Autumn days: Comfort & Company

The leaves have already turned their golden to coral hue -it's fall again, reminding me of another year past, and the beginning of the next. Days shorten like the cervix of a complicated pregnancy, preparing for the release of snow and ice, sooner than we'd like (okay, bad joke, but I can't help myself -it's all high risk obstetrics in Toronto now and then Ottawa, in a week)! Anyway, this city has been good to me, this time around, or perhaps despite the chill, I've been warming up to it a bit. Continuing to discover good eats (Sukothai, Gilead, Oliver & B's) and revisit the places I've enjoyed in the past (Red Lobster, Sushi Bar, Spring Rolls). This is a picture of the best dessert I've had in Toronto (post-lunch indulgence today): Sticky toffee pudding with Chantilly cream at Gilead, in Corktown... yummy! Meeting old and new friends, in various contexts (work & play). I saw a beautiful foreign film at the Film Festival, "Habibi", a modern Laila & Majnun set in Gaza -the poetry on the city walls was the best part really. I've met some lovely physicians and am generally enjoying this downtown hospital. Learning a lot about medicine, life, love, pacing and myself. It's a good place these days, this temple that is my body.

Before arriving here, I had the simultaneous fortune and misfortune of having a retinal tear discovered in my right eye. Right -that side with which we give, share and work. Misfortune in that I was scared out of my wits thinking about the possibility of retinal detachment, going blind in one eye, losing stereopsis, and perhaps not being able to become a surgeon one day. Fortune in that the tear was discovered before I had any symptoms, was incredibly rapidly diagnosed and treated with laser within 24 hours. The other blessing was that I got to re-experience what being a real patient is all about. Fitting for the end of my short palliative care elective -nothing like wearing the shoes yourself, you know.

First of all, can I just say that it is very difficult to be a medical student and a patient at the same time. See, we know what being the "good patient" is, and we understand that medicine makes no guarantees or promises and that there are enough risks in any given situation. Most physicians will tell you that doctors are the worst patients -always questioning, analyzing, etc in their awareness of all the risks. But then there are people like me, who like to be liked. Which means I have to be the "good patient" -smiling, being stoic / tough / courageous, asking a few questions but not too many, and above all, no whining, no complaining, no losing our cool, especially because we are medical students. And yet, despite the fact that the residents and fellows in opthalmology spoke to me and treated me as one of their own and I knew I was in good hands, I found I felt immensely alone in my state of just being a patient: worried, scared, wondering what the best decision for treatment would be, exhausted by having numerous dilating eye drops and many a bright light shone into my eyes for a total of just over 2 hours, feeling stressed and overwhelmed and entirely disrupted and unrooted from my life, even if only for 24 hours. The only moment where I felt myself relax and breathe momentarily again was after my eye had been repeatedly lasered, tears silently running down the sides of my face and temples (it hurt, but I was doing my best to just tough it and ignore the emotional and physical trauma of the whole ordeal) -the fellow put a hand on my shoulder, asking if I wanted a little break and then acknowledged that it couldn't be any fun, that he'd never had it done himself and would probably be a big baby if he was in my place. I was so relieved. I had been wondering whether those strong, brave patients we all love so much, actually never felt the pain that much or whether they just did a good job of hiding it, unlike my own body which betrayed humble suffering.

And so I had been patient, and as kind and empathetic as I could with my palliative care patients prior to that fated day, when in a sense, I became one of them. Not in their state of imminent death of course, but in sharing that heartache of being 'sick', having pain, seeking comfort, company and love. That is just the human condition. That's what I loved about palliative care -it was all about our humanity. Our physical, emotional, psychological and spiritual health, as patients, as their families, and as the interdisciplinary care team. Imagine a doctor walking into a patient's room and asking them how they are doing, how they are feeling, asking about their fears, their pain, their hopes. And then, turning to their anxious spouse, or niece, or young daughter and asking how they were doing, how they were coping and letting them know that all the support resources available to the patient were also available to them -psychologists, music therapists, massage therapists, the works. This is the model for all health care. And in an ideal world, all patients need and deserve it, as do their families.

Until then, I remain yours truly, doing the best that I can. My goal as a physician will be to make sure my patients feel supported and loved as we treat their physical ailments, and also to love and support my colleagues so that as a team, we can do better.

Enchanting Cerebrum & Solidifying the Path

The moon hangs delicately in the dark sky tonight, a solitary pearl on an invisible thread. The humidity seems to have dissipated, somewhat. The light of day that used to linger late, now sets a bit sooner than we expect. The trees still fill the air with their fragrant perfume on a magical night stroll down avenues and park lanes in my sweet neighborhood. August at last.

And, at last, these lovely, wondrous, romantic thoughts fill my mind and spirit all over again. My wounded heart -this cut, not quite so deep as in the past -has healed again. The heart is probably the only organ that scars may beautify, powerfully transforming who we were into who we are. Perhaps, my language here is a bit excessively deliberate, enthralled by this physical world of nature, and the mysterious physical world of the human body. Only a surgical rotation could enchant me to poetry, I suppose, and here I am.

Neurosurgery. The pulsating brain and spine, the intricate vessels above, below and within, that clear fluid unlike any other bodily fluid, the aponeurosis they call the Galea (even their names for certain kinds of anatomy are more magical!), stemming from temporalis that ensheaths the cranium, and a thin sheet of scalp above. Sigh. Really it's a beauty and an honour. And what pleasure to learn about its inner workings, to unveil a sliver of the secrets of this truly supreme human organ. The root of invention, innovation, creativity... even love! Ah yes, this is love.

It's a once-in-a-lifetime experience for a determined would-be obstetrician / gynecologist. Yes, that is still exactly what I want to be. 100% sure. It's just that this is therefore my only chance to learn about and watch the brain and those amazing men (they are 90% men, those particular breed of doctors) perform intricate, delicate surgeries on that most prized cerebrum. It's amazing. It's like watching Picasso or Monet or Renoir in action (or what I would imagine that to be, not knowing from first-hand experience). I'm no Picasso or Monet or Renoir. I'm just me and I know that I would not be happy painting for the rest of my life. I'm a writer and soon-to-be doctor. But I can still admire their artistic works. Appreciate them, perhaps love them even.

Afterall, neurosurgery combined with obstetrics is what inspired me to want to become a doctor -intrauterine neurosurgery on a fetus who would have been born with spina bifida and who, following this intervention, was born with full functioning of their nervous system! Breathtaking, really.

So this is what neurosurgery has been for me so far -I'm loving it, the doctors I work with (striking residents aside) are great, I'm learning a lot from self-teaching, and from their experiences.

My elective prior to this, was in obstetrics and gynecology and was truly fantastic. The independence, the technical skills I got to practice, the one-on-one teaching with many different staff. Learning how to do obstetrical ultrasound at some very, very basic level, all by myself (I can tell you by sonography whether the baby is cephalic or breech, whether they have a heartbeat and their abdominal circumference... I have even had success at determining the fetus' sex -not as easy as you would think!). I got to scrub in for nearly every single C-section. I got to close peritoneum thrice! I got to see how to manage shoulder dystocia twice. I got to assist in laparoscopic gynecologic surgeries and exploratory laparotomies. I got to bond with those lovely, glowing, strong, inspiring women as they became new mothers or continued their already-commenced journey of motherhood. It was fabulous. This is what I want to do, this is for sure.

It's so comforting to know my path in this regard, in the larger trail of whatever my life's work will be. Thank you God, thank you Universe, thank you love. And thank you creative muse, wherever you are.

From the Mind's Gables

I look out to those beginnings with hope, and love and fervour and anticipation. Because I have had my share of endings in a recent short period of time. Always more endings -the end of my short vacation, the end of my third year of medicine, the end of a sweet, brief romance. And with every end, a piece of me dies, making space for something new to grow in its place. I'm no botanist, no herbologist, but this is real. Summer's kiss, the caress of the sun, now a faint memory, life pleading, experience pushing, pressing, pulsing against me, within and through me, that I may shatter infinitely. And who will I be at the end of all that? What will I be like, once I've toughened up real good? Once I weld up and layer this formerly delicate armour? What kind of a person will breathe softly beneath it all? What kind of doctor will remain cloaked in the wine-toned gowns of the Earth, whose gravity pulls her face to the soil, filling her eyes, mouth and nostrils and then demanding that she see, speak, smell and live?

And yet the ending of all these, signal new beginnings too. It's a cliche. But death is necessary for rebirth. Pleasure, joy and fulfilment are known only through our experience and concept of their opposites and their lack. I'm finally going to be doing what I love in this next elective -I can only hope and pray that my path be revealed and confirmed in the coming three weeks, that I fall in love so deeply and so madly with my profession that I overflow, flooding, annhilating all other emotions, wounds, memories. The real romance should only ever be with oneself, one's work, one's God. The rest is for the meek hearted. Be your own rock in the storm. Let the thunder and the waves crash down and around -the water breaks, not the stone. It is hard and cold, perhaps even cracked in some places, but it does not weep nor does it fall to pieces.

As Anne Shirley would say, "Tomorrow is a new day, with no mistakes!" When we get the blessed opportunity for a fresh start, we'd best go into it a little wiser.

Fragmented Moments

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?

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.

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!

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=)