The one patient, my favourite patient said to me, "Thank you, really, thank you -you doctors, you really saved my life!" and smiled with a twinkle in his eye. And then I was back in the ER, excited to do my second blood gas and boom, within 20 minutes, that other patient went from clutching my hand to dead -without warning, without family, without anyone to hold his hand. Just like that. And then there was jazz playing inside the window and cold drinks melting on the patio table, and the deep sigh. Prayers today. I nearly cried, I felt so sad and I didn't know why. It's warm, the air still fragrant with spring before the theoretical lazy bliss of summer. All of this impacted and compacted into a splinter of time, a moment's hair, the poo of the invisible speck that we are in this Universe. It's kind of unreal.
Days like today make you want to retire from it all. Friends moving away from their own cities, not even your own, and yet, you feel sad as though they were leaving you. Patients dying and you feel so shocked, when you know that this is part of your job -people die, just deal with it. But they were in pain, and they were sick and oh, they suffered like hell before the end. And you feel like the fact that it happened that way is like a violation of your own soul. And tonight the deep sigh doesn't reassure you, nor the deliciousness of your dinner. Because all you want is the embrace, the caress, the hand holding yours, someone telling you that it's going to be okay. So that you can still tell your patients the same, without feeling like it's all a lie. But that's the thing. Doctors hold patients' hands... who holds the doctor's hand?
Sunday, June 19, 2011
Sunday, June 12, 2011
Stories from the 'House of God' and Spring's Aphrodite
The confession is that I have never actually read that book. But it's been talked up quite a bit this first month of Internal Medicine. And my sense it that it's probably an apt title for this entry.
It's been a while. That's the nature of Internal Medicine and sweet, fragrant spring days -either slaving, studying or trying to live a little. It can actually be enough to throw you totally off balance sometimes.
My first month was on hematology-oncology wards and I got lucky: best senior residents I've ever had, amazing attending staff who loved to teach, told interesting, funny stories of their own experiences as medical students and residents, sharing their wealth of knowledge and experience, and yes, in the spirit of excellence and love. My patients provided me with challenges, new perspectives, nearly drowned me in the mud of the unfortunate circumstances that were their lives, and once in a while, inspired me with the blessings from their souls. All of them taught me something invaluable. That someone else's mistake would be mine too if I didn't catch it -that although it may take at least 3 levels of error to actually reach a patient, the ultimate responsibility rested with us, the physicians. But that when we find those errors, acknowledge them and apologize, and then try to find solutions, we're helping future physicians, pharmacists, nurses... evolving a system that can better benefit our patients.
I learned that your favourite patient (ah, yes, I will certainly admit to having favourites -they are the ones that keep you going through a possibly otherwise miserable, chaotic day), the one who was doing so well, the one who was meant to go home tomorrow, in the flash of a few moments, can go from stable and smiling to vomiting blood, crashing blood pressure and O2 sat and being rushed to the ICU. All the while, you watch in awe as your beloved seniors, calmly order units of packed red cells, bolus fluids and load him up with pressors before the transfer. But you, you are just frozen. And then you look back at the extremely slowly trending down hemoglobin, the slightly increased BUN that afternoon and think to yourself, "I should have known". But your senior kindly points it out "Okay, let's say you saw it coming. What would you have done?" To which my response was, "Call GI" and which he quickly finished, "and maybe they would have scoped him tomorrow [because until that sudden episode of hematemesis, he was stable -it was not an apparent emergency]" So it wouldn't have made a difference. But still. It scared the crap out of me. Massive GI bleed, requiring over 12 units of blood in 24 hours. One of my happiest moments was when that patient came back to the ward from the ICU. And he was smiling and joking and squirming antsy-ly in his hospital bed, in a grey sweatsuit, anticipating a nice lunch of spanakopita at home.
And for some patients it goes from pretty darn awful, to worse... and no one deserves that kind of hell. Imagine living with poorly controlled schizoaffective disorder, along with at least 7 other serious medical conditions. You come into the hospital with medication toxicity and new pulmonary embolus. And you leave with f-ing cancer. And now imagine being the spouse of that patient. Yes no wonder they're a bit of a grouch. Yet, it's so hard for a medical student to deal with that chronically grumpy, angry, accusing spouse in addition to our clinical responsibilities and trying to learn around our cases and get it all done efficiently. You kind of feel like you're helping nobody and maybe they even hate you, but you learn not to take it personally. Then one day your attending staff comes to you and says, "You wanna call back patient X's husband? I talked to him earlier and he said he only wanted to talk with you" What? Has the world gone mad. And you call back and he's still Grumpy McGrumpster. But he asked for you.
And there's the vibrant, smiling, rosy-cheeked woman with multiple myeloma (a kind of bone marrow / blood cancer) who lights up every morning when you round, and tells you every day that you'll be a wonderful doctor someday, and thanks you for doing your best for her everyday. Her platelets are dropping everyday and then it's time to transfuse her. And she is in tears, and her eyes are filled with fear. This is how her beloved started their downward spiral into the grave... all she can remember was the many transfusions. You explain to her that we expected this though. That this one transfusion does not mean she's going to die too. And you sit there and hold her hand and then, she's smiling again. You have her blessing too, but only because you were blessed enough to know to listen, to know to explain.
At the end of that first month, I admitted an older woman in her 90s. She was basically palliative, with multiple comorbidities, not the least of which was an Aortic Stenosis with an ASA of 3 mm (basically a 3mm diameter through which the heart was meant to pump blood to the whole rest of the body)... 4 years ago (which means, even smaller now). She couldn't talk, she could hardly breathe, she was in pain. She had no family, no friends. She was a Level 3 -no Code. We gave her oxygen, we managed her pain. I would check in on her every morning. And then on my last Friday on the wards, as usual, I couldn't understand a muffled word she uttered. Then distinctly made out her plea: "stay". So I pulled up a chair, took her frail hand in mine, "I'm here now, you rest". The struggle abated, her breathing slowed, her facial muscles relaxed and she held my hand firmly. It reminded me of when I held my grandmother's hand right before the end. That evening at sign-out, the new attending on the wards said, "Oh for goodness sakes, there's nothing really we can do for this patient. What she really needs is someone to sit by her and hold her hand." To which I responded gently, "Yes, I did that for a bit earlier today". "Well, good for you for taking the time to be a human being". She passed away the following morning.
I'm now one week into my second month of Internal medicine and well, let's say the blinders are off. The idealism... has metamorphosed into a compassionate realism. This world is both the filthy garbage dump and the rose garden. And medicine is no different. It's about what we choose to focus on once the sun has set, the moon has risen and we're collapsing into bed. Those fleeting pre-dream thoughts.
Believe it or not though, through the frenzy and chaos, we still make time for a little romance. Walks through pot-holed sidewalks and cobblestone streets, kisses in the park, those fabulous kinds of conversations with the eternal tangent, new flavours in sizzling bowls, or sweet mapley desserts melting in your mouth amidst brightly coloured flowers and live jazz. Or learning a new board game, discovering a funny TV show. Or the beauty of the still, in calm, soothing, comfortable company. Life blesses us with those joyous, carefree moments too.
Whether it's the dark black waters of a bottomless ocean, or the golden shimmer or sunlight hitting petals and leaves in the garden, for such adventure and all these opportunites to learn, grow and share my joy, yes, I am so grateful.
It's been a while. That's the nature of Internal Medicine and sweet, fragrant spring days -either slaving, studying or trying to live a little. It can actually be enough to throw you totally off balance sometimes.
My first month was on hematology-oncology wards and I got lucky: best senior residents I've ever had, amazing attending staff who loved to teach, told interesting, funny stories of their own experiences as medical students and residents, sharing their wealth of knowledge and experience, and yes, in the spirit of excellence and love. My patients provided me with challenges, new perspectives, nearly drowned me in the mud of the unfortunate circumstances that were their lives, and once in a while, inspired me with the blessings from their souls. All of them taught me something invaluable. That someone else's mistake would be mine too if I didn't catch it -that although it may take at least 3 levels of error to actually reach a patient, the ultimate responsibility rested with us, the physicians. But that when we find those errors, acknowledge them and apologize, and then try to find solutions, we're helping future physicians, pharmacists, nurses... evolving a system that can better benefit our patients.
I learned that your favourite patient (ah, yes, I will certainly admit to having favourites -they are the ones that keep you going through a possibly otherwise miserable, chaotic day), the one who was doing so well, the one who was meant to go home tomorrow, in the flash of a few moments, can go from stable and smiling to vomiting blood, crashing blood pressure and O2 sat and being rushed to the ICU. All the while, you watch in awe as your beloved seniors, calmly order units of packed red cells, bolus fluids and load him up with pressors before the transfer. But you, you are just frozen. And then you look back at the extremely slowly trending down hemoglobin, the slightly increased BUN that afternoon and think to yourself, "I should have known". But your senior kindly points it out "Okay, let's say you saw it coming. What would you have done?" To which my response was, "Call GI" and which he quickly finished, "and maybe they would have scoped him tomorrow [because until that sudden episode of hematemesis, he was stable -it was not an apparent emergency]" So it wouldn't have made a difference. But still. It scared the crap out of me. Massive GI bleed, requiring over 12 units of blood in 24 hours. One of my happiest moments was when that patient came back to the ward from the ICU. And he was smiling and joking and squirming antsy-ly in his hospital bed, in a grey sweatsuit, anticipating a nice lunch of spanakopita at home.
And for some patients it goes from pretty darn awful, to worse... and no one deserves that kind of hell. Imagine living with poorly controlled schizoaffective disorder, along with at least 7 other serious medical conditions. You come into the hospital with medication toxicity and new pulmonary embolus. And you leave with f-ing cancer. And now imagine being the spouse of that patient. Yes no wonder they're a bit of a grouch. Yet, it's so hard for a medical student to deal with that chronically grumpy, angry, accusing spouse in addition to our clinical responsibilities and trying to learn around our cases and get it all done efficiently. You kind of feel like you're helping nobody and maybe they even hate you, but you learn not to take it personally. Then one day your attending staff comes to you and says, "You wanna call back patient X's husband? I talked to him earlier and he said he only wanted to talk with you" What? Has the world gone mad. And you call back and he's still Grumpy McGrumpster. But he asked for you.
And there's the vibrant, smiling, rosy-cheeked woman with multiple myeloma (a kind of bone marrow / blood cancer) who lights up every morning when you round, and tells you every day that you'll be a wonderful doctor someday, and thanks you for doing your best for her everyday. Her platelets are dropping everyday and then it's time to transfuse her. And she is in tears, and her eyes are filled with fear. This is how her beloved started their downward spiral into the grave... all she can remember was the many transfusions. You explain to her that we expected this though. That this one transfusion does not mean she's going to die too. And you sit there and hold her hand and then, she's smiling again. You have her blessing too, but only because you were blessed enough to know to listen, to know to explain.
At the end of that first month, I admitted an older woman in her 90s. She was basically palliative, with multiple comorbidities, not the least of which was an Aortic Stenosis with an ASA of 3 mm (basically a 3mm diameter through which the heart was meant to pump blood to the whole rest of the body)... 4 years ago (which means, even smaller now). She couldn't talk, she could hardly breathe, she was in pain. She had no family, no friends. She was a Level 3 -no Code. We gave her oxygen, we managed her pain. I would check in on her every morning. And then on my last Friday on the wards, as usual, I couldn't understand a muffled word she uttered. Then distinctly made out her plea: "stay". So I pulled up a chair, took her frail hand in mine, "I'm here now, you rest". The struggle abated, her breathing slowed, her facial muscles relaxed and she held my hand firmly. It reminded me of when I held my grandmother's hand right before the end. That evening at sign-out, the new attending on the wards said, "Oh for goodness sakes, there's nothing really we can do for this patient. What she really needs is someone to sit by her and hold her hand." To which I responded gently, "Yes, I did that for a bit earlier today". "Well, good for you for taking the time to be a human being". She passed away the following morning.
I'm now one week into my second month of Internal medicine and well, let's say the blinders are off. The idealism... has metamorphosed into a compassionate realism. This world is both the filthy garbage dump and the rose garden. And medicine is no different. It's about what we choose to focus on once the sun has set, the moon has risen and we're collapsing into bed. Those fleeting pre-dream thoughts.
Believe it or not though, through the frenzy and chaos, we still make time for a little romance. Walks through pot-holed sidewalks and cobblestone streets, kisses in the park, those fabulous kinds of conversations with the eternal tangent, new flavours in sizzling bowls, or sweet mapley desserts melting in your mouth amidst brightly coloured flowers and live jazz. Or learning a new board game, discovering a funny TV show. Or the beauty of the still, in calm, soothing, comfortable company. Life blesses us with those joyous, carefree moments too.
Whether it's the dark black waters of a bottomless ocean, or the golden shimmer or sunlight hitting petals and leaves in the garden, for such adventure and all these opportunites to learn, grow and share my joy, yes, I am so grateful.
Tuesday, May 17, 2011
Finding Magic
I miss Nova Scotia so much. Yes, I'm actually pining. Did I tell you I even cried on the airplane on the way back home? I still listen to my pretty fiddle music and get all nostalgic. But it's comforting too and I feel like everything will be okay. I was watching a short bit of movie with my mother this evening and one of the lines really jumped out at me: "Stop looking for obstacles instead of looking for magic".
Isn't that what we do when we feel vulnerable or scared or like we don't have control? Look for obstacles right? Why: because it's easier to identify a problem and then try to fix it as opposed to just riding the Atlantic wave, lest you get crashed up against some jagged rocks hidden (and sometimes not so hidden!) amidst the soft, white sand. But the magic was never about where the current brought you, it was always about the cool, refreshing majesty of blue blue sea (I know, I just changed my metaphor... my best memories of riding waves for hours at a time are in the Mediterranean), around, behind, in front and under you, lifting you up to the pale sky, alight with golden rays, for moments at a time. It's the high. And magically, every high is not followed by blood, scrapes and bruises (however, as a future surgeon, I will gladly sew those up for you!). You don't have to land in sand or split your skin on the rocks. If you flow with the waves, when the one ebbs, the next will cradle you back up -it's the perpetual high, the ever-lasting wet kiss of that crystalline liquid that gives us life at all. And when it's time to rest, we can wash up on shore with the surf -calm, relaxed, composed, radiant with exhilaration and joy. Magic, right.
It's like that with medicine. It's like that with love. It's like that with so many, many things. And the Truth of it gives me goosebumps from head to toe. Letting go is a choice, it's wilful surrender -a gain, a blessing... not a loss, not anything to be feared. Sometimes pretending that not feeling anything is easier or better than feeling so profoundly that your soul may shatter through your broken heart. But by shattering your soul, so many more will know you, and so many more will you touch with your love. I suppose that's where God resides.
I'm just over a week into my Internal Medicine rotation, and thanks to my refreshing Nova Scotian happy-place-in-my-soul, I've actually been able to appreciate, learn and even enjoy parts of it. I have a great team, and a few lovely patients, and there is a wealth of knowledge to be imbibed! Challenging, tiring (and okay, not as cool as surgical things) but so much better than I could have ever imagined! And I finally did my first ABG (arterial blood gas) and I got it on the very first try -it was the best part of my week!
Well, back to my work. Let the magic continue!
Isn't that what we do when we feel vulnerable or scared or like we don't have control? Look for obstacles right? Why: because it's easier to identify a problem and then try to fix it as opposed to just riding the Atlantic wave, lest you get crashed up against some jagged rocks hidden (and sometimes not so hidden!) amidst the soft, white sand. But the magic was never about where the current brought you, it was always about the cool, refreshing majesty of blue blue sea (I know, I just changed my metaphor... my best memories of riding waves for hours at a time are in the Mediterranean), around, behind, in front and under you, lifting you up to the pale sky, alight with golden rays, for moments at a time. It's the high. And magically, every high is not followed by blood, scrapes and bruises (however, as a future surgeon, I will gladly sew those up for you!). You don't have to land in sand or split your skin on the rocks. If you flow with the waves, when the one ebbs, the next will cradle you back up -it's the perpetual high, the ever-lasting wet kiss of that crystalline liquid that gives us life at all. And when it's time to rest, we can wash up on shore with the surf -calm, relaxed, composed, radiant with exhilaration and joy. Magic, right.
It's like that with medicine. It's like that with love. It's like that with so many, many things. And the Truth of it gives me goosebumps from head to toe. Letting go is a choice, it's wilful surrender -a gain, a blessing... not a loss, not anything to be feared. Sometimes pretending that not feeling anything is easier or better than feeling so profoundly that your soul may shatter through your broken heart. But by shattering your soul, so many more will know you, and so many more will you touch with your love. I suppose that's where God resides.
I'm just over a week into my Internal Medicine rotation, and thanks to my refreshing Nova Scotian happy-place-in-my-soul, I've actually been able to appreciate, learn and even enjoy parts of it. I have a great team, and a few lovely patients, and there is a wealth of knowledge to be imbibed! Challenging, tiring (and okay, not as cool as surgical things) but so much better than I could have ever imagined! And I finally did my first ABG (arterial blood gas) and I got it on the very first try -it was the best part of my week!
Well, back to my work. Let the magic continue!
Tuesday, May 3, 2011
Nova Scotian Fiddle!
I'm obsessed. But I found some youtube links of the music i've been playing over and over ever since I acquired it here, and thought you might enjoy a little taste!
Anna Ludlow:
http://www.youtube.com/watch?v=I87h4Hqgj8A&feature=related
http://www.youtube.com/watch?v=xhY4hAxZjFs&feature=related
http://www.youtube.com/watch?v=dotzGF_9-Sc
reel-love,
me=)
Anna Ludlow:
http://www.youtube.com/watch?v=I87h4Hqgj8A&feature=related
http://www.youtube.com/watch?v=xhY4hAxZjFs&feature=related
http://www.youtube.com/watch?v=dotzGF_9-Sc
reel-love,
me=)
Friday, April 29, 2011
Little-Girl Fairytales to Loving Reels
I've already begun to tell you about my sweet, slow, inspired romance with the Maritimes. Like falling in love though, completely drunk and high with passion -grand flames bursting and snapping about with enlightened joy, yet a slow glowing smolder beneath, comfortingly reassuring that this love won't die.
Perhaps today, we're all entitled to a little princess-love fantasy, in celebration of the marriage of the lovely Kate Middleton to Prince William, now Duke and Duchess of Cambridge. That stunning wedding gown of creamy lace and satin, those stolen glances, shy smiles, balcony kisses and general merriment... it's our collective little-girl fairytale! And it was beautiful, the sentiment simple and good -to have happiness aired all day long in the news, on the net, in papers, on the radio -just for a moment to share in that dream, and suspend some of the more complicated challenges of our various realities. So in this spirit, I share with you, my love for this East Coast province.
Today was a glowing, glorious day for me in medicine -small joys make it all wonderful: all by myself, I locally anesthetized, excised a skin nevus (or "mole") and sutured lovingly, delicately and with undivided attention a woman's inner thigh. Time flew as I practiced the artful technique of my supervisor, under his supervision, earning his praise, the patient's praise and my own satisfaction. I will be a surgeon. Hopefully an obstetrician, but certainly a surgeon of sorts. Today made it so obvious to me, I had to laugh that I ever thought I could ever be anything else!
Earlier this week, on the afternoon I had off, I was treated to the experience of the stunning, understated beauty of Nova Scotia's South Shore, visiting Bridgewater, Lunenberg and Mahone Bay. Listening to Celtic reels (Nova Scotian though) and other Canadian musical artists to get us into the free, local spirit, driving along a mesmerizing coastline, the sun gradually peeping through the clouds, finally breaking and bathing the Atlantic waters in that infinity sky-blue, brightly coloured little cottages and fishermen's homes (and sometimes mansions -who said fishermen were poor ;), docks, churches, friendly, smiling faces, little shops, golf courses, lighthouses and harbours (including the home of the Bluenose -the large sailboat on the back of the Canadian dime... though it wasn't there yet, so we settled for the Caledonia). 
We passed little brooks and streams, pebbled streets called "Kissing Bridge Rd", smiling faces, and inhaled big wafts of salty sea air filled with the promise of summery days, tourists and ice cream. We had a scrumptuous lunch of homemade fishburgers, chips and Nanaimo bars at Lahave Bakery, amidst old newspaper clippings, wood-cottage-like warmth, British and communist flags, hanging guitars and corners filled with old books. The day ended with a visit to Greenfield -and the most serene cottage on one of the two lakes, cozily nestled in a forest of fragrant pine, birch and soon-to-bud leafy trees. I was recounted stories of community wide feasts of planked salmon over large fires, and starry nights over the lake, family time and love -a little Maritime Eden. 
Then after my final 24-hour call, instead of taking the usual post-call day of rest after a night of 3.5 hours of sleep, I spent the day gallavanting about Halifax. Starting bright and early with the Maritime Museum of the Atlantic -nothing like a healthy dose of history, monuments, anecdotes, tales of sinking ships, treasure hunters, privateers, Canadian naval stories, hundreds of ship and sailboat models, real artifacts from the Titanic, lighthouse magnifying glass, old paintings, film clips and diary entries of the 1917 Halifax Explosion to provide a little context, to this captivating, unique and beautiful province and region. This was followed by a delightful lunch at McKelvie's: seafood chowder, fresh lobster roll, rasberry zinger mocktail and mini-carrot cake dessert, topped with lemon cream, burnt coconut shavings and a chocolate drizzle -at long last, a "very Maritime", seafood experience! 
I really got walking after that, unfazed by the rain, determined to make the most of my one day in the Maritime capital -truly felt like a cross between Ottawa and Quebec city -small city town, lots of character, right on the coast (a harbour town indeed... or as my father used to call it, "a sailor town", though less so now than 20 years ago, probably!), plenty of university students wandering or rushing about, buses and cars milled about in traffic, but only on the few 'main roads', with a downtown core only a few blocks long by a few blocks wide. Still, distinctly a city, albeit not a typical one. Dinner theatre, musical theatre, banks, high rises, restaurants, bars and pubs, a few Starbucks, local cafe franchises, eccentric little shops, parks, statues and monuments, residential streets with those typical, brightly coloured, gabled Maritime homes -prettier areas and less pretty areas. Overall, entirely endearing. Walking along Barrington St and up Spring Garden, I began with a visit to the IWK children's and women's hospital, one of the Dalhousie teaching sites, skirting past the main Dalhousie campus... the same university that graduated many a bright Canadian scientist, lawyer, doctor... including the late CD Howe, the politician responsible for the funding of the Avro Arrow project. 
Then a lovely stroll through the Public Gardens -one of Canada's oldest and probably prettiest Victorian-style gardens, with little man-made ponds, picture-book walking bridges, ducks, Renaissance-style, goddess-like statues, gazebos, gardens-yet-to-be-flower-filled, magnolias already abloom with young blossoms, people young and old, taking rest on the park benches, or jogging along the trails, and a beautiful empty stage, with rows of empty benches below (perhaps for summer performances of opera or theatre or fiddle-playing? I'll bet this is wedding-central in the summer!). I made my way up to the Citadel, full of history and great views of the coast and the city from above, walking along the top of high stone walls, old canons with some kind of army training happening down below. Meandered my way back to where I started, popping into Starbucks to juice up my phone, over a long-craved green tea soy latte, and into strange little shops full of imported Indian jewlery and knick-knacks, or tarot cards, scented candles, rocks and Celtic folk books, or the most fantastic used book store I've seen in a while, where I purchased a second hand copy of Robertson Davies "Tempest Lost" and some other book on the peaceful coexistence of diverse religious groups in medieval Spain. Quickly flitted into the gift shop of the art museum to pick up some stationary (I'm such a sucker for stationary and the most beautiful and interesting ones always come from museum gift shops! would have liked to see the actual museum, but it was closing in 10 minutes!)... and then a lazy drive back. We came home after eating a decadent serving of "garlic fingers" -like pizza, but garlic butter instead of tomato sauce, topped with mozzarella, cheddar, banana peppers, which you then dip generously dip into the side order of "donair sauce" (really like a sweet garlic cream... mmmm), at the local pizzeria in town. Early night to bed (much needed)! Definitely "burned the wick at both ends", but well-worth it!
P.S. all the photos of the food, except for the garlic fingers + donair, are all dishes that I have cooked / baked since being here... various seafood concoctions of salmon, scallops and shrimp, pasta with a hearty sauce, asperagus omelet with canned salmon mixed with dill, lemon and mayo, and of course my "specialty" (after being taught by my college roommate, followed by my own modifications) chocolate chip cookies... yes, be impressed ;)
Wednesday, April 13, 2011
Hidden Gem: Nova Scotia, Seafood delight and Shaving to Save!
So this is also about my thoughts on family medicine, but in short, although I was sincerely hoping to have my mind changed about family medicine in this new setting, I am learning quickly that even in the best possible situation, the bread and butter of family medicine is not for me!I do however find myself madly in love with this Nova Scotian countryside coast-town, where I am currently doing the second half of my rural family medicine core rotation. The first half was in a small Quebec town, close to the Ontario border -it was... adequate. The best part was assisting in a delivery that became complicated, with failed vantouse and having to go to C-section done by a general surgeon and beautifully finished with a clean subcuticular stitch as opposed to the tackyness of clips. It was a cute little town, a nice little hospital, simple, friendly farmland folk -I probably would have loved it if I was doing obstetrics or surgery... I just don't get excited by the typical family medicine run-of-the-mill type issues.
I thought I was into "women's health" -their "whole bodies, not just their vaginas and pregnancies", but actually, I only get excited when I get to do procedures... PAPs, deliveries, etc. The rest is rather unfulfilling (though I do enjoy the mental health stuff, in all fairness). I did learn a lot though. And am continuing to learn away through 24-hour calls and busy days here in this little Maritime town. My supervisor here is truly amazing -so passionate, really loves to teach, very hospitable and fun, so I am enjoying the experience of medicine more generally here, as well as the experience of Nova Scotia. 
So when I was post-call yesterday, I got to do a little exploring of this place, and really I am in love. This little town is right on the coast, beautiful Atlantic ocean all around, cute non-cookie-cutter homes (pretty architecture, very different from the French Canadian of home, or the tackiness of some of big city Ontario buildings) with lots of forest and garden space, and there are actually little brooks that bubble and run between properties in some places! 
There are 4 churches within 4 blocks right in the heart of town, whose bells chime every hour on the hour, and beautiful old mansions have been converted into doctors' offices on the main street. Lovely parks with old fashioned street lamps lining the paths, and benches right on the banks of the blue Atlantic are just a few steps away from where I'm staying. 
And just a few minutes drive away, there are beautiful white, sandy beaches -hidden gems -pristine, uncommercialized, with forest along the banks, sea shells and sand dollars on the shores, and giant rocks to pick your way through and stand on so you get the best view of the waves crashing up against them... the lady I'm staying with took me there around sunset yesterday evening. It was gorgeous, and we were literally the only people on the whole beach! Also, the people are also so friendly here, non-pretentious, genuine... all the cars stop if you want to cross the road, if you make eye contact with someone, they will absolutely say 'hello' (I often smile at strangers when i'm walking about and usually, the best I get in return is a reciprocal smile, let alone a "hi")...
It's like the beauty of British Columbia without the pretention and granola... very real and grounding with the gentle, soothing waves kissing the sands of this little Canadian province. I'm such an East Coast girl (though I've only been to the Maritimes once before for a road trip when I was 10... a pilgrimage to the home of Anne of Green Gables in PEI ;) But really, this place is full of that ethereal spiritual kind of romance that I love, as well as a very peaceful and enjoyable solitude. I love it. Also one can get great seafood here.Case in point, I bought salmon at the grocery store and baked it up very nicely at home, for the first time ever, and honestly, it was the best salmon I've ever had in my life -really! Here it is below:
Purple Pebble's Salmon ConcoctionHeat oven to 425F. Line pan with aluminum. Wash salmon filet and lay on aluminum. Mix crushed garlic, lemon juice, capers, dill, chives and onion salt in a bowl. Sprinkle some lemon juice onto salmon filet, followed by some lemon pepper. Pour mixture onto salmon liberally. Dot with butter. Close up aluminum foil around salmon, leaving a little opening on top (keeping the moisture in, but not letting it get too mushy when it cooks in the oven). Pop in the oven for 15-17 minutes. Let each forkful melt in your mouth (as it surely will). Repeat :)
And finally, I am so proud of my little sister who "shaved to save" last weekend, along with 2 of her friends to raise awareness about the socio-cultural reality that people undergoing cancer chemotherapy have to live, donating her hair to make wigs for people with cancer, and raising nearly $7000 in just 1 week for the Children's Wish Foundation. She was right when she said "but if I shave it all off, more people will donate, and they will donate more!" So courageous, such a great cause! Check out the awesome short link below to witness this beautiful act of love:
http://www.youtube.com/watch?v=7TNrzxtpc_k
Friday, March 11, 2011
General Surgery: the Fire and the Patient's Blessing
--
The Fire
In medicine, and in clerkship particularly, it is so easy to get caught up in the hospital madness. I felt it most ostensibly during my general surgery rotation this past month: patients waiting, nurses hollering, the requests for consults beeping, beeping; running up the stairs, down the stairs, finish rounding on 30 patients by 7:30 am and rushing off to the OR; running up the stairs, down the stairs, checking labs, nagging interventional radiology and nutrition and physio and thrombosis (advocating for your patients, essentially), and at the end of the day, pre-ops for the next day (so that you can repeat it all over again). It is exhausting.
The fulfilling part is the patients. Seeing patients, talking to them, operating on them for sure! Goodness, I love the OR. It's a beautiful place where you see the beauty of God's work in the fascial layers, muscles, nerves and vessels of the human body. And then you cut and resect and stitch with love and fervour. Yes, with fervour. Does anyone realize how passionate surgeons are about their work? I have not seen that anywhere else so far. They know true love, really. They will not eat or sleep or pee (or care to complain) if they are operating.
But it's not just about the surgery -I found that they are just the 'passionate type', period. For better or for worse, they will aggressively advocate for themselves, their patients and their cause. They will walk into the ER for a consult, glance around at the beds of patients in the halls and angrily vociferate, "This is disgusting -it's inhumane! You'd think we're in the third-world here!" Some will flex the muscle of their reputation or hierarchy to turf colleagues out of the OR so they can operate on their own patients first. Certainly egos are huge like nobody's business, but they would also give their lives for the love of their work... and they do. They will review their mistakes and take themselves and each other to task so it doesn't happen again. They seek the tangible Truth, not mere theory. On our last day as clerks, we had breakfast with the residents, while engaging in passionate and witty banter about politics in the Middle East -it was fireworks, cynical, reality-checked humour. And yes, there are lots of innuendos, double-entendres and sexual jokes between colleagues. But they've got that Fire. They embrace it, they fight for it and they become it, for all its potential to provide warmth, destroy and salvage. Surgeons are like the warriors of medicine, with their fair share of villains and heroes, and the Iliad is in the OR.
I am so a 'surgical' type, I don't care what people say... whether or not I decide to become a surgeon, that's a different story, but am I the type? Absolutely, yes. I am all about the Fire.
The thing is, when you play with fire, you risk getting burned. And when the fire's all up inside you, you risk spontaneous combustion. Firstly, people forget that the warriors are still human. Odyssius sure was and so are surgeons. We had been in the OR for nearly 7 hours (of a 12-hour surgery) and the general surgeon, although he had given the resident and I breaks, had not taken any himself. So I asked him, "Doctor, are you planning on taking even 5 minutes of a break?"
"If I wanted to take a break, I would have taken one already, but you never know what can happen when you step out of the OR and if something goes wrong later, how would I know that it's not because of what happened when I left for a few minutes? So I prefer to just stay."
But I pressed, "Okay, Doctor, 'makes sense. But if you feel you want to step out for even just 2 minutes, I have a granola bar in my pocket, so you can eat something."
The surgeon literally stopped what he was doing for a moment in his surprise. The medical student was making sure that he was okay? Of course, I was. Isn't that the human thing to do? Someone is hungry, offer food; someone is tired, offer rest. And if the scrub nurses weren't rotating off every few hours, I would have offered them the same. He was so touched that someone should care for his well-being as a person. Not as a big-shot doc, but as a human who has basic needs, and who may function optimally if those needs are met.
And then it struck me that perhaps people get so caught up in their roles in the hospital that they forget each other's humanity. Nurses get frustrated with docs (sometimes rightfully so, sometimes completely uncalled for), so their tone can be rude and demanding (and they probably don't realize it). Doctors are perceived as gods by some and devils / assholes by others (the worst is when they buy into these delusions themselves). Orderlies are there to bring you stuff. Unit coordinators are there to be efficient for the floor. And all these egos clash and flail, slave and dominate. And unfortunately, if often becomes a survival jungle: everyone for themselves. People forget that if you show love and compassion towards your colleagues, and if in the heart of a fire, with flames licking your feet, you can show patience and humility, the blessing of that service to humanity comes back to you. In essence, you won't burn.
The Patient's Blessing
So anyway, I was burning in one of these fires at the end of a long, trying day, with everyone snapping and nagging all around me, for what I could recognize as nothing that I did wrong. But I have learned that when one reaches that moment of loathing and despair, despite this awareness (because really, how much can you take before, very humanly, losing your patience), the best thing to do is go see patients. Go see patients and remember that it's about them, it's not about you and count your blessings.
I had no choice anyway, the pre-op history and physical had to be done. So I did. The patient's wife was in the room and his two daughters as well. And you could literally feel the worry and anxious energy in that room. I sat down next to the patient's bed and went through my questions: you know why you're here, you know what surgery you're having, what are your meds, allergies, medical conditions, what symptoms are you having and not having right now; stop eating at midnight, drink this bowel prep, etc. And then came his questions. And oh, so many! So I would explain, smile, reassure, which obviously only led to more questions and sometimes, repeating the same question over.
It had been a very long day, and I was honestly at my wit's end. But then I reminded myself of what it would be like to be that patient, right now, not fully understanding why I need surgery again, not fully understanding exactly what will be done and scared shitless that something could go wrong or that I might need surgery yet again in the future. I briefly thought, "Really, I can't believe the surgeon didn't explain this to him! It's the least that could have been done!" But then I remembered all that medical anthropology, all that history of medicine, all those books I've read by surgeons and other doctors, all those anecdotes and testimonials from patients and from Physicianship in the early days of medical school. When people are sick and scared, they remember F-all. Most likely the surgeon did explain everything, but my patient had some fear-induced amnesia. It happens all the time. So my job was to judge no one and make no assumptions, but just calmly and patiently explain one more time, and perhaps, one more time after that.
I took a deep breath, smiled, put my hand on the patient's arm and explained again, this time, drawing diagrams on the back of my report. I reassured them about what I knew, looked up what I didn't know and came back to the room 5 minutes later to explain further and reassure further. I explained the reasoning of risk management that we do in medicine -what happened to you happens to a small percentage of surgical patients; the reason we are doing so much radiological imaging is because the benefit of finding stuff and then being able to fix it outweighs the risk of having too much exposure to radiation. And only once my patient was as satisfied as he would be, had no further questions and seemed a wee-bit calmer did I leave that room. 40 minutes later.
I realized that the reason they teach us about these scenarios and empathy in Physicianship is not because they think we're a bunch of cold, heartless dweebs and that they're going to "teach us empathy". It's because even the nicest, most compassionate people could easily become jerks under stress, or just become slightly less thoughtful, slightly more self-involved... basically, what came naturally before, may not come so easily under the high levels of stress we experience as clerks at the bottom of the medical food chain. By drilling all the official empathy diagrams and physicianship mumbo-jumbo into our conscious awareness, this program has essentially created a sort of safety valve so that when the unconscious, naturally-flowing compassion and kindness very humanly wavers under stress, there is a conscious secondary mechanism for empathy to kick in. And that is exactly what I used that day with that patient.
Two days later, post-op day #1 for my patient, during rounds after the residents had asked all the questions and I had scribbled them down as efficiently as possible in the patient's chart, I had smiled warmly at the patient and said "Good to see you're doing well, sir". I was about to leave the room and then he said "Wait, please come here". I approached his bedside. He took my hand in both of his own and looked into my eyes with his soul. "Thank you. Thank you so much for taking that time to explain everything to me that night." From the other side of the bed, his wife added "Oh, it made such a difference, you have no idea! You will make such a good doctor one day."
I looked back at the patient, "I'm glad I could make you feel better about the surgery -that's my job!"
"Well, it really helped a lot -thank you."
"You're happy, then I'm happy. Have a lovely day, sir -be strong, you're doing great."
It is our job. It is, and it feels wonderful to hear that you are doing your job well from the people who matter the most -the patients. In my ethnic and religious culture, we call this kind of feedback, in this particular way that it happened, the patient's du'a, or prayer. Appreciation or positive vibes that come from the heart. It's really only with the blessings of our patients that we can truly become good doctors, the only evaluation that counts for anything, in the end.
As I continue making my way through the fires of medical school, at times singed senseless, at times cremated and reborn, I am so grateful for each one of those blessings.
The Fire
In medicine, and in clerkship particularly, it is so easy to get caught up in the hospital madness. I felt it most ostensibly during my general surgery rotation this past month: patients waiting, nurses hollering, the requests for consults beeping, beeping; running up the stairs, down the stairs, finish rounding on 30 patients by 7:30 am and rushing off to the OR; running up the stairs, down the stairs, checking labs, nagging interventional radiology and nutrition and physio and thrombosis (advocating for your patients, essentially), and at the end of the day, pre-ops for the next day (so that you can repeat it all over again). It is exhausting.
The fulfilling part is the patients. Seeing patients, talking to them, operating on them for sure! Goodness, I love the OR. It's a beautiful place where you see the beauty of God's work in the fascial layers, muscles, nerves and vessels of the human body. And then you cut and resect and stitch with love and fervour. Yes, with fervour. Does anyone realize how passionate surgeons are about their work? I have not seen that anywhere else so far. They know true love, really. They will not eat or sleep or pee (or care to complain) if they are operating.
But it's not just about the surgery -I found that they are just the 'passionate type', period. For better or for worse, they will aggressively advocate for themselves, their patients and their cause. They will walk into the ER for a consult, glance around at the beds of patients in the halls and angrily vociferate, "This is disgusting -it's inhumane! You'd think we're in the third-world here!" Some will flex the muscle of their reputation or hierarchy to turf colleagues out of the OR so they can operate on their own patients first. Certainly egos are huge like nobody's business, but they would also give their lives for the love of their work... and they do. They will review their mistakes and take themselves and each other to task so it doesn't happen again. They seek the tangible Truth, not mere theory. On our last day as clerks, we had breakfast with the residents, while engaging in passionate and witty banter about politics in the Middle East -it was fireworks, cynical, reality-checked humour. And yes, there are lots of innuendos, double-entendres and sexual jokes between colleagues. But they've got that Fire. They embrace it, they fight for it and they become it, for all its potential to provide warmth, destroy and salvage. Surgeons are like the warriors of medicine, with their fair share of villains and heroes, and the Iliad is in the OR.
I am so a 'surgical' type, I don't care what people say... whether or not I decide to become a surgeon, that's a different story, but am I the type? Absolutely, yes. I am all about the Fire.
The thing is, when you play with fire, you risk getting burned. And when the fire's all up inside you, you risk spontaneous combustion. Firstly, people forget that the warriors are still human. Odyssius sure was and so are surgeons. We had been in the OR for nearly 7 hours (of a 12-hour surgery) and the general surgeon, although he had given the resident and I breaks, had not taken any himself. So I asked him, "Doctor, are you planning on taking even 5 minutes of a break?"
"If I wanted to take a break, I would have taken one already, but you never know what can happen when you step out of the OR and if something goes wrong later, how would I know that it's not because of what happened when I left for a few minutes? So I prefer to just stay."
But I pressed, "Okay, Doctor, 'makes sense. But if you feel you want to step out for even just 2 minutes, I have a granola bar in my pocket, so you can eat something."
The surgeon literally stopped what he was doing for a moment in his surprise. The medical student was making sure that he was okay? Of course, I was. Isn't that the human thing to do? Someone is hungry, offer food; someone is tired, offer rest. And if the scrub nurses weren't rotating off every few hours, I would have offered them the same. He was so touched that someone should care for his well-being as a person. Not as a big-shot doc, but as a human who has basic needs, and who may function optimally if those needs are met.
And then it struck me that perhaps people get so caught up in their roles in the hospital that they forget each other's humanity. Nurses get frustrated with docs (sometimes rightfully so, sometimes completely uncalled for), so their tone can be rude and demanding (and they probably don't realize it). Doctors are perceived as gods by some and devils / assholes by others (the worst is when they buy into these delusions themselves). Orderlies are there to bring you stuff. Unit coordinators are there to be efficient for the floor. And all these egos clash and flail, slave and dominate. And unfortunately, if often becomes a survival jungle: everyone for themselves. People forget that if you show love and compassion towards your colleagues, and if in the heart of a fire, with flames licking your feet, you can show patience and humility, the blessing of that service to humanity comes back to you. In essence, you won't burn.
The Patient's Blessing
So anyway, I was burning in one of these fires at the end of a long, trying day, with everyone snapping and nagging all around me, for what I could recognize as nothing that I did wrong. But I have learned that when one reaches that moment of loathing and despair, despite this awareness (because really, how much can you take before, very humanly, losing your patience), the best thing to do is go see patients. Go see patients and remember that it's about them, it's not about you and count your blessings.
I had no choice anyway, the pre-op history and physical had to be done. So I did. The patient's wife was in the room and his two daughters as well. And you could literally feel the worry and anxious energy in that room. I sat down next to the patient's bed and went through my questions: you know why you're here, you know what surgery you're having, what are your meds, allergies, medical conditions, what symptoms are you having and not having right now; stop eating at midnight, drink this bowel prep, etc. And then came his questions. And oh, so many! So I would explain, smile, reassure, which obviously only led to more questions and sometimes, repeating the same question over.
It had been a very long day, and I was honestly at my wit's end. But then I reminded myself of what it would be like to be that patient, right now, not fully understanding why I need surgery again, not fully understanding exactly what will be done and scared shitless that something could go wrong or that I might need surgery yet again in the future. I briefly thought, "Really, I can't believe the surgeon didn't explain this to him! It's the least that could have been done!" But then I remembered all that medical anthropology, all that history of medicine, all those books I've read by surgeons and other doctors, all those anecdotes and testimonials from patients and from Physicianship in the early days of medical school. When people are sick and scared, they remember F-all. Most likely the surgeon did explain everything, but my patient had some fear-induced amnesia. It happens all the time. So my job was to judge no one and make no assumptions, but just calmly and patiently explain one more time, and perhaps, one more time after that.
I took a deep breath, smiled, put my hand on the patient's arm and explained again, this time, drawing diagrams on the back of my report. I reassured them about what I knew, looked up what I didn't know and came back to the room 5 minutes later to explain further and reassure further. I explained the reasoning of risk management that we do in medicine -what happened to you happens to a small percentage of surgical patients; the reason we are doing so much radiological imaging is because the benefit of finding stuff and then being able to fix it outweighs the risk of having too much exposure to radiation. And only once my patient was as satisfied as he would be, had no further questions and seemed a wee-bit calmer did I leave that room. 40 minutes later.
I realized that the reason they teach us about these scenarios and empathy in Physicianship is not because they think we're a bunch of cold, heartless dweebs and that they're going to "teach us empathy". It's because even the nicest, most compassionate people could easily become jerks under stress, or just become slightly less thoughtful, slightly more self-involved... basically, what came naturally before, may not come so easily under the high levels of stress we experience as clerks at the bottom of the medical food chain. By drilling all the official empathy diagrams and physicianship mumbo-jumbo into our conscious awareness, this program has essentially created a sort of safety valve so that when the unconscious, naturally-flowing compassion and kindness very humanly wavers under stress, there is a conscious secondary mechanism for empathy to kick in. And that is exactly what I used that day with that patient.
Two days later, post-op day #1 for my patient, during rounds after the residents had asked all the questions and I had scribbled them down as efficiently as possible in the patient's chart, I had smiled warmly at the patient and said "Good to see you're doing well, sir". I was about to leave the room and then he said "Wait, please come here". I approached his bedside. He took my hand in both of his own and looked into my eyes with his soul. "Thank you. Thank you so much for taking that time to explain everything to me that night." From the other side of the bed, his wife added "Oh, it made such a difference, you have no idea! You will make such a good doctor one day."
I looked back at the patient, "I'm glad I could make you feel better about the surgery -that's my job!"
"Well, it really helped a lot -thank you."
"You're happy, then I'm happy. Have a lovely day, sir -be strong, you're doing great."
It is our job. It is, and it feels wonderful to hear that you are doing your job well from the people who matter the most -the patients. In my ethnic and religious culture, we call this kind of feedback, in this particular way that it happened, the patient's du'a, or prayer. Appreciation or positive vibes that come from the heart. It's really only with the blessings of our patients that we can truly become good doctors, the only evaluation that counts for anything, in the end.
As I continue making my way through the fires of medical school, at times singed senseless, at times cremated and reborn, I am so grateful for each one of those blessings.
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