Today, I want this to be beautiful for you. It is intense and trying and miraculous and interesting for me, but for you it is intended straight for your heart (especially since I was planning on studying, but decided writing was more important for my mental health right now and honestly, the only place to which I can turn, really). I do begin with some frank explanations though -you will need them to be able to feel what I feel and hopefully, just know from feeling (oh, how very unscientific a statement that is!).
Honestly, I was quite apprehensive about pediatrics -after 4 half-days in family medicine about 8 months ago, I had decided that I particularly disliked dealing with sick children in a healthcare setting, with all their crying and squirming, etc. But so, I started my pediatrics rotation with two weeks in the Neonatal Intensive Care Unit (NICU) -this is week 2. And goodness, it is heart wrenching... though not only in the way you think.
This is the hardcore, stereotyped stuff of medical school: the typical making Rounds on all the patients every morning and evening, the "pimping" as they call it (i.e. getting constantly put on the spot with a zillion questions to which you mostly do not know the answer, often guess the answer and sometimes, miraculously and from God-knows-where, very certainly and quite confidently know both the answer and the answer behind the answer... of course, this gets better as you go along, so basically, we are all totally and utterly stupid the first few days and by the end we learn so very, very much that we can actually say that... well, we're still relatively pretty ignorant...), and of course the very intense call schedule.
For all the non-medical people (most of you), let me clarify what this "on-call" jargon is all about and how it works, because depending on who you are in the medical food-chain, call entails different things. In the NICU (as in some other specialties as well), med students and residents on-call keep a pager on them while they actually stay in the hospital for the duration of the shift. For med students, because of accreditation standards of the 21st century and the university trying to meet them, this means call until 11 pm on weekdays, but 24 hr call on weekends when you can get the post-call day "off", without the hospital actually giving you a real extra day off... oh those exploitive geniuses! Don't misunderstand me, I'm not complaining because I know how much worse it used to be, but it still could be better... like who wants someone cutting them open when they haven't slept in 24 hours, I ask you?
So what exactly happens when you're on call in the NICU? If you're not being paged for the caseroom (i.e. labour and delivery, who generally call if there's going to be a risky delivery, in terms of premature deliveries, fetal distress, other complications, etc... so they call up NICU, we run in there and prepare to resuscitate the neonate, sometimes just assess a healthy infant, decide whether the baby needs to be admitted to the NICU for observation / investigations / treatment, etc...), then you're rounding on the 20+ infants in the NICU, making sure to follow-up on labs / blood-work / microbiology, stabilizing babies on different forms of supportive ventilation, antibiotics, nutrition protocols, inserting or removing IV lines, etc... and there are bjillion monitors all beeping, all the time for various reasons.
In just little over 1 week, I have seen a few deliveries, assisted / tried to stay out of the way for a few resuscitations, examined a bunch of healthy and sick newborns, learned to juggle keeping up to date on labs and examining and writing up patients and trying to establish a good rapport with the nurses and administrators and my supervisors and colleagues all at the same time, have had 3 calls in 7 days (including one 24-hr call), assisted with 3 circumcisions and prepared and delivered a presentation. I have dealt with desperate parents, sometimes annoying parents who are really just scared to death about whether or not their baby will survive the great physical effort of living, overjoyed mothers, and even a mother who has been to Hell and back after delivering twins prematurely, losing one of them after a short while and now lives for every breath, test and feed of her remaining darling.
I have been deprived of sleep and rest and sometimes, of meals. I have become addicted to matcha green tea soy lattes at Second Cup. I have sneaked scrubs away from the surgery nurses who guard over blues (blues, greens = synonym for scrubs) like crows over cheese (Aesop anyone?)... I have felt privileged and grateful, angry and ashamedly, momentarily hateful. There has been joy and energy, and dragging lethargy. Sometimes, all of these, simultaneously (or at least variable from moment to moment). I have been thrilled with the vibrating of my pager, and also wanted to beat the pager to a pulp at 4:45 am.
Such is the emotional life of a medical student. We are veritably thrown into the rose -the spiral of fragrant petals, blood red, silky soft in its heart, and perilous anywhere else around it. It is beautiful and delicate and ethereal, blossoming and then drooping, perking up with a little nourishment, before wilting again and requiring the extremes of protection in order to survive the harsh weather. I nearly forget whether I am in the rose or whether I am the rose or whether the rose is me. But I know that I am thrown.
Today though, is the reason that I write to you. I assisted with the re-intubation of one of my patients, one of my babies in the NICU. The doctor was having a hard time getting the tube into the infant's tiny orifices (teeny, tiny nostrils and a mouth into which I could barely fit my pinky) -the goal of all this, of course, being to allow for proper and easier ventilation for respiration (ahem, sorry... the more jargon we learn, the harder it is to avoid using it... basically, breathing). Anyway, so doctor and respiratory therapist are failing miserably (before eventually succeeding, many an oxygen desaturation, bagging and suctioning episode later) at intubating this 600-gram baby, in the first few tries (hey, it's a complicated business for anyone, I can assure you!).
And what is my job? To hold baby down. This tiny little thing squirming and crying with its teeny-tiny limbs and tiny little rib cage moving up and down and baby abdomen twisting from side to side, writhing in distress. So I gently hold her limbs down and out of the way of the people who are trying to save her life, really. But I also profer my finger for her to hold onto in her delicate, miniscule hand. And she squeezes hard with all her might through the whole ordeal. I am there to hold her hand. That is all I can do for her right now. She is so small but in all her anguish, there is surprising strength in that grasp, and she squeezes till her fingers and toes are ghostly pale. Her oxygen saturation plummets down and then comes back up with every attempt to intubate and she cries and writhes and squeezes my finger. I tap her feet to help stimulate her and also to reassure her that here I am, baby, I am still here, I am right here, here. It is torture to watch this little thing fight for her life, struggling relentlessly with every effort. And the tears well up, threatening to spring from my eyes... twice. And I hold it together -of course I do, that's my job and my function here. And I pray and I pray and I do what I'm told, and I help suction and I hold baby's hand. And also I love her because everything we do in medicine is so vitally important, but love heals too and she needs my love in all that frenzy. So I just stand there and hold her hand and love her like she was a part of my soul. And then she is stable. She does not die in my arms as in the morbid image that flashed in my mind earlier that morning when I was on the metro. She is alive and more stable than she was before the intubation.
That's the rose. That's where I flew for a few eternal moments in a long and difficult day for many a baby in the NICU. It's true that you should not get too emotionally attached in some ways, but there is so much more to learn and to be gained and to be given if you do allow your heart to be opened. If you choose to go there, it is worth all the pieces of your soul and every breath of your life.
Tuesday, October 5, 2010
Saturday, September 11, 2010
Reflections on Psychiatry: We're all in the Madhouse
It is a beautiful pre-fall day in Montreal -perfect temperature in the low 20s (Celsius) and bright and sunny without too much wind. I am 3/4 of the way through my psychiatry rotation and think that it's important to reflect a little on all I have learned and am continuing to learn, and to document it, lest I forget the moment I dive into pediatrics at the end of the month.
What have I seen so far -lots of schizophrenia, bipolar disorder, personality disorders (borderlines for ever more turning up in the emerg!), substance abuse, eating disorders, suicidal people, post-suicide attempt people, children with adjustment and attention deficit disorders, anxiety disorders... basically, the heart of the DSM (ha, just kidding! have you seen how thick that book is with diagnoses? probably impossible to see every last one!).
And things have been going great for the most part -lots of work of course, especially on in-patient wards, following five patients on a daily basis, lectures, calls in the emergency, child psych clinic once a week, out-patient consults, etc... I have had a lot of opportunities to practice the Mental Status Exam, talk to different kinds of people (old, young, different backgrounds and cultures, even a patient on the verge of deportation... seriously, society is responsible for quite a lot of these mental health problems -the government is so out to lunch most of the time, honestly). My supervisors have been giving me a lot of positive feedback and of course also guiding me to further improve.
It's enjoyable and varied -psychiatry is probably the specialty of medicine that gets most involved with legal issues because acutely psychotic patients do not think they are sick and do not want to stay in the hospital. So, we go to court to have them mandated to stay in hospital against their will "closed treatment", and sometimes even have the court mandate a treatment order so that the patient receives treatment whether they want it or not. And yes, these are serious ethical issues. But honestly, if you had a patient who had stopped taking their meds and became so psychotic that they were a danger to themselves and to others (walking on the highway, sleeping with a hammer, behaving aggressively with complete strangers), don't you think it's kind of half-assed to just have them locked up in a hospital? Unless they receive treatment, they don't actually get better. For most compassionate and risk-averse human beings, this is a sufficient argument for a treatment order.
For those more materially minded, I might say, this means the patient will be hospitalized for longer, using up your valuable tax dollars in hospital resources and the longer they go untreated, the less likely they will respond to treatment, which means that if and when they do leave the hospital, nobody benefits. Similarly, the government wants to deport people whose children are Canadian citizens because they want to save a couple of bucks on a welfare check, but who benefits when those kids get beaten from foster home to foster home, become delinquent substance abusers which may or may not trigger psychosis, doing damage to themselves and to society, not to mention the deliberate breaking apart of a family against their will? This is not a fiscally nor morally sound action. Sigh. So anyway, I have learned that a lot of "grey area" issues in theory can be very obvious in practice -it's often not much of a dilemma. That's the reality.
The most important and humbling thing that I learned though, was about myself, this past week. I also believe that this understanding is somehow deeply connected to the essence of good psychiatry and good medicine. Perhaps it is all based on counter-transferance, but that does not mean that the lessons learned are not valuable. Doctors are imperfect human beings, like anyone else. I am wholly imperfect, but as Deepak Chopra would say, the positive qualities and the shadows within us make us complete as people since we're not meant to be perfect (I know, this is the hardest thing in the world for someone like me to accept, believe me!). Anyway, so generally, I am caring and compassionate, even patient with my patients. I respect them, I try to understand them and learn from them. But when I am overwhelmed and stressed, I get frustrated, I get annoyed, I wonder why the hell these people won't just tell me openly about what's wrong so that I can help them more efficiently.
I don't actually act this out -I maintain the facade, even though I might feel this way. But non-verbal cues apparently insist on getting in the way of the whole act, and my impression so far is that psych patients are particularly sensitive to how you're really feeling and any judgmental attitudes. Really, you can't hide from them. And they will react in more extreme ways to that emotional reality. So if you feel like you severely dislike one of your patients one particular day, they will act it out for you, reflect yourself back at you. They will tell you to "go to hell, go F yourself" or will stare at you insolently and refuse to answer any of your questions. You may turn around and superficially think, "Wow, I did nothing and look, this dude is so crazy", but really, they're just reflecting the truth back at you. Maybe you're the one in the Madhouse, maybe you're the delinquent thinking one thing and behaving oppositely (hey, don't get me wrong, we all prefer incongruence in thought and action to a French Revolution-style bloodbath -how else would society function?) The point is, you're so going to get called-out on your hypocrisy.
So, this means, you have to make yourself congruent. You can't just walk the walk, you have to think the thought too. Your patients reactions (to some extent -sometimes nothing you do will make a difference because the patient is too hallucinated or delusional) are your barometer of how grounded you are and this will affect the quality of care you give and whether or not you'll do any good. Of course, this is not always the case -borderlines will remain emotionally labile and sever psychosis may be beyond anything you said or did, perhaps even most of the time. Still, your job is to make the alliance. So you failed today, try again tomorrow, and try again in a different way the day after that, and again the day after that. Because it does matter and it does make a difference and it will affect how patients cooperate and how they get better (in conjunction with medication, obviously -good luck trying without it in a psychotic patient; note that it can work without medication in other kinds of patients).
And if you made a mistake, it is actually possible to make ammends. I was never rude to my patients, nor did I verbally indicate any transient callous thoughts or frustration. But I still had to make ammends. I had to change my approach for a couple of my patients, with genuine good-will, renewed respect and transparency. And you have to be delicate. In one such encounter yesterday, my patient asked me, before agreeing to respond to any of my questions and after several long pauses, "Do you perceive me as 'sick'?" If I would have said "yes", I would have broken the alliance, he would not have trusted me, he would have clammed up and that would be the end of the interview. So I said, "I see you as a person who values X, Y and Z. X, Y and Z make you happy, and [only say this if it's true] I can understand that because X and Y (in some way or another) are important to me too. I am trying to help your body stay healthy and strong, so that you will have the energy to continue doing those things that make you happy". Maybe this only worked for me the one time and maybe I established enough trust to last a few days, or maybe not (because afterall, the patient remains somewhat psychotic). But after that encounter, I knew I did my job. I want my patients to see me as the ally that I am and I want to understand them better so that I can advocate for them better. And when I make a mistake, I can go slowly and carefully and make ammends.
I also learned that I have a lot more in common with my patients than one would think. Just because I am in medicine, does not mean that I do not embrace the concept of God and religion (half the medical staff was absent for Rosh Hashana, if you want to put things in perspective here). Perhaps I'm considered even more eccentric because I can appreciate the truth in statements like "everything is energy, the universe is energy" and even "i see the world as a field of energy" (and honestly, Einstein did too: E=mc2 anyone? So it's not that crazy of an idea... so does Deepak Chopra, so do a lot of people who do Yoga, etc...) Psychotic patients will say things like this, but these comments alone are not what make them delusional and psychotic. The best thing is when you are able to show that you 'get them' at some level because then they feel respected, rather than being ridiculed, and are more willing to open up to you. And you will totally recognize the moment when an abstract idea, perhaps held by many, is so obviously taken too far, and even more importantly, when a fixation on those ideas impairs rather than enhances the individual's social functioning. There is nothing inherently crazy about saying "the universe is a field of energy and I have that energy", "I'm going to be Prime Minister" or "God sent me message Q". It's the further probing of these ideas -the hows, the whys, the subsequent meanings derived, the details and most importantly, the emerging behaviours -that reveal the incongruencies and the illness.
And as one of my supervisors constantly reminds us, a lot of famous people suffered from those tabooed mental illnesses. John Nash lives with schizophrenia. Robin Williams and Eminem have Bipolar Disorder, so did Winston Churchill, Ernest Hemingway, Beethoven, Newton and Vincent Van Gogh. All of these people have made important contributions to the societies in which they lived, in their different ways. It is worthwhile to try to understand not only the illness, but the people who suffer from them so that maybe they don't have to complete a poetic and tragic suicide.
Anyway, maybe I'm completely off base. But apart from learning the DSM criteria for various mental illnesses and the mechanism of action of various drugs and their side-effects, I feel these are really important lessons to be learning, and better sooner than later. It probably applies to other areas of medicine too. And also, to other aspects of life on this Earth.
What have I seen so far -lots of schizophrenia, bipolar disorder, personality disorders (borderlines for ever more turning up in the emerg!), substance abuse, eating disorders, suicidal people, post-suicide attempt people, children with adjustment and attention deficit disorders, anxiety disorders... basically, the heart of the DSM (ha, just kidding! have you seen how thick that book is with diagnoses? probably impossible to see every last one!).
And things have been going great for the most part -lots of work of course, especially on in-patient wards, following five patients on a daily basis, lectures, calls in the emergency, child psych clinic once a week, out-patient consults, etc... I have had a lot of opportunities to practice the Mental Status Exam, talk to different kinds of people (old, young, different backgrounds and cultures, even a patient on the verge of deportation... seriously, society is responsible for quite a lot of these mental health problems -the government is so out to lunch most of the time, honestly). My supervisors have been giving me a lot of positive feedback and of course also guiding me to further improve.
It's enjoyable and varied -psychiatry is probably the specialty of medicine that gets most involved with legal issues because acutely psychotic patients do not think they are sick and do not want to stay in the hospital. So, we go to court to have them mandated to stay in hospital against their will "closed treatment", and sometimes even have the court mandate a treatment order so that the patient receives treatment whether they want it or not. And yes, these are serious ethical issues. But honestly, if you had a patient who had stopped taking their meds and became so psychotic that they were a danger to themselves and to others (walking on the highway, sleeping with a hammer, behaving aggressively with complete strangers), don't you think it's kind of half-assed to just have them locked up in a hospital? Unless they receive treatment, they don't actually get better. For most compassionate and risk-averse human beings, this is a sufficient argument for a treatment order.
For those more materially minded, I might say, this means the patient will be hospitalized for longer, using up your valuable tax dollars in hospital resources and the longer they go untreated, the less likely they will respond to treatment, which means that if and when they do leave the hospital, nobody benefits. Similarly, the government wants to deport people whose children are Canadian citizens because they want to save a couple of bucks on a welfare check, but who benefits when those kids get beaten from foster home to foster home, become delinquent substance abusers which may or may not trigger psychosis, doing damage to themselves and to society, not to mention the deliberate breaking apart of a family against their will? This is not a fiscally nor morally sound action. Sigh. So anyway, I have learned that a lot of "grey area" issues in theory can be very obvious in practice -it's often not much of a dilemma. That's the reality.
The most important and humbling thing that I learned though, was about myself, this past week. I also believe that this understanding is somehow deeply connected to the essence of good psychiatry and good medicine. Perhaps it is all based on counter-transferance, but that does not mean that the lessons learned are not valuable. Doctors are imperfect human beings, like anyone else. I am wholly imperfect, but as Deepak Chopra would say, the positive qualities and the shadows within us make us complete as people since we're not meant to be perfect (I know, this is the hardest thing in the world for someone like me to accept, believe me!). Anyway, so generally, I am caring and compassionate, even patient with my patients. I respect them, I try to understand them and learn from them. But when I am overwhelmed and stressed, I get frustrated, I get annoyed, I wonder why the hell these people won't just tell me openly about what's wrong so that I can help them more efficiently.
I don't actually act this out -I maintain the facade, even though I might feel this way. But non-verbal cues apparently insist on getting in the way of the whole act, and my impression so far is that psych patients are particularly sensitive to how you're really feeling and any judgmental attitudes. Really, you can't hide from them. And they will react in more extreme ways to that emotional reality. So if you feel like you severely dislike one of your patients one particular day, they will act it out for you, reflect yourself back at you. They will tell you to "go to hell, go F yourself" or will stare at you insolently and refuse to answer any of your questions. You may turn around and superficially think, "Wow, I did nothing and look, this dude is so crazy", but really, they're just reflecting the truth back at you. Maybe you're the one in the Madhouse, maybe you're the delinquent thinking one thing and behaving oppositely (hey, don't get me wrong, we all prefer incongruence in thought and action to a French Revolution-style bloodbath -how else would society function?) The point is, you're so going to get called-out on your hypocrisy.
So, this means, you have to make yourself congruent. You can't just walk the walk, you have to think the thought too. Your patients reactions (to some extent -sometimes nothing you do will make a difference because the patient is too hallucinated or delusional) are your barometer of how grounded you are and this will affect the quality of care you give and whether or not you'll do any good. Of course, this is not always the case -borderlines will remain emotionally labile and sever psychosis may be beyond anything you said or did, perhaps even most of the time. Still, your job is to make the alliance. So you failed today, try again tomorrow, and try again in a different way the day after that, and again the day after that. Because it does matter and it does make a difference and it will affect how patients cooperate and how they get better (in conjunction with medication, obviously -good luck trying without it in a psychotic patient; note that it can work without medication in other kinds of patients).
And if you made a mistake, it is actually possible to make ammends. I was never rude to my patients, nor did I verbally indicate any transient callous thoughts or frustration. But I still had to make ammends. I had to change my approach for a couple of my patients, with genuine good-will, renewed respect and transparency. And you have to be delicate. In one such encounter yesterday, my patient asked me, before agreeing to respond to any of my questions and after several long pauses, "Do you perceive me as 'sick'?" If I would have said "yes", I would have broken the alliance, he would not have trusted me, he would have clammed up and that would be the end of the interview. So I said, "I see you as a person who values X, Y and Z. X, Y and Z make you happy, and [only say this if it's true] I can understand that because X and Y (in some way or another) are important to me too. I am trying to help your body stay healthy and strong, so that you will have the energy to continue doing those things that make you happy". Maybe this only worked for me the one time and maybe I established enough trust to last a few days, or maybe not (because afterall, the patient remains somewhat psychotic). But after that encounter, I knew I did my job. I want my patients to see me as the ally that I am and I want to understand them better so that I can advocate for them better. And when I make a mistake, I can go slowly and carefully and make ammends.
I also learned that I have a lot more in common with my patients than one would think. Just because I am in medicine, does not mean that I do not embrace the concept of God and religion (half the medical staff was absent for Rosh Hashana, if you want to put things in perspective here). Perhaps I'm considered even more eccentric because I can appreciate the truth in statements like "everything is energy, the universe is energy" and even "i see the world as a field of energy" (and honestly, Einstein did too: E=mc2 anyone? So it's not that crazy of an idea... so does Deepak Chopra, so do a lot of people who do Yoga, etc...) Psychotic patients will say things like this, but these comments alone are not what make them delusional and psychotic. The best thing is when you are able to show that you 'get them' at some level because then they feel respected, rather than being ridiculed, and are more willing to open up to you. And you will totally recognize the moment when an abstract idea, perhaps held by many, is so obviously taken too far, and even more importantly, when a fixation on those ideas impairs rather than enhances the individual's social functioning. There is nothing inherently crazy about saying "the universe is a field of energy and I have that energy", "I'm going to be Prime Minister" or "God sent me message Q". It's the further probing of these ideas -the hows, the whys, the subsequent meanings derived, the details and most importantly, the emerging behaviours -that reveal the incongruencies and the illness.
And as one of my supervisors constantly reminds us, a lot of famous people suffered from those tabooed mental illnesses. John Nash lives with schizophrenia. Robin Williams and Eminem have Bipolar Disorder, so did Winston Churchill, Ernest Hemingway, Beethoven, Newton and Vincent Van Gogh. All of these people have made important contributions to the societies in which they lived, in their different ways. It is worthwhile to try to understand not only the illness, but the people who suffer from them so that maybe they don't have to complete a poetic and tragic suicide.
Anyway, maybe I'm completely off base. But apart from learning the DSM criteria for various mental illnesses and the mechanism of action of various drugs and their side-effects, I feel these are really important lessons to be learning, and better sooner than later. It probably applies to other areas of medicine too. And also, to other aspects of life on this Earth.
Monday, August 9, 2010
Summer Post-Mortem and "Crazy" New Beginnings
Well, let's just forget that "summer" ever happened. Those 5 precious weeks have come and gone with their hurdles and minimal pleasantry, save a lovely week with family and the delicious food eaten throughout and still now (smoked meat, lobster, french onion soup, etc...)
Ok, maybe I am being a little ingracious. Despite the restricted fun of the first few weeks amidst lots of studying (which doesn't always pay off in obvious, material, measurable ways, although one certainly does learn and re-learn a whole heck of a lot!), I did become quite engrossed in the FIFA World Cup and was extremely pleased to see my Spanish Roja win.
But one never expects or rejoices in heartache. It is more like a death all over again really, except it also leaves an abominable hole (I swear it feels very somatic -left parasternal border, 4th intercostal space... a physical hurt). As they say though, we're meant to learn from these things. And I did -I learned a whole heap about so many things (the vagueries are deliberate as a eulogy or shrine to the flitting beauty of affection and tenderness that imbued that tie). The longing remains, as does the love and memories (both wonderful and awful)... I'm basically counting on Lady Time to heal it all eventually.
So, anyways. This week is my second week of my Psychiatry rotation (my first official clerkship rotation) and it is awesome! The learning curve is pretty much vertical -I learned crazy amounts of stuff (no pun intended...) in just 6 days already (+1 call). Seen lots of schizophrenia, schizoaffective disorder, bipolar disorder, major depression and a few suicidal cases -emotionally tiring but very rewarding interactions and I very much enjoy the general demeanor / attitude of most of the psychiatrists and residents I have met so far. I follow 4 patients on a regular patients and basically spend more time with them than any of my superiors and it's amazing to observe and understand how they progress or deteriorate, followed by discussing potential management plans etc with the attending staff. So much fun, really... I am that much closer to becoming an almost-doctor! And the psych-social stuff is awesome, so you get to better understand the legal system (for example when you have a patient from the prison, who, in a state of acute psychosis nearly stabs someone to death...), the welfare system (a lot of psych patients are on welfare, though in some cases a third of it may go towards supporting a hefty drug habit or "self-medicating"... still they could not survive without it!), and social institutions that provide activities for people who otherwise could not work and would have nothing to occupy their days, which honestly would make anyone crazy out of boredom (so they can go to these centres and do wood-working, or plant-care, or computers or ceramics and get 'paid' for their work, a nominal $1.60 per day) and it's awesome, because a part from anti-psychotics, mood stabilizers and anti-depressants, or electro-convulsive therapy (hey, don't knock it! it's the most effective therapy for acute suicidality and mania, there's proper anaesthesia involved and all you see is a foot-twitch!), you can also prescribe these activities, like, on a prescription. It's pretty neat. The whole big picture I mean. It's not just brain drugs. It's a whole system of bio-psycho-social care and it is great (so far. from what I've seen.).
Anyways, I know. As fascinating as this part of my life is, everyone probably wants to know more about the heartache. You know, human beings are so fascinating in that way. It's like Elizabeth Gilbert wrote in Eat, Pray, Love (btw, I'm sure the book will be better than the movie, though I am so pumped to see the movie!): there are psychologists who have talked to people who have survived genocides when they were in refugee camps and all they could talk about was how that guy left me and took up with my best friend and that girl is in love with my brother, etc, etc. For all our grand achievements and terrible atrocities as a species, all we can think about is love.
Or at least I know that I certainly fall into that category. And, frankly, thank God I do. Love makes life worth living... even when it doesn't quite work out the way you thought it would (and believe me, my hurt is fresh enough, but this really is just the truth of the whole thing).
Ok, maybe I am being a little ingracious. Despite the restricted fun of the first few weeks amidst lots of studying (which doesn't always pay off in obvious, material, measurable ways, although one certainly does learn and re-learn a whole heck of a lot!), I did become quite engrossed in the FIFA World Cup and was extremely pleased to see my Spanish Roja win.
But one never expects or rejoices in heartache. It is more like a death all over again really, except it also leaves an abominable hole (I swear it feels very somatic -left parasternal border, 4th intercostal space... a physical hurt). As they say though, we're meant to learn from these things. And I did -I learned a whole heap about so many things (the vagueries are deliberate as a eulogy or shrine to the flitting beauty of affection and tenderness that imbued that tie). The longing remains, as does the love and memories (both wonderful and awful)... I'm basically counting on Lady Time to heal it all eventually.
So, anyways. This week is my second week of my Psychiatry rotation (my first official clerkship rotation) and it is awesome! The learning curve is pretty much vertical -I learned crazy amounts of stuff (no pun intended...) in just 6 days already (+1 call). Seen lots of schizophrenia, schizoaffective disorder, bipolar disorder, major depression and a few suicidal cases -emotionally tiring but very rewarding interactions and I very much enjoy the general demeanor / attitude of most of the psychiatrists and residents I have met so far. I follow 4 patients on a regular patients and basically spend more time with them than any of my superiors and it's amazing to observe and understand how they progress or deteriorate, followed by discussing potential management plans etc with the attending staff. So much fun, really... I am that much closer to becoming an almost-doctor! And the psych-social stuff is awesome, so you get to better understand the legal system (for example when you have a patient from the prison, who, in a state of acute psychosis nearly stabs someone to death...), the welfare system (a lot of psych patients are on welfare, though in some cases a third of it may go towards supporting a hefty drug habit or "self-medicating"... still they could not survive without it!), and social institutions that provide activities for people who otherwise could not work and would have nothing to occupy their days, which honestly would make anyone crazy out of boredom (so they can go to these centres and do wood-working, or plant-care, or computers or ceramics and get 'paid' for their work, a nominal $1.60 per day) and it's awesome, because a part from anti-psychotics, mood stabilizers and anti-depressants, or electro-convulsive therapy (hey, don't knock it! it's the most effective therapy for acute suicidality and mania, there's proper anaesthesia involved and all you see is a foot-twitch!), you can also prescribe these activities, like, on a prescription. It's pretty neat. The whole big picture I mean. It's not just brain drugs. It's a whole system of bio-psycho-social care and it is great (so far. from what I've seen.).
Anyways, I know. As fascinating as this part of my life is, everyone probably wants to know more about the heartache. You know, human beings are so fascinating in that way. It's like Elizabeth Gilbert wrote in Eat, Pray, Love (btw, I'm sure the book will be better than the movie, though I am so pumped to see the movie!): there are psychologists who have talked to people who have survived genocides when they were in refugee camps and all they could talk about was how that guy left me and took up with my best friend and that girl is in love with my brother, etc, etc. For all our grand achievements and terrible atrocities as a species, all we can think about is love.
Or at least I know that I certainly fall into that category. And, frankly, thank God I do. Love makes life worth living... even when it doesn't quite work out the way you thought it would (and believe me, my hurt is fresh enough, but this really is just the truth of the whole thing).
Saturday, June 19, 2010
Post-surgery & half-doctor: Yes, she still writes!
Surgery has come and gone, and look, I haven't even written to you! For shame. In short, surgery was a wonderful experience overall... hard work, no doubt, but also awesome. I had the best mentor surgeon of all time. She was not a 'typical surgeon' -lovely bedside manner, attentive, patient and caring, gentle, loved by her patients even when they had complications... and really, just a beautiful person. And she was the chief of general surgery at the hospital where I was placed.
Cool points of the rotation: I got to scrub in on a couple of surgeries -an open indirect inguinal hernia repair and a laparoscopic cholecystectomy (gall bladder removal), the latter in which I almost fainted while retracting (luckily I had the sense to mention that I was "feeling a little faint", so that the scrub nurse could quickly take over and make me sit on the floor before I totally blacked out!). I also watched 2 cataract surgeries and a corneal transplant (awesome to watch, but I never want to be an opthalmologist. I also never want to be a radiologist. Something about spending all your days in a dark room, I think...). The OR is kind of amazing though -thrilling (and hardcore, I'm not going to lie)!.
You know what else is thrilling and hardcore? The season finale of Grey's Anatomy (which of course I only finally had the chance to watch yesterday after my surgery exam and before the end of ICM BBQ at Beaver Lake). Stunning episode, amazing acting, and so intense. Not only did I tear up, I was actually sobbing -best outlet of life, I say!
And now I am half a doctor (well, you can't really be half a doctor... just like how you can't really be half pregnant, but it sounds cool doesn't it?). Start up again end of July and no holiday for the next 2 years (for real. like I have to choose whether I want to take Christmas Day or New Year's Day off). So my exciting summer plans include writing the USMLE Step 1, having my extended family come visit from out-west (first time in over 10 years for most of them, so that will be wonderful!), and then retreating up north for a few days to recharge before Clerkship officially begins.
However, before I get back to studying for this next exam, I am taking this weekend off. Le battery is dead, the tank is on empty, le brain is nearly dead, exhaustedly, I have nothing left to offer the world at this very moment. So today there was some self-pampering with an aromatherapy massage, a nice vegetarian lunch... also I have taken to drinking homemade matcha green tea-almond milk frappes... so delicious and energizing! I played the piano a bit (for the first time in a long time), I watched the end of a devastating FIFA World Cup match for Cameroon.
The best thing in life these days though is reading Three Cups of Tea and worshipping Greg Mortenson (hopefully I will finally finish this amazing book by the end of tomorrow!) Another best thing in life was going to my first wedding of an undergrad roommate. It's official. I will be going to weddings for the next 10 years, right? Then it will be time for, as Franc, in Father of the Bride II, would say, "the behbeh showa". Life is too crazy.
But overall, I think it's good. Just important to recharge those batteries. And to always take the time to write. Note to self: do as I say, not as I do!
Cool points of the rotation: I got to scrub in on a couple of surgeries -an open indirect inguinal hernia repair and a laparoscopic cholecystectomy (gall bladder removal), the latter in which I almost fainted while retracting (luckily I had the sense to mention that I was "feeling a little faint", so that the scrub nurse could quickly take over and make me sit on the floor before I totally blacked out!). I also watched 2 cataract surgeries and a corneal transplant (awesome to watch, but I never want to be an opthalmologist. I also never want to be a radiologist. Something about spending all your days in a dark room, I think...). The OR is kind of amazing though -thrilling (and hardcore, I'm not going to lie)!.
You know what else is thrilling and hardcore? The season finale of Grey's Anatomy (which of course I only finally had the chance to watch yesterday after my surgery exam and before the end of ICM BBQ at Beaver Lake). Stunning episode, amazing acting, and so intense. Not only did I tear up, I was actually sobbing -best outlet of life, I say!
And now I am half a doctor (well, you can't really be half a doctor... just like how you can't really be half pregnant, but it sounds cool doesn't it?). Start up again end of July and no holiday for the next 2 years (for real. like I have to choose whether I want to take Christmas Day or New Year's Day off). So my exciting summer plans include writing the USMLE Step 1, having my extended family come visit from out-west (first time in over 10 years for most of them, so that will be wonderful!), and then retreating up north for a few days to recharge before Clerkship officially begins.
However, before I get back to studying for this next exam, I am taking this weekend off. Le battery is dead, the tank is on empty, le brain is nearly dead, exhaustedly, I have nothing left to offer the world at this very moment. So today there was some self-pampering with an aromatherapy massage, a nice vegetarian lunch... also I have taken to drinking homemade matcha green tea-almond milk frappes... so delicious and energizing! I played the piano a bit (for the first time in a long time), I watched the end of a devastating FIFA World Cup match for Cameroon.
The best thing in life these days though is reading Three Cups of Tea and worshipping Greg Mortenson (hopefully I will finally finish this amazing book by the end of tomorrow!) Another best thing in life was going to my first wedding of an undergrad roommate. It's official. I will be going to weddings for the next 10 years, right? Then it will be time for, as Franc, in Father of the Bride II, would say, "the behbeh showa". Life is too crazy.
But overall, I think it's good. Just important to recharge those batteries. And to always take the time to write. Note to self: do as I say, not as I do!
Wednesday, April 7, 2010
Confronting the Internal Issue
So why have I not said a word about medicine lately. I am sure you are wondering this. Or maybe I flatter myself here. But well, let's confront the hard, cold truth here. Which is that I am not particularly enjoying it these days. In fact, sometimes I resent it. I am glad to be learning a whole lot of stuff, of course. It's the pressure-cooker I can't stand. That is what I am in right now, veritably. Believe me -Internal Medicine is no picnic. And I would know, because I actually did go for a lovely picnic this past summery long weekend in Montreal. We ate delicious avacado, havarti, sliced turkey, tomato, lettuce and dijon-mayo with salt and pepper sandwiches. And there was bocconcini, baby tomato and pesto salad. And later that weekend, my semi-salty chocolate chunk cookies. And Internal Medicine is galaxies away from that.
If I had to describe Internal in one word it would be this: a drag. But actually soul-sucking, opposite of joie-de-vivre, let's watch really sick, really old people who are too far gone to actually help -let's watch them get sicker, be in more pain, deal with more side effects, happily acquire C. difficile and VRE until their bodies and spirits and minds waste away, wrangle their friends and families haggard, give up with one last moan and at last, die. Now, you might be wondering how on Earth I could utter these words and yet be so infatuated with Palliative Care. That is because in Palliative, the goal is not "one last damn fight" to manage or control or cure the pathology. It is to manage pain, to make patients comfortable in their last days so that they can attend to more important material and spiritual concerns before leaving this world. The goal is the patient, not the collection of systems that happen to find themselves in a single human body. Bleak, you say? My friends, you ain't seen bleak until you've lived Internal.
And maybe that's life's ironic metaphor. That anything Internal is really an Inferno, which, if you're not careful, will burn you up and leave behind nothing but smoke and ash. Now really, this is not to say that the doctors in Internal Med are not good doctors. As a darling friend would say, "Au contraire mon frère!". They are some of the best doctors, hands-down. They are bright, compassionate, award-worthy, have one hell of a memory, boundless energy and the ones I have met really love what they do -really, exemplary physicians, no question. But it's the culture of Internal that is soul-sucking, the know-it-all, we're-so-busy-and-important and frankly reductionist 2D-attitude that rubs up so hard against me. I don't know. Perhaps I'm being unfair. Perhaps these guys have all read Kuhn's The Structure of Scientific Revolutions and Kleinman's What Really Matters and Andrea Tone's Medicating Modern America and enjoy reading fiction on occasion.
Just, well, my imagination feels so... stunted. Not because they don't think out of the box -believe me, if anyone has to think outside the box, it's these guys. But... there's... I just have a general feeling that there is a missing-the-forest-for-the-trees here. There ain't no space for no existential crisis. Nobody has the room to break themselves open and re-make themselves whole. And I can't quite touch the tangible problem here, except that I feel like my favourite part of me and what will make me the good kind of doctor that I want to be, kind of dies a little every day in there. Like someone rubbing margarine all over your windows... I mean, you can't see anymore! Really see. Because the science of the medicine is extremely important, absolutely 1000% necessary (and I plan on doing my 1000% best in learning it, I swear), but so wholly and fully insufficient. There is no way anyone is seeing the whole picture when the body is just an ammalgamation of systems. The whole is greater than the parts. And when it comes down to it, even Internal cannot explain the whole -they'll just call it 'autoimmune' instead. Sometimes they'll say 'idiopathic' (as in "we're idiots on this one"). They'll diagnose your COPD, your CAD, your CHF, your RA, your pancreatitis, your anemia... but when it comes to managing the whole picture and the person that actually manages to get them all (these poor patients, yes, they exist)... it's a sad deal. And it's suffering and wasting away and then a long (or short), painful death.
Yes, all areas of medicine deal with suffering and pain and death. But there's something about this baby that just saps my energy to negative 10,000. Really. I don't know what it is. But it makes me miss Anaesthesia like nobody's business. Okay. So there you have it. I think I'd most likely rather be a surgeon than an internist any day. But who knows -I have yet to do my ICM surgery rotation.
If I had to describe Internal in one word it would be this: a drag. But actually soul-sucking, opposite of joie-de-vivre, let's watch really sick, really old people who are too far gone to actually help -let's watch them get sicker, be in more pain, deal with more side effects, happily acquire C. difficile and VRE until their bodies and spirits and minds waste away, wrangle their friends and families haggard, give up with one last moan and at last, die. Now, you might be wondering how on Earth I could utter these words and yet be so infatuated with Palliative Care. That is because in Palliative, the goal is not "one last damn fight" to manage or control or cure the pathology. It is to manage pain, to make patients comfortable in their last days so that they can attend to more important material and spiritual concerns before leaving this world. The goal is the patient, not the collection of systems that happen to find themselves in a single human body. Bleak, you say? My friends, you ain't seen bleak until you've lived Internal.
And maybe that's life's ironic metaphor. That anything Internal is really an Inferno, which, if you're not careful, will burn you up and leave behind nothing but smoke and ash. Now really, this is not to say that the doctors in Internal Med are not good doctors. As a darling friend would say, "Au contraire mon frère!". They are some of the best doctors, hands-down. They are bright, compassionate, award-worthy, have one hell of a memory, boundless energy and the ones I have met really love what they do -really, exemplary physicians, no question. But it's the culture of Internal that is soul-sucking, the know-it-all, we're-so-busy-and-important and frankly reductionist 2D-attitude that rubs up so hard against me. I don't know. Perhaps I'm being unfair. Perhaps these guys have all read Kuhn's The Structure of Scientific Revolutions and Kleinman's What Really Matters and Andrea Tone's Medicating Modern America and enjoy reading fiction on occasion.
Just, well, my imagination feels so... stunted. Not because they don't think out of the box -believe me, if anyone has to think outside the box, it's these guys. But... there's... I just have a general feeling that there is a missing-the-forest-for-the-trees here. There ain't no space for no existential crisis. Nobody has the room to break themselves open and re-make themselves whole. And I can't quite touch the tangible problem here, except that I feel like my favourite part of me and what will make me the good kind of doctor that I want to be, kind of dies a little every day in there. Like someone rubbing margarine all over your windows... I mean, you can't see anymore! Really see. Because the science of the medicine is extremely important, absolutely 1000% necessary (and I plan on doing my 1000% best in learning it, I swear), but so wholly and fully insufficient. There is no way anyone is seeing the whole picture when the body is just an ammalgamation of systems. The whole is greater than the parts. And when it comes down to it, even Internal cannot explain the whole -they'll just call it 'autoimmune' instead. Sometimes they'll say 'idiopathic' (as in "we're idiots on this one"). They'll diagnose your COPD, your CAD, your CHF, your RA, your pancreatitis, your anemia... but when it comes to managing the whole picture and the person that actually manages to get them all (these poor patients, yes, they exist)... it's a sad deal. And it's suffering and wasting away and then a long (or short), painful death.
Yes, all areas of medicine deal with suffering and pain and death. But there's something about this baby that just saps my energy to negative 10,000. Really. I don't know what it is. But it makes me miss Anaesthesia like nobody's business. Okay. So there you have it. I think I'd most likely rather be a surgeon than an internist any day. But who knows -I have yet to do my ICM surgery rotation.
Sunday, March 28, 2010
Post-Baking...
So, yes. I did, in fact, actually bake. I didn't pull the "oh it would be nice to start baking in theory" stunt. Just pulled out my first batch of chocolate chunk/chip cookies, which are huge because how would i know those dollops would expand into massive, flat... things. The dough tasted a bit salty for some reason, even though i put everything in exactly like the recipe said to, except I cut the sugar quantity in half, just like my mum always does. Cookies are successful in being crispy on the outside, soft and gooey on the inside, but they crumble a bit -why is that? Anything to do with the changed sugar to everything else ratio? And although the cookies are not quite as salty as the raw dough, they taste just a tad on the saltier side... I don't know. I feel a bit discouraged to be honest. Like how am I going to one day bake the world's most fabulous red velvet cake if I can't even get a batch of standard, run-of-the-mill chocolate chip cookies done right? Sigh.
I have a headache now. True, I did eat a massive Sunday buffet brunch at this Indian restaurant in the West Island that I had never been to before... fried fish, tandoori chicken, another kind of barbecued chicken, pakoras and puri-chaat... those were just the appetizers (I went up twice for these). Then three naan slices with aloo gobi, butter chicken, lamb curry and spicy chicken curry (this was in 2 plate-fulls). Then dessert of kheer and gulab jammun... that was done thrice. And a cup of chai. Then in making my cookies, I ate some cookie dough. Then of course once the cookies were made, even though I felt like I was going to explode, I had to try 3/4 of one, having already downed 2 glasses of water to compensate for the salty dough. Now I really feel bloated, sick, tired... I even did yoga this morning (but apparently not enough to prepare for all these obnoxious assaults on my body...).
Really... I should just fast the rest of the day. Maybe a nap will help before trying to study... gotta get rid of this food overload, but I feel too tired to join my father for a walk. Ok... here's the plan: nap for half an hour, learn how to read ECGs better for 30-60 min, read some Blueprints afterwards. God give me strength. At least we know I won't get hungry in between...
I have a headache now. True, I did eat a massive Sunday buffet brunch at this Indian restaurant in the West Island that I had never been to before... fried fish, tandoori chicken, another kind of barbecued chicken, pakoras and puri-chaat... those were just the appetizers (I went up twice for these). Then three naan slices with aloo gobi, butter chicken, lamb curry and spicy chicken curry (this was in 2 plate-fulls). Then dessert of kheer and gulab jammun... that was done thrice. And a cup of chai. Then in making my cookies, I ate some cookie dough. Then of course once the cookies were made, even though I felt like I was going to explode, I had to try 3/4 of one, having already downed 2 glasses of water to compensate for the salty dough. Now I really feel bloated, sick, tired... I even did yoga this morning (but apparently not enough to prepare for all these obnoxious assaults on my body...).
Really... I should just fast the rest of the day. Maybe a nap will help before trying to study... gotta get rid of this food overload, but I feel too tired to join my father for a walk. Ok... here's the plan: nap for half an hour, learn how to read ECGs better for 30-60 min, read some Blueprints afterwards. God give me strength. At least we know I won't get hungry in between...
Wednesday, March 24, 2010
Spring Fever? More like "this season is on 'shrooms"...
It has been a long time since I have written. Really, it's just not healthy for a writer not to be writing more often... like an athlete who stops training -they get out of shape, they're not on their game, and most importantly, they probably also feel terrible (endorphins-withdrawal or something!). So forgive the off-beat style today.
The weather has gone nuts. Ya think it's spring, and then, BOOM! Hail, snow, rain... all at the same time. The trees that had just begun to bud were dipped in crystal and cold, along with that spring optimism. But take heart -we are stronger and tougher than that. And this morning, the sun shone bright as lamp posts cried puddles around us, and the glistening rainbows between the branches of the phantom-like trees dared another storm. It's so bizarre. And frankly, it's sickeningly exhausting sometimes (as in, I am actually sick because what ordinary human body can handle such temperature fluctuation without reeling just a little!).
Anyways. I think I want to learn how to bake some stuff. Mostly, because I realize I have become a cookie monster over the last month or so... it's great when the crispy-on-the-outside, soft-and-chewy-in-the-middle varities of chocolate chip heavenly morsels are free. (Aside: why does free stuff always taste better? look better? wear better? i mean seriously, isn't your favourite pen that free one you got at recruiting 2 years ago?) But you know, these days are not like those good ol' days... to purchase a gourmet cookie, will cost one roughly $3.99 -for one bloody cookie! It's insane. And multiply that number by 100 and you've got the calorie count for that same cookie -again, for one bloody cookie! And although these cookies do tend to be delicious, they are invariably too sweet. So like, I need to find a good cookie recipe and just cut that sugar in half. That way, I can eat 2 whole cookies for roughly 399 calories, savvy? Good recipe suggestions welcome. The other nice thing about baking is then sharing the goods with the people you adore -always a much enjoyed and heartily appreciated gesture to indulge a gourmande (and let's be serious, I do not befriend people who are not gourmandes ;).
Speaking of good food. I ate quite a delicious margherita pizza last weekend (yes, in Toronto of all places... i know, i know, incroyable, really! but good food in that city does in fact, exist... actually, since the last 3 months I have been visiting Toronto, I have yet to have an unpleasant culinary experience, which believe me, surprises both me and you... not to diss Toronto, but you know, I'm still a little sore about last weekend's hockey game -hopefully we beat the Sabres tonight though... then all will be well =) So anyway, this pizza. Hole in the wall place -Buddha Pie. Gourmet-pizza standard price. Thin crust (a bit too crispy, I will admit... yet not a deal-breaker by any stretch!), fresh crushed tomatoes as a base 'sauce', buffalo mozarella (slightly over-melted, but again, still fantastic), and freshly chopped basil. Really. Really. It was good. It was mmmmmm... good.
Well, nothing like writing - writing about the natural world, writing about food, to cheer one up amidst these seasonal upheavals!
The weather has gone nuts. Ya think it's spring, and then, BOOM! Hail, snow, rain... all at the same time. The trees that had just begun to bud were dipped in crystal and cold, along with that spring optimism. But take heart -we are stronger and tougher than that. And this morning, the sun shone bright as lamp posts cried puddles around us, and the glistening rainbows between the branches of the phantom-like trees dared another storm. It's so bizarre. And frankly, it's sickeningly exhausting sometimes (as in, I am actually sick because what ordinary human body can handle such temperature fluctuation without reeling just a little!).
Anyways. I think I want to learn how to bake some stuff. Mostly, because I realize I have become a cookie monster over the last month or so... it's great when the crispy-on-the-outside, soft-and-chewy-in-the-middle varities of chocolate chip heavenly morsels are free. (Aside: why does free stuff always taste better? look better? wear better? i mean seriously, isn't your favourite pen that free one you got at recruiting 2 years ago?) But you know, these days are not like those good ol' days... to purchase a gourmet cookie, will cost one roughly $3.99 -for one bloody cookie! It's insane. And multiply that number by 100 and you've got the calorie count for that same cookie -again, for one bloody cookie! And although these cookies do tend to be delicious, they are invariably too sweet. So like, I need to find a good cookie recipe and just cut that sugar in half. That way, I can eat 2 whole cookies for roughly 399 calories, savvy? Good recipe suggestions welcome. The other nice thing about baking is then sharing the goods with the people you adore -always a much enjoyed and heartily appreciated gesture to indulge a gourmande (and let's be serious, I do not befriend people who are not gourmandes ;).
Speaking of good food. I ate quite a delicious margherita pizza last weekend (yes, in Toronto of all places... i know, i know, incroyable, really! but good food in that city does in fact, exist... actually, since the last 3 months I have been visiting Toronto, I have yet to have an unpleasant culinary experience, which believe me, surprises both me and you... not to diss Toronto, but you know, I'm still a little sore about last weekend's hockey game -hopefully we beat the Sabres tonight though... then all will be well =) So anyway, this pizza. Hole in the wall place -Buddha Pie. Gourmet-pizza standard price. Thin crust (a bit too crispy, I will admit... yet not a deal-breaker by any stretch!), fresh crushed tomatoes as a base 'sauce', buffalo mozarella (slightly over-melted, but again, still fantastic), and freshly chopped basil. Really. Really. It was good. It was mmmmmm... good.
Well, nothing like writing - writing about the natural world, writing about food, to cheer one up amidst these seasonal upheavals!
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