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.

Intimate Insight

I know that these images and this story are making the rounds on social media these days, so my apologies if you're feeling inundated. I felt that these images were too profound and raw and beautiful to pass over.

It is one of the most heart wrenching photo essays I've had the privilege of seeing. I think it shows so poignantly the suffering, strength, love, hope, fear, and anger that features in the struggle with such a devastating diagnosis. To me, these photos express very clearly the questions that we struggle to form when we ask about cancer, and I believe they show the answers to those questions. A few of Angelo Merendino's photos from the website are shown below. In my opinion he is a brilliant photographer, and she a powerful subject.

http://mywifesfightwithbreastcancer.com/

Need Not Apply

This is what it feels like to be an IMG in the medical community:

MAN
WOMAN
HORSE
DOG
CAT
RAT
COCKROACH
LIVER FLUKE
Clostridium difficile 
IMG

I found out this weekend that I am inelegible to apply to the UK for internship.

Is this some kind of sick joke??

Yes, if you are not a UK, Irish or EU citizen then you need to write the PLAB (Professional and Linguistic Assessment Board exam) which ensures you have a basic grasp of the English language and basic clinical medicine. The downer is that I can't write it while still in medical school which means I am not eligible to meet the criteria to apply for internship. Annoying because Irish students don't have to write it, yet...I am going to graduate from an Irish medical school.

I was really getting excited about the prospect of possibly going to the UK if Canada didn't work out, so having another post-graduate door tightly closed in my face really is starting to get to me.

I feel like standing on top of something large and yelling,

"HEY! Will someone just GIVE me a CHANCE?!? 

I am competent and eager and ridiculously excited about medicine!!!"

It is so hard to stay positive and upbeat about things. I am working really, really hard studying for the Canadian exams, working on CaRMS, doing my current school work, applying for more electives...and sometimes I just feel like it is for nothing. It feels like no one will even consider me as a legitimate applicant because I have a big NEON sign that says, 

****WARNING---IMG---WARNING***

over my head. 

Ok. I am done ranting for now. I am letting it go. No sense regretting things from the past and no point worrying about the future. 

My only request is that if you happen to see an IMG walking around your neighborhood you should give them a hug. And tell them not to let The Man get them down.   

One...Week...Left...ughhhhh

Cottage Love

I have been commanded by my friend Ryan to update the blog (so he can get Guns and Roses out of his head). I figure I need to make the few people that still check in on me happy, so here's a quick post!

I am in the final stretch of 3rd year. I spent the last 4 days holed up in a classmate's cottage, attempting to cut myself off from the world and bury myself in the books. Amazing how much more productive I am when the only internet I have access to is an intermittent flickering of 3G on my burner when the planets align.

I had planned to go just for the night but the fireplace and views were too lovely to tear myself away from. So I burned home, picked up the rest of my books (oh, Toronto Notes, you monkey on my back...you) some tinned mackerel, instant coffee, and returned.

A week from today final exams will all be behind me. And two weeks from today I'll be on a plane back to Canada. I am mentally composing my ode to the Irish countryside already. Some questions that will remain...Year three, where did you go?? Did I squeeze every last drop out of my year on the wild west coast?

I Simply Could Not Help Myself

Another Charming Trend in Medicine

"IMG" means "International Medical Graduate". As in, anyone who studied medicine outside of Canada and wants to do post-graduate studies in Canada.

Did I mention there are 45 Canadians in my medical class alone?

Dare I delve into how many of those 6.5% matched to something other than internal or family medicine?

Hello, Ireland. Need a doctor?

Leaving On A Jet Plane

Tobie just dropped me off at the Ottawa airport. I will admit that I feel a little nauseated and quite sad. We're not exactly sure when we'll be seeing each other again but the earliest time is December. This is the first time that heading back to Ireland has been painful. I feel like a little kid about to have a tantrum, at the security gate I wanted to throw everything down and kick for a few minutes.

I enjoyed my summer here so much despite the fact that I spent so much of it in the study hovel. Getting to spend time with my family, dear friends, cherished mountains, favorite grocery stores...it was hard to pack my bags this morning.

Tobie and I are ready to build our lives together...inane things like buying colanders or walking to the store for milk. We're at the nestling and nesting stage and we're facing the reality of 2 years in different countries. We are both trying to be positive but it is going to be a very challenging time.

I'm hoping that the 13 episodes of Parks and Recreation I downloaded keep me from becoming a slobbering mess on the flight to London.

End of An Era

So Thursday marked the end of an era in our lives.

Tobie had his final lesson with his master's supervisor. I am not sure if I am allowed to say who he is, on the blog, so let me just point out that the guy is kinda a big deal in the viola world. And he knows it. And he is very, very demanding and hard on his students. And not in an inspiring Dead Poets Society kind of way but more in a Scarface fear for your life kind of way.

So naturally we had to celebrate Tobie's final lesson, though it was a bittersweet celebration as it also makes us realise that Tobie is getting closer to moving back to Canada, and I am merely getting closer to spending another two years (minimum) here.

But hell, we had the Champagne. And if nothing else, having good Champagne is a reason to celebrate. The last time I tasted those particular bubbles was the night of my MCAT, and oh they were sweet that night as well. I discovered these particular (very hard to find) bottles in Galway a few months back and excitedly bought two, one for Tobie's last lesson and one for my end of exams.


Step one: change into a relaxing suit. If you can't drink fine alcohol together in your pajamas, something is not right.  

Step two: note the not-so-smiling face of Veuve Clicquot. She should have been smiling. After her husband died she took over the business and made it a raging success...and this was in the days when it wasn't proper for women to be involved in man work. Go Veuve Clicquot!!

Step three: pop your first bottle of Champagne off the deck, have your girlfriend catch the moment, by
chance, in the sweetest cork-popping action shot ever.

Step four: find a water glass and the one remaining wine glass that you still own, and get down to business. C'mon, give us a break, we are still students, after all...

Step five: Sláinte! (And spend the rest of the evening trying not think about a final performance that is still looming, or exams, or the fact that you will soon be living very far away from your beloved).

The Dreaded Mini Mental State Exam

For the uninitiated, the Mini Mental State Exam (or MMSE) is a fairly quick way of assessing a patient's cognition.

Academic side: Though it has reasonably high sensitivity and specificity (i.e. low false positives and false negatives) it can be somewhat biased in favor of younger patients with higher levels of education.

Reality side: It is a horrible, annoying, frustrating test for many elderly people. Either they are sharp as a razor and the test is insulting, i.e "tell me where you are, the month, name this object, write me a sentence", or they are mildly demented and get quite upset and befuddled when you ask them to do things like count backwards from 100 in increments of 7.

I thought that there was no way that administering a MMSE could get any more heartbreaking and painful than having to conduct it on someone who had Alzheimer's.

Well today I found out that there is one more thing which is worse: having to watch it conducted by a train of medical students, in front of about 20 people, on a mildly demented patient. Oh, yeah.

It was sad. And I felt so awkward and uncomfortable watching this burly, checkered-shirt-wearing retired farmer trying to scrawl a sentence on his knee.

The session was conducted professionally, I must say, but it still made me think that if it had been my Grandad up there I'd have probably swooped to the front of the class (created a scene) and escorted him out for an afternoon of fishing.

Check. Reality.

If you want the whole story, go to Head Nurse's blog. Read about how a thank you letter to Roger Ebert turned into a tweet from him, which resulted in some very deserving people getting a little help from a lot of strangers.

It is a story of a young man, dying of cancer. He and his wife are trying to patch a living together for his final months on the planet. Because his insurance coverage is now non-existant, they are having to worry about how to pay rent, and how they will cover the cost of his palliative medications (oh, on top of coming to grips with being newlyweds that are now discussing his funeral and how he hopes to spend his remaining days). Inhumane. It is shocking to me, to read this, from citizens of one of the richest countries in the world. The advice they were given: move to Canada.

Well, they can't move to Canada.

But maybe Canada can still help out a little.

I am not an 'internet donation' person but this is legit, and these folks could certainly use a little help.

Kicked in the Face

This morning we got report about a woman who was in the trauma bay waiting to be sutured by the doctor of the day. She had come in during the night, a head injury with two facial lacerations. There was alcohol on board so she had no recollection of how she had received said injuries. She denied that it was her husband that had inflicted them. He was at the bedside, in faded blue jeans and a thick black sweatshirt. When I walked by I saw that he was holding her hand through the siderails of the stretcher.

I had a brief glimpse at half of her face as I proceeded into the ICU to say good morning to my cardiac patient. What I saw momentarily jarred me. Her head looked deformed from the swelling. I didn't want to stare but it seemed her skull was double the size it ought to be. Jagged streaks of dried blood still criss-crossed her face. I heard howling coming from the room later as she was being frozen for her sutures. I tried to block the sound out.

I busied myself with my ICU patient and then went back out to the floor to bring in emergency patients.

I went into her room to start a saline lock in order to give her some I.V antibiotics. The sutures were perfectly aligned and identical. A vertical line of knots traversed her face in two places, each about 8-10cm long. Her eyes were nearly swollen shut. Her mouth looked almost like a snarl due to the swollen, abnormal position of her lips. Her nose was broken, but not displaced. Sadly, I doubt it was the first time.

I asked her how she had received the wounds to her face. She said she'd been at a party and had gotten into a fight with some people. I asked if it was fists that had cut open her face. She said, "no, their boots".

I remember the first domestic abuse patient I had as a shiny new grad working in the emergency department. She came in because she was having a hard time breathing. Her story was that she had fallen down a flight of stairs. There was a perfect imprint of a boot tread on her neck, starting to turn bluish-purple.

A boot tread.

That image haunted me for years, though time caused it to fade into the background. I had forgotten that woman until today.

I worry a little about the shell I have developed in the past 7 years. Back then, the image would have been right behind my eyelids every time I closed them for a couple of weeks. This time, I felt a pang of sadness and despair for the patient, but was able to carry on my day without much more thought.

When I scrubbed away in the shower tonight I wondered how I had gotten so callous. The irony is I devote myself to this work because I believe that health care is a way to make a positive impact on humanity. Yet somehow it seems that through the years I've lost some of mine along the way.

World Without Tears

Some songs just nail it.

When I hear this song I see so many faces and broken bodies from the emergency department float in front of my eyes.

Still gives me goosebumps.

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.

Tough Day At the Storage Locker

Of course it was drizzling a bit this morning and cold. I was making trips back and forth to the storage locker all day, moving my things into AMG and Ryan's basement to get the goods on display for the "binge and purge" party.

Going through all of my boxes with a ruthless "am I going to want this in 10 years?" attitude was what kept the "for sale" piles much much more plentiful than the "going into storage in my mom's basement" pile. But every box I opened flooded so many memories back to me, from my stemless wine glasses to my flour crusted cook books to my tattered pink feather boa. I remembered what road trip I bought those engraved glasses on, what gig I wore that skirt for, what used bookstore I bought that Timothy Findley book in. Every piece has a story, a little part of my history, a little part of my life.

It was a tough day. There were a few times when I couldn't help the tears that welled up in my eyes as I stared at a handmade mug or a handful of arctic cotton that I had carefully wrapped up from Baffin Island. I couldn't help but wonder what I was doing, getting rid of all these little treasures. But the truth is, I'll be gone for at least the next 4 years and likely a residency in the US (which tacks on another 3-5 after that). And I know, it's only stuff, but it has taken me years to acquire and attain these things, some of them from many different corners of the world.

Soon my friends were stopping by and putting their bids on my various belongings. The buzz of activity jerked me out of my 'how sorry for myself can I feel as I get ready to embark on the adventure I've been hoping for for so long' reverie.

It ended up being quite the evening. Verena just kept saying "This is so weird! You're getting rid of all of your things! This is sooo weird!"

Small bidding wars have started over things like my retro dressers and Ikea lamps. Tomorrow we'll finish up the not-so-silent auction and I'll take whatever doesn't go to the second hand store, the bookstore, and the dump. The nostalgic bits are heading back to the storage locker and then to mom's basement (again).

AMG's contractions are now 1 minute apart and they are off to the hospital.

New beginnings all around.

Lucky

I remember reading some Gary Zukav book years ago when I was in India. I was staying in this dingy 3$ per night hotel in Bangalore which had cockroaches crawling up through the sink and a single metal fan on the ceiling that rotated at a speed just fast enough to create noise but no breeze. I got to this section in the book where he said,

"If you had three minutes left to live who would you call? What would you say? And why aren't you on the phone right now?"

I know, it is nothing that profound at first glance perhaps. But I remember racing down the stairs and out into the dusty streets, finding an "STD" Booth (as they are called) and tracking my mother down for a strange, random, out-of-the-blue profession of admiration, love, and gratitude.

Working in the ED one gets reminded (too often sometimes) that many people never get to have those conversations before they unexpectedly leave this earth.

And so, that quote haunts me still from time to time. Who would I call today? And what would I say? What words are unspoken?

I am grateful for the phone calls and emails I've received lately regarding Jody, and grateful also for the conversations her death has inspired.

Today was Jody's funeral and thankfully the emotions and expressions were not too little, too late. Jody knew how much she was loved and respected, and in turn she made sure we knew the same.

It made today truly a celebration of her life, and not merely a declaration of our loss. I doesn't make her any less missed, but it does make all of this just slightly easier to bear.

Goodbye Beautiful Friend

Todd told me that Jody might not make it through the night. The indolent DIC had caused her to have multiple pulmonary emboli and her respirations had become labored, O2 sats dropping to the 40-60% range. I found this out in the back of an ambulance as I was returning from a spiral femur fracture transfer.

Earlier, I had received a message from my ED asking me to go on the transfer. I had no time to listen to the other 2 voicemails as I raced home from hot yoga, showered, changed, and headed back to the ED for the trip. It wasn’t until 4h later that I finally listened to the remaining messages and heard the one from Todd.

Too late to catch the last ferry to the island I went home and packed. I caught a few fitful hours of sleep, got up at 4am and drove to catch the first ferry of the morning. The whole time I prayed my phone wouldn’t ring with another call from Todd.

Jody was diagnosed in October 2007 with breast, lung, brain, and retinal cancer. She had just turned 39. In the ensuing months it spread throughout her bones and internal organs but she kept her sharp wit and smile. She somehow continued to glow even as the cancer raged inside her. She’d turn to you and say, “Look at me! Look at my skin! Does this look like the skin of someone who has the cancer?” And you couldn’t deny it--she was gorgeous.

When she was raising money for lung cancer research she told me—“lung cancer is the dirty cancer. There is much less funding and fund raising for lung cancer because society thinks it is only deserving smokers that get it. Well, it isn’t.” It made me take a look at my own buried biases about obesity and heart disease, diabetes, and yeah…cancer. She never smoked a day in her life, was athletic, and a veritable fireball of positive energy. She didn’t do anything to deserve this, but really—does anyone? I am still unable to stifle a bolt of anger when I see a 60 year old obese chain smoker and think—Jody will never get to that age.

In this world you will come upon a select few people who have a spark, a light in their eyes. People who draw you into their orbit simply because they take such joy in the dance of life. Jody was one of those people. I have always been in awe of her ability to act on, seek out, and attain all of the experiences she wanted to have in this life.

Our first night shift together in the ED I knew she was my kind of woman when she told me she was learning to grapple—and was the only female in her class. Soon there were two females and our friendship grew from there.

I was able to make it back to the island on time and even had one last visit with Jody before she slipped into unconsciousness. Her breathing became wet and ragged. Several of us gathered around her with Champagne and cake, telling stories and laughing about our many adventures in Jody-land. We took turns holding her hand and rubbing her back as she continued to work to breathe.

One of the hospice nurses, Christina, set up a bed for me on a fold down chair in a common room and I curled up for some sleep after we had arranged Jody so that she and Todd could fit in the bed together. I dreamed of Madeline, my mentor and beloved nursing instructor who taught me so much about grieving and death.

Around 7 am this morning Jody took her last breath in Todd's arms as he wished her peace and love. Her nurse came and introduced herself to me as Madeline. I shook my head at the coincidence.

Jody's wedding ring from Todd depicted the symbol of the Hummingbird totem, a Haida symbol often associated with marriage. I found this excellent summary of Hummingbird symbolism, the words describe Jody with shiver-inspiring accuracy...

When we assume hummingbird consciousness, our life becomes a wonderland of sensuous delights. We live for beauty, delighting in flowers, aromas, fine mist, and delicate tastes.

When it becomes our totem, the hummingbird teaches us to laugh and enjoy the creation, to appreciate the magic of being alive, and the truth of beauty.

Hummingbirds awaken us to the beauty of the present moment. As they dance the four quarters of embodied existence, they bring us medicine to solve the riddle of duality....

Hummingbirds teach us fierce independence. They teach us to fight in a way where no one really gets hurt. They teach us simple courage....

In hospice, the tradition is to open the window when someone dies--this allows the spirit to fly free. Then someone will travel upstairs to the garden on the roof and ring the bell to notify the spirit world that a new arrival is on the way.

When Todd went upstairs to ring the bell a hummingbird appeared on the roof. He marveled at the birds proximity. As Randi and I joined him on the roof we hugged and cried for a few moments before we noticed the bird had returned and hovered close by, it's tiny wings a blur. The delicate creature stayed near and we couldn't help but feel a sense of wonder and reassurance.

Jody is free now, and though we are sad she only was a part of this earth for a short time, we rejoice that we were among the lucky ones who got to share it with her.

...Only when you drink from the river of silence shall you indeed sing.
And when you have reached the mountain top, then you shall begin to climb.
And when the earth shall claim your limbs, then shall you truly dance...

Kahlil Gibran

Props to Pops

This Friday marks the anniversary of my dad's death in 2002. For me this year will be a bit sadder than most. My dad would have been over the moon had he been alive to see me start medical school. Many of the folks on his side of the family never even completed high school let alone university.

I had a few random things in a bag I brought with me from storage when I last moved. And I mean random...plunger for French press, old camera, greeting cards, mesh bag, mail, incense... and as I sorted though--a photo of my dad and I on his ride-a-mower when I was about 4 emerged. This photo floated out of my stack of paperwork and landed on the table. I had completely forgotten about it-- most of my photos are in storage about 900kms away.

I stared at it for a while then tacked it up on my fridge. I realised that his death day is tomorrow and that he died not knowing I'd reach my goal of medical school. Hadn't pieced that reality together yet. After losing a parent it seems all victories become somewhat bittersweet because that tender spot inevitably gets reactivated with each triumph. Our parents are the only people in the world that genuinely care when we succeed or when we fail. Our accomplishments to them are uncomplicated in ways that cannot be with a spouse or friends.

Many people say to me "oh, your father knows what you are up to" but honestly, I don't know if I believe that. I think (if there is an afterlife) it will be so unimaginably wonderful that our souls will be preoccupied with much more important things than hanging around earth to see if our living offspring become doctors or not. I know my father was very proud of who I was even when I was just a punk-assed 22 year old. I think a part of my wishing he were around to see me off in May stems from my desire to show him "See dad! You and mom done good!" Giving me the chance to say thank you for eating my watery scrambled eggs, letting me put rollers in your hair, and tolerating the boyfriends who wore trench coats.

It all worked out in the end Dad.

Thank you.

I hope you're riding some cosmic wave or fishing off a plentiful dock with Cubby right now.

I Was There, In the Room

I was just having a conversation with a friend of mine a few days ago about when people cry out in true anguish, and how those cries remain carved into your memory.

I told her of the two cases which still make me shiver when I think of them.

The first was a 43 year old woman who miscarried 14 week old twins in the department. Her absolute desolation was heart wrenching as she sobbed and cried out for her babies, apologizing to her husband, and uttering, "this was my last chance..." It was enough to move several of the staff to tears that night. I can close my eyes, and I am standing in the hall between the patient bathroom and the gyne room. A small basin is in my hands, and there are two baby boys in it.

The second case which comes to me often, was a 13 year old girl who jumped out of her second story window to sneak out to a party. She landed on her back, crushing her lumbar spine. I knew it was bad when I looked in the report room where the MD's pull up imaging results. I saw the ER doc sitting with his head in his hands. He got up and walked into the patients room, and a few minutes later the scream of despair at her diagnosis of paralysis echoed through the department. For hours she screamed and screamed, "NOOOOOOOOOOO!"

I can still feel myself standing behind that nursing station desk, the desk lamp shining on the charts beneath it, the overhead lights dimmed. My heart pounding.

I know that last night will be one of those nights now too. One that will stay with me a long, long, while.

4 teens were in a car which lost control and rolled over down a rocky embankment. The front seat occupants were both killed and the two back seat occupants were brought into the department. Both were in mild shock but physically stable. While we waited for the urine test to come back on my patient I sat and talked with her. A gorgeous girl with long curly hair down to her waist, mascara lining the contours of her face. She kept telling me she was fine and wanted to know how her friends were doing. She'd start crying softly and apologize to me for doing so. She told me the driver was her best friend, that she tried to wake her up at the scene but couldn't. "Please try to find something out about her, why isn't she here? Can I see her?"

I'd been told that her friends were waiting outside and that they didn't want her to know until she was sent home. Her urine came back clear and she was discharged. I walked with her out to the parking lot just as the parents of one of the surviving friends showed up. The night air has a chill to it now and soon we were both shivering as we walked out to the cluster, she asked me, "is she out here?" Her friends put their arms around her. I walked back into the department to grab her a blanket. Just as the ambulance bay doors swooshed closed behind me I heard her cry out "NOOOOO!!! YOU HAVE GOT TO BE KIDDING! YOU'RE LYING!!!! LYINGGGGGG!!!"

I came back out and she was being supported but her friends, she was wretching, crying, knees buckling. Her white shorts and legs were spattered with blood and on her feet the blue OR booties I'd given her. We gathered around, tried our best to support her.

After some time myself and the other nurse returned inside. I went into the staff lounge and fell asleep. I know that sounds harsh but I was running on 4 hours of sleep and the high emotional intensity of the night had sucked the remaining drops of energy from my bones.

After my break I returned to a quiet department. When the shift was over I felt the beginnings of my cold getting worse and exhaustion seeping in. Stepping outside the sun and seeing the rising mist at the bases of the mountains, I was reminded that there were things to be celebrated, and things to be grateful for. I drove out of the city limits, pulled my bike out of the back of my car. I went for a long road ride to think about the evenings events, how the feelings were going to be shaped in my memory.

My job, which can be horrible (yesterday's post), can turn around on a dime and suddenly become a high honor. When Eve Ensler writes about birth she starts with a line, "I was there in the room..."

For birth, and death, and everything in between...we are there...in the room. And that is why, I love this work.