no record of my luggage in the system and that there was nothing he could do.

Um. No. Unacceptable.

I had to politely ask him to remove my bag tags from the garbage and return them to me. Thankfully a competent agent came to my rescue and actually made phone calls and tacked away on his keyboard for a while.

Apparently the bags are going to arrive this evening, fingers crossed. My first shift back in the ED wearing scrubs and heels would have been interesting.

Now I must forage for food, nap, and hope that my belongings arrive*.

A bald eagle just flew past my window. Actually. God I love this province.


*Update: Everything has arrived, intact and unmolested. The lady is pleased.

Who Walk Among Us

This post was written last summer on my old blog. I like going back to those past entries from time to time so that I can remind myself of all the reasons I chose this path, and why I am here.

--


I was tired this morning when my alarm went off at 0445h. I had to drive to the city to catch a 0750h flight and therefore didn't want to leave the house later than 0515h.

I hit the 'dismiss' option instead of 'snooze' on my phone and fell back asleep. I awoke just after five and raced around the house gathering up the last of my belongings, showering, and grabbing some toast for the road. Ugh! I realized I needed gas as well. Of course, when I am running late...

Zoomed into the quiet station and put 15$ in only to find I had locked my keys in my car.

Aghghg! Remembered my hatchback was unlocked. Sigh, ok, I can handle looking like an idiot to the gas station attendant for a few minutes vs missing my flight. Finally I got on the road, but I was pretty frazzled.

Going to a new contract always makes me a bit edgy...What will the staff be like? What is the housing going to be like? Is my roomie going to be a psycho-chain-smoking-television-blaring-messy-chews-with-mouth-open-racist? Will there be internet? Will there be soymilk in town? Will there be a gym in town?

So when I arrived at the airport I was not in the mood for the baggage lady to tell me my bag was 3 kilos overweight. I fought the urge to make a sarcastic remark about all of us probably being 3 kilos overweight. So there I was, the girl who has to open her suitcase for all to see, randomly pulling hefty objects out and stuffing them into a plastic bag (classy). Thankfully I didn't send a shower of tampons into the air or accidentally fling a pair of underwear at a baggage handler.

I was cursing Air Canada and the woman who kept calling me "ma'am".

Oh how I hate flying Air Canada.

And I hate all the little invasions of my personal space when I fly.

Take off my shoes? Undo my belt? Open my top button? Take out my toiletries bag? Really? Is this all really necessary? Sigh. Remember the good old days when you could fly with a leatherman on your belt and have toothpaste in your carry-on?

I was muttering to myself about my severe dislike for all-things-air-travel as the dude in front of me in the security line was completely faffing with this ridiculously large bouquet of flowers.

Finally got to the gate and sat down for a few minutes before having to board.

My flight arrived on the island and we then waited for about 45 minutes for a shuttle to take us across the inlet on a ferry to the town. Yawwnnnnnnnn. Sleepy. Hungry. Cranky.

A taxi stopped to give me a ride to the hospital. The driver was a middle aged Vietnamese man, very pleasant and upbeat, waving and smiling at people as we drove through town. He laughed when I asked him if he knew where I was staying,

"25 years in a 4 mile radius town you know where everything is!"

Right. Good point.

So I asked him how he had ended up here of all random places in the country to be, it didn't seem like a place that would jump out at someone immigrating to Canada.

He said, "have you heard of the boat people?"

I scanned my thoughts wondering if admitting that would seem racist, I had assumed that term was only used in a derogatory sense.

"Ummm yeah...you mean people that escaped Vietnam and came on boats to North America?"

"Yes, that was me and my sister. I was 16, she was 14. Our boat ran out of gas in international waters and it took 7 days for a US coast guard to find us, there were 49 of us on the boat. They brought us to their ship and people were given the choice of moving to Canada or US. I chose Canada and was sent here, neither my sister or I spoke a word of English. I started out washing dishes in a restaurant, getting the waitresses to teach me English. Now I have the good life."

I asked him if anyone died on his voyage. He told me that they had been 2 days without food and water when they were rescued, that two children had almost died but ended up surviving. I told him he should write a book about his life, his bravery, his story. He said, "no, that journey brings up too many sad memories". And that was that, he popped the trunk and was soon on his way.

I've thought about our conversation all afternoon. Here was this man who survived a very dangerous voyage to a completely unknown land. When he arrived he had no money, no education, and couldn't speak the language.

And here was I. Cranky at having to suffer the inconveniences of air travel. I wasn't leaving my family behind on a dangerous journey where I'd arrive and not know how I'd get food in my belly or a roof over my head.

I am glad this man held a mirror up to my irritations of the day. How truly fortunate I am in my comfortable life.

I am glad I got to see how my day of travel compares to some of the travels that have been endured by the people around me. People who will never whisper a word of it to me, stories I will never know.

I like being reminded that sometimes I should stop to consider what chain of events have brought me  to the place I'm at.

That perhaps I could never know in a thousand lifetimes the experiences of others.

And how thankful I should be that my 'humiliations' only include locking my keys in the car and having to take off my shoes to show a hole in my sock.

Death Be Not Proud

Enough of trying to pretend that I am coping well. I am not.

There are a few workplaces in this world where you might have the wonderful advantage of a colleague who is always willing to help you out. This is the person you can call in the middle of the night, when you are alone in the clinic and suddenly overwhelmed with a septic child and casualties from an ATV accident. This amazing colleague does not ask questions or complain that she's exhausted, she just gets down to it. Her experienced and gentle hands start the IV while her stern voice gets a room full of hysterical teenagers under control.

I was lucky enough to have this colleague become my friend. She taught me how to make blue cheese bread twists out of the limited groceries we had access to in the Arctic. She rented a boat with me so we could see the icebergs up close, feel the gravel of a glacier under our feet, and bob alongside seals for the afternoon. She taught me to fish and she taught me how to do a proper head-to-toe assessment on a neonate.

Fortune continued to smile upon me.  This woman generously invited me to her home in New Zealand, letting me use her place as a base while I travelled around exploring the beautiful landscape of the South Island. She introduced me to her friends and colleagues and they embraced me as an honored guest.

Eventually she became one of my wisest confidantes, and I was truly blessed for this. She listened to my dreams, and encouraged me relentlessly to pursue them. She would write to me, telling me to push on when she knew that my determination was faltering. She sent me gifts when she was far away reminding me of how proud she was. She was one of the few people on this earth truly in my corner, championing my successes and lamenting my failures. When the first round of medical school rejections came, she pushed me back into the ring to keep trying.

She never married or had children. Her spouse was adventure and her children were the thousands of sick babies she held in her arms. Her entire career as a nurse was devoted to the vulnerable and weak, the poor and the forgotten. She spent years volunteering in Zimbabwe , Vietnam, Cambodia and Myanmar. In New Zealand she worked in a special care babies unit and in Canada she took care of First Nations and Inuit communities.

She took me under her wing during my first contract as an outpost nurse in the Arctic and tirelessly answered my endless barrage of questions those first months. If it hadn't been for her I am sure I'd have left the North with my tail between my legs, succumbing to the crushing weight of inexperience and fear.

Mentors and kindred spirits do not come along very many times in ones life.

In Nancy I had both.

She died from cancer on Thursday April 8th, 2010. 

Now that she is gone there is an empty void left in this world and in my heart.

Death be not proud. You have taken a shining star, a selfless healer, a wise woman, a sister, a daughter, and a friend.

Nancy I pray that you may now see all of the hearts you've touched, the lives you've saved, and minds you've inspired. Rest in peace my dear friend. 

What's the Craziest Thing?

My last post was getting a little long so I thought I'd break it up into two, on a similar theme. 

Often when I am out with non-medical people, after a few glasses of wine someone will ask,  "What is the craziest thing you've ever seen in the emergency department?"

This is a tough question to answer because there are many different kinds of crazy.

There is crazy-sad, crazy-funny, crazy-weird, crazy-annoying, crazy-smelly, crazy-gross, crazy-bloody, crazy-interesting, crazy-crazy...you get the point.

Of course I love telling stories and talking about my work but the point is to entertain, not to bog a captive audience down in all the depressing things that haunt you.

For now, these are two of my crazy-wow stories from the ED. 

When you are a health care worker you have to really work at an impassive expression when you see things that disturb you. Mostly because patients are acutely aware of even the slightest muscle tic on your face when you greet them and their problem. The last thing you want to do is make them feel more embarrassed, upset, exposed, or vulnerable. You really want them to feel like you've seen, smelled, heard, felt, their problem 1000 times before and they can just relax and not worry about it.

There are very few sights that freak me out. But two patients in the past 6 years have actually caused me to take a quick polka step backwards before collecting myself (and my professional behavior) again.

The chief complaint on the emergency form said "bit tongue".  It was busy in the department and I was annoyed that someone would actually come in for such a trivial complaint. (This is where I think--do people in this world have absolutely *no* coping skills for minor injury??)

The couple was a calm middle-aged duo, a little wobbly from the drink, in matching leather jackets and riding boots. The patients husband smiled when I approached, almost giggling as he told me the story---she'd slipped in the bathroom and bit her tongue when her head hit the sink on the way down.

I was now doubly annoyed because it is a major pet peeve of mine when husbands speak for their wives (or parents for their children and vice versa with the elderly). I asked her to open her mouth and out dropped 95% of her tongue, sagging down to her jaw line, hanging by a thin ragged edge.

Yep. I actually jumped back in surprise. She then jerked her head to throw the thing back in her mouth. They both found my reaction hysterical. Ok world, I get it...preconceived judgments are a bad idea.

I kindly warned the plastic surgeon before he examined her that this was no small injury. Even he came out of the room with his eyes widened.

The other time I did a dance step away was when one of our more colorful frequent flyers developed a severe cellulitis, with a twist.  He was coming in four times a day-ish for IV antibiotics and every three or four days for a massive dressing change. The weeping, festering wound stretched from just below the knee to the ankle. He told me one day that there were maggots in his wound and he wanted them cleaned out and the dressing changed. He wasn't due for a dressing change for another couple of days and the department was swamped so I tried to talk him out of it. When I worked in adult psyche probably every third person complained of 'bugs crawling out of their skin' when they were going through withdrawal so I was nonplussed by his description. But, truth be told, I felt bad for the guy and life afforded him no luxuries, so if a dressing change was going to make him happy, I'd do it.

I peeled off the dressing and much to my shock and "egad!" I jerked back at the sight of dozens of tiny white wiggling maggots diving back into the flesh from the bright disruption to their darkened world.

"Seeeeee! I TOLD you there were maggots* in there but no one believed me!!!"

The timing for these types of encounters seem to always coincide with getting too cocky developing a false sense of confidence in your powers of prediction and assessment. 



*And yes I know that maggots are grand for wound healing and debriding necrotic tissue...but it was shocking nonetheless to see it unexpectedly.

Umm...yes please!

I made the mistake of drinking wine around our class rep/journal club president a few weeks back wherein I agreed to do a presentation on my arctic nursing adventures...he asked me to make said presentation for today's Journal Club and it seemed like a good idea at the time. This morning I actually woke up with sweaty palms. That is how nervous I was.

Initially I was afraid that no one would turn up. I told my two close friends here and Manfriend that thay HAD to come so that there would at least be 4 people in the audience. Then I became very afraid that people *would* show up. Sweat. Palms. Underarms.

Much to my surprise a decent crowd of 1st and 2nd year students showed up--I mean besides my friends that I basically strong armed to attend. Even a handful of faculty, including the Associate Dean/Director of Education for the medical school. Yikes!

I think part of the turnout had to do with the poster my friend Mike made to advertise the event:

Ok so people came on some false advertising, and the promise of brownies....but hey...sometimes you gotta play dirty to draw a crowd.

Overall the presentation went well--I missed a few really big points that I wanted to make but managed to touch on most of them. My stats prof came up to me at the end and said that she loved it and wanted to generate some ideas for research up there--very cool. But the cherry on top was--as I was leaving the building the Associate Dean shakes my hand and tells me that he really enjoyed the presentation and then asks me if I'd like to skip into 4th year next year.

Umm...yes please!! Especially with the $65 000/year tuition I would save!

(That *was* my final answer but alas I think he was joking.)

I was feeling so behind after spending a big chunk of my weekend preparing this and not doing school work, but it was actually a lot of fun and already it looks like the Nursing and Midwifery school is going to have me speak to them!

PUSH!

Finally when the baby's head was crowning, just after midnight, I heard the irritating sound of the downstairs doorbell. Knowing that Jason (who was actually the first nurse on call) was not downstairs and that he hadn't radioed me to expect anyone--the midwifes and I decided whomever it was--was going to wait.

It seems that often in the crux of situations; when you are taping a baby's IV in place, suturing in a sterile field, or doing a pelvic exam, the phone or doorbell will ring. Most of the time, it is a relative just calling to see how so and so is doing. When you're on call at night in the clinic you have to be the janitor, the nurse, the doctor, the mental health counselor, the medevac coordinator, and secretary-- so these interruptions can be aggravating to say the least.

So as the PING PING PING sound of the doorbell chimed over our shouts of "PUSH!! KEEP PUSHING!! YOU'RE ALMOST THERE" we didn't think much of ignoring it.

I saw a contraction starting to wane and decided I should run downstairs and just make sure everything was copacetic. I got down there and no one was in the foyer, I wasn't surprised as in other health centers kids often would hit the buzzer and run off at night  This doorbell needed only be touched once and it would ring until someone unlocked the front office and manually turned it off. 

I unlocked the office and turned off the bell. The shouts on the other side of the door startled me to a new level of adrenaline. I found two men banging on the door and shouting at the window which separated us. One had a fat lip and a wild look on his sweaty face. I jumped back initially and then went into the corridor which lead upstairs. No way in hell was I opening the door to these two menacing creatures who were obviously pissed about something and more than likely pissed drunk. They both looked like the usual Friday Night Crowd that we stitch up, either when their friends drag them in or when they start to sober up and feel the throb of the cut. I pointed upstairs and yelled back through the glass that I was dealing with a birth, turned and ran up the stairs. Dammed if I was going to miss something happy and beautiful happening at the health centre for once.

As I took the stairs two at a time I radioed Jason , "Call the RCMP, there are a couple of drunks banging on the entrance to the health centre and there is no way I am letting them in down there alone. You better come down here to see what's up".

"I'm on my way".

Jason was  a 1 minute ride from the health centre and he had confessed to an America's Next Top Model addiction-so I knew he wasn't in bed yet.  I got back into the birthing room just in time to see another contraction starting and again the baby's head peeking out then deciding not to stick around, ducking back behind the skin of his mother. 

The doorbell starting ringing again and the midwives looked at me for the update. I told them about the two guys, that Jason was calling the RCMP, and that he was on his way down.

My radio cut into the silence between pushes,

"Get down here now."

I pulled myself away from the evenings climax and ran down the hall. Took the stairs as fast as I could and opened the door to the main floor. There I saw the foyer door propped open, a stain of blood  more than a foot in diameter marked the spot. Bloody smears covered the hand railings and buzzer, the floor showed footprints of blood leading to the emergency room. Yelling came from the room and my adrenal glands were pinched into action once more, with the main thought in my head a clear "ohhh shit!!!"

Jason stood over a man, naked but for his underwear and caked in dried blood. His clothes lay in a saturated heap on the floor. Jason looked as though he'd just had a walk through in a meat processing plant. The man lay with his back toward the door,  the white gauze Jason was holding against a hole in the mans back was quickly becoming red like the rest of the bed.  I couldn't tell if Jason was putting pressure on the wound or holding the guy down as the patient yelled and struggled beneath him.

"I WANT A DRINK OF WATER"  he yelled over and over.

"Call Doctor Friedman, tell him Bobby's been stabbed, get O2 on this guy and try to get a set of vitals, he needs 2 large IV's going NOW".

"Friedman, we need you in here now. Bobby D has been stabbed in back, he's bleeding profusely, combative. No we haven't got vitals on him yet, it's just the two of us and Jason is trying to keep pressure on the wound".

Friedman showed a few mintues later while I was in the middle of trying to keep Bobby still long enough to get an IV in him, he kicked and yelled about wanting water. No matter how much we'd give him to sip he wouldn't settle. Plus we could be sure this guy would be going to the O.R and so the less in his stomach the better. Bobby flailed around grabbing angrily at anything he could. In no time my arms were covered in bloodly hand prints.

"That bitch did this to me--she punched my face and when I said I was leaving, she stabbed me in the back! That fucking bitch! Hey leave me alone! Stop pressing on my back so hard! It fucking hurts. FUCK OFF".

"Bobby. Calm the fuck down! We are trying to help you. If you don't let us press on your stab wound you will bleed to death." Friedman yelled to his face.

"Get me some fucking WATER".

"Bobby! Look at me---look into my eyes--NO--LOOK INTO MY EYES! You are FUCKING BLEEDING TO DEATH! You need to let us help you, now calm the fuck down. We'll get you some water as soon as we get an IV going and get your blood pressure back up okay?"

I hadn't ever heard a doctor drop and F-Bomb on a patient before, but if there ever was an appropriate time, this was it. Bobby was yelling. Jason was yelling. Friedman was yelling. I was yelling. For a minute it felt like we were locked in a power struggle in which there were only losers. This guy could tear a bleeder that was barely staying together, or maybe he was bleeding into his belly as much as he was onto the floor. His bowel contents could be seeping through a hole into his peritoneal cavity, his lung could be filling with blood, or air, or both.

Jason took over the IV attempts after my first one was pulled out by Booby's thrashing, the dripping catheter being dragged along the floor with the sweeping arc of his arm. I was facing him now, hunched over as I pressed on his right flank, feeling his heartbeat under my fingers.

Friedman came to the other side of the bed and I pulled off the soaked gauze to take a look at what we were dealing with here. Down through the thin layer of fat and fascia a shiny encapsulated mass reflected the ER lights.

"Looks like his kidney there..." I remarked.

The dark red glistening sponge of liver also appeared in our field of vision--"and there's his liver" said Friedman, "put pressure back on".

Friedman went to the phone and called Aparna, the resident, and Sue the X-ray tech. They both arrived in short order despite the hour.

We were a montley crew to say the least, Sue in her "I Like to Show My Dog" cartoon shirt and sweat pants, Aparna in wool sweater and sandals, me in my running pants and blood soaked scrub top. Jason in dark bloody jeans, hikers and a scrub top, Friedman in a holey t-shirt and kakis.

Enter Bobbys extremely intoxicated parents. Neither of them looking like they'd been sober, or in a clean change of clothes for a week.  His mother weaving unsteadily to the only unoccupied space at the bedside. His father staring glassy eyed at nothing in particular was riveted in the middle of the room. Aparna relieved me of my pressure duty as my back and arms began to cramp from the sustained position and effort required to do such a task on an uncooperative person.

"Let 'im sit up if he wants, he can shhht up if he wants" his mother slurred at me, her eyes not focusing on anything in particular, just in my general direction. I really didn't have the patience for this right now. I escorted them to the door of the trauma bay to wait and look on from there.

Finally, some vital signs on the monitor. Two lines running wide open. With the x-ray machine warmed up we maneuvered him into the room and were able to get him to sit up, supported by the bed, for a dodgy chest x-ray. We knew that having him stand was not only a danger but an impossibility at that time, thus leaving anything that would show on an abdominal x-ray useless.

From what we could tell no major lung damage, but soft tissue or bowel injury was unknown to us. His belly did seem to begin to swell as the minutes ticked on.

During the lull with x-rays I was able to take a few breaths and organize my thoughts. I had taken a bag of blood from the lab and was trying to remember how to hang it. I had given blood dozens of times in the south, but it had been a long time. I knew if I made any errors the blood would be useless. I also remembered that there was a technique to priming the bag and tubing that contained a filter for the blood to pass through. If I rigged it wrong the saline would back flow out into the bad of blood and it'd have to be chucked. Something about gravity, clamping off certain lines....shit!!! The thick red liquid flowed down into the chamber, through the filter and down the tube. It wasn't running as it should. The saline should be dripping in the chamber as well-diluting the blood. Now the droplets spattered on the floor next to Bobby's own splatter pattern.

"Shit". I clamped the line off with a bloody thumb.

"Don't run it if you don't know what you're doing!" Freidman was watching me try to figure it out. No one knew how. Having blood up north was such a rare occurrence none of us could do it with any confidence. I was frustrated and angry with myself, this was a simple task and I needed to be able to perform it now more than ever.

I stood over the garbage can, sticky IV line in one hand, saline bag in the other I took some deep breaths. I closed my eyes. Just for a second. And then, with just a little more coaxing of the clamps and a slight modification to the height difference the saline flowed into the chamber, diluting the blood as needed. The two solutions swirled together and flowed through the filter. Becoming one brightly colored infusion as I let dribble out the few cc's of undiluted blood.

"Now I've got it. Ha! It just took me a few minutes."

Bobby returned into the x-ray department and I felt a small serving of pride cover the insecurity I'd been feeling after the failing to secure the I.V's and my initial botched priming of the solution. The blood was running in. A conservative estimate might be that he'd already lost over a litre since arriving at the health centre. This infusion might prove to be vital depending on how much was being lost in his ever-firming abdomen.

We were told by the people who organize medevacs that the flight crew would be 'timed out' once they returned from their last flight to Winnipeg and thus we'd be waiting until at least 6 am for a team to arrive to fly him the three hours south. Not knowing what was happening internally that delay meant a possible death sentence. He had already received our only supply of blood and there was nothing more we could do with our limited  resources.

Despite the strict aviation guidelines against pilots flying when they are 'timed out' Friedman was able to convince the powers that be that the situation was a life or limb emergency and this man needed to be transferred immediately. A quick letter drafted and faxed in the middle of the night from his office took care of the red tape. At around 3 am the flight team showed up.

The usual chaos ensued when the flight nurses arrived. In their blue flight suits, they unloaded their large bags packed full of the kind of gear one needs for any possible emergency situation. Our lines were changed over to theirs, their monitors were applied.  The dose of black humor, friendly chiding, ego overlapping, and introductions began. Through the bustle a catheter was inserted with much difficulty, another pressure dressing was applied to the wound, and an ativan was given to calm the patient down.

His vital signs remained stable and he was much more compliant now. Not necessarily a good sign, but certainly easier to deal with than he had been upon arrival.

Soon he was 'packed and stacked'. The ground transport arrived with stretcher in tow. Gingerly we lowered him, mindful of the various tubes, bags, and monitoring devices present. And off he went.

The clinic looked like a disaster had blown through it. A bloody disaster. Both stretchers had torn and stained sheets, the floor still held on to a film of blood despite Donna's quick mop job. The IV poles, the BP cuff, the O2 sat machine, counters,  garbage, side tables...everything had the same blood smeared horror-film appearance.

Jason rolled up the mat in the front hallway. Aparna busied herself scrubbing the hand rail and the buzzer with some windex and pilling paper towel. I bleached the stretchers a couple of times, washed the pillows and again mopped the trail from the emerg to the front door. The heavy metallic stench of drying blood still hung in the air.

Friedman, Aparna, Jason and I were the only ones left now. We chatted excitedly in the entrance. An informal debriefing over the way the night had unfolded. Each of us cutting the other off as we took over to tell our view of things. Friedman started doing one liners from the old television show "Emergency" yelling about ringers lactate and various code words. We all laughed and breathed sighs of relief with it all. The nervous energy and adrenaline of the night was starting to flow out of us. Soon it'd be replaced with the unavoidable adrenaline hangover of gut-and-head-ache.

"What are we supposed to do now??? Go home and sleep! What I wouldn't do for a beer right now...Jesus!" Jason shook his head and walked toward his office.

"Come look at this!!" He hollered from down the hall.

"I must have come in to grab something in the middle of it all..."

A bloody hand print covered the light switch in his office. Enough to make us all shake our heads and chuckle with laughter again.

And so.

I long hot shower later I crawled into bed knowing in a couple of hours I'd be up again for a full day of clinic.

Closed my eyes and played out many scenes from the night. I berated myself for not opening that door when I first saw them. My thin slice of the situation in that snapshot of time had been totally off. My instinct had been wrong. Just as I was thinking that I was getting some of that "spidey sense" that experienced health practitioners get.

It is frustrating to realize that sometimes your gut instinct isn't right. Scary to think that man could have bled to death in the foyer if he'd been more badly injured and if I hadn't called Jason.

But maybe that is what forms a more accurate instinct. The near misses (or the misses in some cases). That is what makes us take a step back at our assumptions and what we think we know and realize that sometimes we need to go deeper than the thin slice. Skirt around what we hope it is and look at a situation for what it is, what it could be. Unbiased. Objective.

Impossible.

Of course we are fallible.

Turns out Bobby survived. A nicked liver and kidney. A litre of blood in his belly when they got him into the OR.

I guess we all were lucky that night.


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It Comes Back

We're learning about G.E.R.D this week, or G.O.R.D --as it's called here thanks to the (o)esophagus.  I am reading about adenocarcinoma tonight when suddenly a patient's face comes sharply into focus in my mind.

A 41 year old male who was about 7 days post-op from a partial gastrectomy due to stomach cancer.

He was brought in by his wife because he hadn't slept for 2 days due to extreme abdominal pain. He was obviously very fit before this ordeal had started but now the weight loss had sunken his large dark eyes into the sockets, his cheek bones pressed upwards under the skin. His tanned skin had changed to greyish.

He never made a sound while I removed the dressings on his abdomen, which was rigid with pain. He just stared at me. Both of them were so afraid, it was unsettling. When you see fear like that you never forget it.

I am again reminded that these diseases don't only exist on histology slides in my Robbins and Cotran Pathologic Basis of Disease textbook.

You Know You are in the Arctic When...

So picture Saskatchewan. Now go straight up, through Nunavut. Over all the rocks and trees and tundra. Over the caribou, lichen, streams, and ravens. Drop off the top of Canada's mainland, cross the frigid waters that will turn you to ice in minutes, then stiffly climb onto the shores of Victoria Island. There you are. In Cambridge Bay.

Imagine a flat, white, landscape. Depending on the day that white will be cut in half on the horizon with blue-bird sky that surrounds you 180 degrees or with a matching shade of blowing white which makes you feel like you are in one of those snow globes someone is shaking vigorously.

Welcome to the North.

It has been cold up here. Not just "oh I think I'll wear a coat today" cold but more like "oh, I think I have to bring my blowdryer and an extension cord to work today so I can de-ice my lock when I get home" cold.

My walk to work is approximately 5 mins (or 1.5 Lucinda Williams songs I've discovered). And in that time all kinds of fun and interesting things can happen to you when it is -50 with the windchill.

Things like:
-your face freezing to the inside of your coat from the moisture in your breath. As if you licked the entire front of your face then stuck it to the side of a metal door.
-your eyelashes freezing shut
-a trail of snotcicles (icicles made of snot) clinging to your upper lip
-a pain, burning, immobility of movement in the fingers which leads you to believe that your fingers are actually freezing. It is not just an expression any more.
-your earphone cord seizing up to a taught, brittle, wire instead of the normally flexible plastic handing loosely by your side.
-tendrils of hair coated by breath moisture turning into wisps of ice hair framing your face, which then melts and plasters to your forehead imediately after stepping indoors.

It's fun. It's something different all the time. Today it is only -37 with the windchill so people are outside snow kiting in the bay to celebrate the chinook like change in weather.

Got to love those hearty northeners, hey?

 

ABB in 2006. Like my mitts?

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I am bringing over more posts from my other blog on the days when there are no politically incorrect professors, no bizarre statements from classmates, and no flashbacks to my emergency department days.