Standing here, face to the wind -a storm this way comes!

Something funny happened since last time. I just stopped wanting to write about my job. I have still had great days and awful ones, moments of inspiration and others filled with doubt and the lurking jaded, feeling insecure and out of place and occasionally, like I totally fit in. But I didn't feel like telling you about it and I didn't feel like it was worth telling.

Today I realized that I'm just over the anecdotal form. I want more from my life, I want more from my reflections and when I see that 'more', then I'll really have something to write to you about. Part of me still drifts off into the fantasies of those unwritten stories -real good fiction that tells itself in my head, at random points in the day.

Pacing, driving, not sleeping, restlessly eating, walking about the hospital and the city and through the maze of my overwhelmed thoughts, it was gently and beautifully pointed out to me this evening that this is all part of the process. I'm not the first one to feel all this, and to feel alone in it. For moments at a time, I still feel alone. Despite making lots of friends at work and somehow, spectacularly, outside of the health professionals circuit too; despite enjoying my work and the people with whom I spend the greater part of my life these days; despite indulging in the breathtaking scenic and culinary delights of this coastal city; despite the rejuvenation and pleasure of rigorous, near-competitive Masters swim classes... despite all this, I find that I am sometimes overcome by a sharp sense of alone-ness.

Initially, I mistook this for loneliness. But they are not one and the same. I stole myself in the secret shame of longing for old loves, that familiar intimacy and companionship, as I stressed about belonging in a new place, all the work there is to do, the magnitude of the demands on me spiritually, intellectually, emotionally and physically. Nuits blanches, fretting and frittering. It's not an honest agony though. The real source of all that is in the anticipation and the stress of personal transformation. Living alone, having a real, serious, grown-up job, getting settled, and preparing for the quest within that this residency will be. I am alone in this. Even if I found my 'great love', even if I lived with my family, even if I was surrounded by old friends who really knew me. That "me" is changing. It has to. And it will do it alone. With hard work, prayer, and of course plenty of support and love from all those wonderful people with whom I share my past, as well as with all the new and interesting people with whom I share this present and future, I will be an evolved me at the end of these five years. Not really an island at all, but fundamentally experiencing exactly what I only can experience and know, completely alone.

How does one accept aloneness so well that it's nearly impossible to be lonely? I'm a natural introvert -even though I can be gregarious and social and enjoy good company -I draw my energy from within and cherish the sanctity of my solitude! Yet I feel restless and uncomfortable with the realization that at a certain point in life, you're alone in exactly how you think, what you want to do, and how you feel you need to do it... like you've "specialized" in the general ideas you used to have, that perhaps more people could understand or relate to or share. Some things can no longer be fully shared. Maybe not even with that great love of your life with whom you might share plenty else. I've never really been confronted so fully with that reality as now. And I'm still working on it.

This evening, I walked down the slanted streets of this town in the blues and silvers of dusk on the shimmering harbour waters. I smelled that smoky-pine in the air that kissed summer heat and the golden early fall farewell, with a brisk chill breeze through my hair. Winter winds, gales, blizzards, snow and ice are on their way -I feel them coming, within. I only hope the dazzling sun will reflect those sparkling bright fuscias, greens, yellows, violets... the whole spectrum of joy in the diamonds they leave in their wake. 

Folk Fiddle-Dee-Dees At Last!

If a picture is worth a thousand words, then how much is a video clip worth? 

Suffice to say that on a day when the young woman felt simultaneously rested, refreshed, alone and sad, with that little hint of an insatiable emptiness deep in the hollow of her gut, she sought out some live music with a friend. And after already a few disappointments as far as music went until this point, she was pleasantly surprised, at long last, to have found the folk fiddle music she had been craving. Her favourite was definitely the local Newfoundlander 'kids' (or at least she thought they looked so young... and so multitalented for so young!) who called themselves The Freels, though the Donahues from Northern Ireland were pretty good too. 'Couldn't really put the whole experience well into words, so she attempted her first video clip montage. It didn't quite capture the energy in the pub, the stories of the Irish and Newfoundlander musicians who sang the songs of their grandfathers, the back-stories of songs about ships that sank on their way from Ireland to Newfoundland, or the farmer who murdered his landlord in Ireland and then ran away to America. But still, at least she could share the music of the 3 of the 4 groups of musicians she had the pleasure to hear in those blessed two hours at the Ship Pub (formerly the Ship Inn).

Breathtaking Newfoundland!

The young woman thought that today perhaps she ought to share some of the hidden beauties of her new abode. First, the majesty of the brilliant ocean on a warm, sunny, windy day, with the coastline along the base of Signal Hill.

Last weekend she had ventured to Ferryland, on the Rock's Southshore. It was nearly forlorn when she had hiked up the little trail to the lighthouse with one of her new friends from work. They had stopped to gaze at the rocky islets in the midst of the ocean on one side, giant windmills turning on the other, above coniferous forest that stretched on, untouched, unscathed all around and below.

Home on the Quidi Vidi Lake Trail

The young woman -that same one, so melancholy and lonely just a few days ago -early one evening, pulled up into the grocery store parking lot. Hopping out and locking up the car with a beep, she made her way to the pebbly gravel trail that snaked around the lake. The summer sun shone bright yet, blessing the Earth's garden here with it's golden rays. Ducks swam and scratched, ruffling their feathers, quacking and honking, ducklings swimming along behind them close to shore. A dark ponytail swooshed by and then a blond one. A couple walked by hand-in-hand. A youthful man jogged slowly by, another at least thirty years his senior sprinted past. Everyone went at their own pace here.

A cool breeze blowed through the young woman's dark locks, strands of her curls flew into her face and flirtatiously played at her shawl, sliding it off her shoulders. She chose to wear it as an open scarf instead, smiling to herself and pulling down her shades. Today her earphones whispered the light gentle airs of her college years, music she had ripped off the dorm network -Paul Simon, The Dispatch, 80s Madonna, Ben Folds, Guster, Journey. It was that kind of balmy eve.

A gazebo approached on her left, snuggled in the grassy hill. The water rippled and shimmered to her right. And then the exercise park was before her. A couple of women lifted bars with plump arms and laughing faces, a lone boy lay hanging off a low bench by one hand. Just behind, the swings beckoned, old, but solid, big kid swings along side the baby basket ones. The wind tickled her neck again, the scarf blew up like a blue flame about her arms. She sat in the black curve and pushed off into the freedom of that bright, nearly cloudless sky above, letting the air caress her face, her arms, her legs and collar bones. One father pushed his little daughter in the neighbouring basket, another his toddler son, adjacent. The former squealed with delight as the other cried out, fearing the fall. There is no fall though, only flight, she thought to herself, now dragging one foot in the rocks and then walking slowly back towards the trail.

Long, lush green and purple grasses blew like rivers to kiss the lake, The underside of little leaves shooting up on the tops of the trees, like silver-white flowers of a different place and time. The trail hid shyly now amidst weeds, rocks, trees and more of the grasses. Buttercups scattered themselves between bushes of big pink flowers and little red ones, a cluster of violet lupins off to one side, park benches, docks, picnic tables and artist's nooks in the perfect places. Wish I had that body, the young woman thought as a slim figure ran towards her in a bright turquoise sports top. The wrinkled smile under the blonde bob surprised her as the timeless woman ran past. Something out of a picture book for sure. The air had grown sweetly fragrant, melting away those insecurities and she inhaled deeply -it was intoxicating. Then the sharper whiff of a lone pine amongst the leafy shrubs and trees. She passed circularly about a brooke that really did bubble into the lake. Bliss was poetic too, she thought, but the cliches are way more obvious. She wished she knew what azaleas were in that moment, just so she could say that she then spotted a cluster of those, but she didn't know the name of those flowers. Neither did she know what birds chirped by as they sailed up into the tree overhead, maybe swallows? Did they even have swallows out here? A tree bough leaned gracefully over the lake with a sort of honouring tenderness. The young woman felt so blessed and alive. What a beautiful place this was, what peace it brought... home indeed.

Walking leisurely behind the regatta boathouse and then back onto the last bit of trail, all she asked was that she could remember as much of this enchanting beauty as possible. Perhaps this place would make her a real writer yet.

From the Old City Fountain to the Harbour on the Ocean...

A young woman picked up her long powder blue skirts, pale pink flowers swishing in the cool breeze of dusk. Down her new hilly street and right in the heart of town. A town once utterly foreign, now slightly familiar within the few blocks radius of her new home. A gentle loneliness snuggled close to her heart as she slipped on the ear buds. She had made it a point not to wear earphones until today -stay open to the novelty, the opportunity for happy coincidence, surprise meetings and the forging of friendships. No more formality now, no more niceties. Enough trying to make this place home. Home was lost somewhere inside of her... it was not outside.

She took a long breath, walking past a group of protestors down to the waterfront. Even here, there were protestors, she thought, sighing to herself, choosing to walk the outer perimeter of the park to avoid the ruckus. Motorcyclists revved up at the zebra crossing, after slowing to watch the mini-parade.

But she walked onward onto an abandoned road that ran parallel to a wired fence, broken glass and garbage strewn amidst dirt and gravel. At least no one was here. The green ocean ran thick and milky, silver shimmers and mirrors appearing between waves as the sun set behind. Dark forested cliffs ran towards each other on the other shore, never meeting as the water opened out into the forever of the horizon.

The clamour died down and the woman made her way back up and around into the park, wrapping her shawl closer around her bare shoulders. It was the first time she walked this city avoiding people's gaze, looking up, down and beyond, but choosing not to acknowledge those souls that ventured neighbourly friendliness. She passed the stone dogs that stood guard -this province's namesake, the Newfoundlander  and the Lab. Quickly scanning the park bench for signs of spilled booze or human expectorations from the long-weekend's festivities (and finding neither), she took a seat, near the edge of the dock.

Small boats rocked up and down, swaying slightly from side to side, well-anchored. Second Chance and some lame name from Toronto. She liked Second Chance, blue and simple with that picture-bookish scrawl of the painted white name on its side. She stared into the wind, into the green water, the colourful houses in the distance on one of those reaching cliffs -mere lego structures from here -the large boats, the small boats, the smell of a salty sea. And the tears had already arrived. What was she doing here? Did she even belong in this far-away place? The a cappella in her ears soothed like a lullaby, as she watched a couple birds fly off together, grazing the coastline and then up into the fluffed eggshells on the last bit of blue sky.

An old man with his dog, stopped by before leaving -"Wouldn't want to go out on them boats, no. I'm gettin' sea-sick just lookin' at 'em." She laughed good-naturedly in agreement, but only to be agreeable. Truthfully, she wanted nothing more in that moment to go out in one of those boats right now, out into that infinite ocean and far away from all the unknowns of this new life, all the expectations, mainly of her own self. And far away from the loneliness in her heart and soul. At least sadness is more poetic she thought, as she stood to leave. Turning around, a peach stingray shone against the sky before morphing into a little dragon and then dappled cotton. The cars stopped to let her cross. A hundred wreaths of flowers and conifers were strewn about the grand statue and she didn't know why or what they commemorated. The restaurant she had been recommended a week ago that had been closed because of a "small fire" had reopened and teemed with hungry locals, couples and tourists amidst candlelight and dark tables and chairs. She walked past the Long Dick's Sausages truck, past the family-run chocolaterie and the Heritage Shop, then up past the brown, turquoise and yellow clapboard townhouses until she reached the navy blue of her own. My ship, my home.

As she unlocked the door and put on some tea, she found that the sadness had lifted, washed away in that sea. 

A Critical Day in Critical Care and Med School.

It is my final clinical rotation as a medical student, and my last few days of it. I have spent this past month doing an elective in Critical Care medicine. But today was truly a critical day -the most intense of all my days on this intensive care unit, revealing a lovely synergy of lessons from my entire experience as a medical student. How appropriate for the metaphorical 'eve' of my becoming a real doctor.

It started off ordinary, unremarkable -dare I say, a "slow" day, in the ICU. I joked with the other med student, "It's the calm before the storm". I was lucky to even have a patient by the end of the morning. Something was amuck with her -we knew that since yesterday. Now, more obviously in Acute Respiratory Distress Syndrome (ARDS) -not ASA toxicity, not as likely an inflammatory / autoimmune process, most likely infectious and not faring too great. We decided it would be best to intubate her. With that small chin and big, thick tongue, we predicted a difficult intubation and had anesthesia present for back-up. The room was loaded: nurses, resp therapists, students, residents, fellows and staff physicians, and the bunch of us watching through the glass, from the outside. One, two, three tries; oxygen saturations plummeting down within moments from 90% to 80, to 70, to 40, to 7. I was strongly reminded of my little NICU baby who had also been difficult to intubate and had so desaturated a year and a half ago. Mask ventilate. Then the fourth try, and the tube is in. The tube is in, but the balloon is busted, so the other staff comes, threads a guidewire and then another tube. Stable on the vent. That got our own adrenaline going, but the patient was okay -we felt she was safer. Yes, this was better. "That was a close call" said the others. Someone started to go on about what they would have done differently -easy for them to say, but I know it's not the same when you're there. I had been there, with that baby -I could at least appreciate that it could happen to any of us, so cut them some slack.

And then a good, long lull. We went for lunch. I had some Mediterranean vegetable and cheese streudel and a Cott Black Cherry. Laughed, vented, talked shop and life. Walked back to the unit. Still nothing. The residents had sorted who would be presenting at Morbidity & Mortality (M&M) Rounds the next day. We still had a lot of empty beds. It was just hitting on 1 pm. The fellow and I sat at the desk, wondering what to do next.

"Code Blue. Code Blue."

The ICU nurses had already run upstairs. The code team was huge -ER docs, Medicine docs, nurses... we didn't think we'd be needed so much, but we walked up briskly anyway. One year ago, it would have all been a blurr. But I wasn't shocked or frightened this time. I listened, I stood back and out of the way. Surgeons spoke with the nurses, who spoke with the medicine residents and fellows. Our team hung back for a moment. I caught bits and pieces of the patient's history. She had been on the ward a while, a complicated post-op cancer patient, with multiple other illnesses -the standard poor old lady. Stable this morning and then suddenly, vomited massive amounts of blood and just wouldn't stop. And then somebody said "Anesthesia?" and our team member disappeared into the room to help intubate the patient. The morning's episode turned out to be a 'dry run' for this afternoon crisis. They pumped fluids, pressors, unit after unit of packed red blood cells, platelets and clotting factors and still the patient bled and was unstable.

And then on one side, stood the third year medical student, shocked in a daze, running frantically to get things that the doctors inside asked for, but always returning after someone else had already acquired what was needed. That was me last year, with my jolly, Greek patient, who was always "fine", teased me regularly, but always said "Thank you Doctor". And then one day, the day before he was meant to be discharged home, he had vomited blood. So much blood. He had lost consciousness. My seniors had pumped him up with the goods, just like the more experienced residents, fellows and staff were doing for this poor old lady now. My patient had spent a week in the ICU where they finally managed to control the bleed. But he almost died.

Here now, this girl, only one year my junior, her patient was almost dying the exact same way. Nobody was with her, nobody was explaining anything, understandably, given the circumstances. I went over and asked her to tell me more about the patient's history -afterall, she was the one who followed this poor old lady every single day. I nodded, sometimes asked a question, mainly just listened to the story. A pause. And then she added, "You know, I really liked this patient a lot -she was one of my favourites."

"Yes, I know. I had a patient like her once."

"She would joke with me a lot about how she was going to eat pizza once she left the hospital. Oh, and juice. She really likes juice and was looking forward to being able to have some again."

"Okay. Once she is stable in the ICU, I will give her your regards and let her know you would have really liked to bring her some pizza."

"Okay."

"Also, feel free to come visit her when she's in the ICU -she'll appreciate the familiar face and you'll have the continuity of care, if you would like. Now do you want me to explain what's going on in that room?"

"Yes!" replied the other medical student, with that yearning for understanding, for knowledge, and a way to cope. And though I am not that knowledgable, I have learned a thing or two through my experiences as a medical student and now, during this ICU rotation.

So I explained that when a patient has massive bleeding, the main concern is that they are losing volume. So we give lots of fluids and fast, and then we give lots of blood, and then once we give lots of blood, we have to also replace platelets and factors, and when we give lots of those we also need to give calcium since the preservative in blood products will bind the calcium in a patient's blood, so in very large quantities, this matters more and we have to replace it at some point. I explained that it is important to keep the patient's blood pressure high enough to perfuse / oxygenate their organs well, so we also give pressor medications to help with that, and I specified which ones we usually give.

And then, still standing back, we watched the dynamic scene before us. I was struck by how much I was moved by the whole endeavour, in the middle of seemingly organized-chaos. Yes, the Canadian medical system is so imperfect on so many levels, but acute care management is not one of them. There in front of us, it was plain as day that the hospital and the whole system was designed for this very moment. Here it was that cherished cliché: doctors saving lives. We watched them, the whole fleet of 10, 15, 20 residents, fellows, staff physicians and nurses, so many nurses, called from almost every corner of the hospital -general surgery, ENT, anesthesia, internal medicine, ICU -pumping, poking, loading, watching, organizing, moving, down to the ICU from the ward, down to angiography from the ICU and finally, to the operating room. Her red face, blood-stained cheeks, sheets and lines, her empty blue eyes. But not dead yet. An army of medical personnel for a whole half day and evening to save one life.

It is the greatest blessing we have in this country, and an honour to witness it. That we can value one life so very much -that one life is so precious that a team of 20 or 30 health care professionals will drop everything they are doing for their other patients, to go save that one life. It is moving to witness that. It reminds us why we went into medicine. And while it is true that in the hospital, we mobilize so many resources -blood, people, drugs, technology, time, money -to save that one life, and yet, people in the community die everyday from poverty, homelessness, and other, less costly social ills, the point is, that this single act within the hospital, represents the most beautiful aspects of our humanity. The love of life, no matter whose life it is, if they are a Level 1 (i.e. they want their life saved at all costs), that person will not be allowed to die without a fight.

I have no illusions about the reality of medicine. We try to do the best we can by our patients. We can help, but we're usually not drastically changing outcomes on a regular basis. Patients are resilient, tremendously so -it's actually amazing. So often, they live despite us, not because of us.

But the spirit of the true physician, who wants so much to help and serve and save their patients, spare them from suffering... it is an honour to witness their passion and love for life and their patients in action. This institution and this profession may be flawed, but it is still inspiring.

And for me, on just another day where I couldn't do much more than watch -just another medical student -I felt I had played my own part in the process, taking on the role of little teacher. I will never know everything, but a big part of being a doctor is in fact, teaching others -colleagues, juniors, even patients and their families. We impart whatever little knowledge we have, but also, we can impart the spirit of this profession. We can validate feelings, we can provide emotional support, we can teach each other to be the kind of doctor we want to see more of in this world, and we can lead by example. I learned something by watching my seniors go through the code and I taught by guiding my junior through her first one. That was a profound lesson for me today. Perhaps it was an early initiation into the role of teacher that I will play for the rest of my medical career, and especially, as I start my obstetrics & gynecology residency in just a few months time, on that far away rock they call 'Newfoundland'.

Almost a Doctor

I haven't written in a long time. Deliberately. CaRMS rank order lists being in now, I am free once again. But I cannot really blame residency programs and the match system for my cautionary tip-toeing... really, it was my own stress and anxiety that stifled me.

I knew what I wanted or at least I thought I did. Then the "Tour": flying in and out of sleepy towns and bustling cities, run-down hospitals and new facilities, friendly faces, impersonal glares, plastic smiles, dancing eyes. Crisp and clean, sharp and smart, strutting down corridors, streets and wards. I sell myself and then it's your turn. We eat sandwiches and cookies and more of the same. Hotel for a day, steak almost every evening, it's crowded, yet lonely, hectic and exhausting, yet I read three novels and a philosophical treatise. Prepping, handshakes, tours and every night a new bed, dropping cash and credit cards the whole long way... the damage done is more than my pocketbook. But only once damaged do we really learn, grow and change, ready to start anew soon enough. Perhaps it is fitting afterall.

Repeatedly building up and shattering my ego and my life for people I hardly knew and could only hope would be kindred spirits. And then they ranked, and now we rank. What do I want? Where do I want to be? But these questions merely gloss the beast beneath: I am almost a doctor and am I really ready? Will I thrive or barely survive the next step of my training? People's lives will truly be in my hands... am I ready? Will I deserve the title of "Dr."?

I am scared. I secretly think we all are. Yes, there is so much to look forward to, following our specific passions at last, making more of a difference (for better or for worse), maturing in this profession and having a voice -these are all good. But are we ready to pay an increasing price for each mistake and will the lessons we continue to learn be truly worth the resulting damage? We will have to be more efficient... does that mean we have to love less? We're meant to advocate, yet not rock the boat too much. We're meant to diagnose and treat rapidly and discharge. We will need to know so much and practice that art the most -the art of knowing, the art of doing. How much space will there really be for the art of learning?

I have more questions you know, they are endless. More uncertainty and mystery. But it will be my confidence that my patients and colleagues will most need... How do I draw water from that well amidst all this? Diagnose and plan, but we're told to treat patients, not diseases, while medicine teaches us mainly the latter and less so, the former.

And speaking of former, I am trying to find my constant. These four years have changed me so -it's nearly impossible not to transform. And with that transformation, there's experience, a vascillating hardening and softening of the mind and spirit and heart. We have new eyes even though we didn't realize that we were asking for them all along. Is my essence the same or has that changed too? And is it for the better? Will I be happy on this path, always? Will I be good enough? Should my happiness depend on how good I am or how well I do or how much I am liked?

Ah, well, you see, I am still that same philosopher girl. Still asking and wondering. Yes, now after watching vibrant, accomplished women deteriorate before my eyes, and once-strong men succumb to the deadliest illnesses, after seeing babies die and the elderly cry, families scream and groan while their loved ones sleep and moan, I must say this: Our world is filled with tragedies and joys, catastrophes and miracles, every single bloody, but light-filled day. It is a strange and beautiful place. But as the 6 year-old me once said, "The sun is shining and I love the world".

My last book for pleasure was The Untethered Soul by Michael Singer. It has shown me this Universe through yet another lens, and perhaps the question I should be asking, the one that penetrates through all these many layers of fear, worry and insecurity, is not "Why?" or "How", but "Who?" In mindful practice, it is the Observer within, in the seat of consciousness, who is aware and watching all this internal chaos. I am not the chaos though, nor am I in crisis. I am neither afraid nor alone. In all that dark unknown, one might ask, "Who is aware of the darkness?"

Doctor, don't worry, everything will be alright.