Today in clinic a Dene Elder says to me while I am listening to his heart, "If it sounds a little different, it's 'cuz it has a Native beat".

I have never laughed so hard with a stethoscope in my ears.

One of those patients that I felt an instant connection with. I stared at those deep laugh lines etched in his tan skin while he told me about his cardiology appointment. He pulled out a palm sized moleskin notebook and recited ejection fractions and names of specialists and amiodarone adjustments (which he doesn't care for, after all the reading up he's done on it). He told me that when he had his heart attack he remembered being wheeled in through the hospital doors and that when they closed behind him, many other areas of his life closed behind him too. He woke up eight days later in a cardiac intensive care unit.

He golfs, he lifts weights, he walks everyday. His intensivist told him he was a "ticking time bomb" but he pointed out to me that he was still here. I told him I was glad of that.

I wanted to cancel the rest of my afternoon and just listen. Such a vivid cast of characters in this unfolding narrative which is my life.

Last Day

Today is my last day as an R1, which officially marks the halfway point in my rural family medicine residency training. I find it amusing that I have to have my orders and prescriptions reviewed and see patients in a parallel consulting style today, but once the weekend is over, I don't. It is a magical weekend I suppose wherein all the wisdom of my R1 training will culminate and crystallize to make me safe on Monday morning in a way that was different from today. Ha!

I laugh because this is almost as ridiculous as the fact that a year from now I could go to sleep on Sunday night as a resident and wake up Monday morning as an attending (well if it weren't for the extra training I'm planning in surgery).

These days seem, like all other milestones, eerily anticlimactic. It is exciting though in some ways to feel that sense of independence slowly developing, to find myself feeling slightly more confident with certain things that were so scary and daunting a year ago (my first order as a doctor was for a chest x-ray and I remember being completely freaked out when I wrote it! How pathetic is that?!)

Maybe today to mark the occasion ALL my patients will get chest x-rays! (I'm kidding, of course.)

Onward and upward, amigos!

I See You

My first year of residency is winding down and I've been in my last rotation, internal medicine. 

I've been taking care of a patient who has given me a glimpse into how horrifically a human can hurt another, humiliate another, destroy another. I've had forms to fill out, phone calls to make, family members to meet with. All of this has provided enough busy work to keep my mind from drifting into actually processing the things I see in front of me. It has kept me from considering, for more than a fleeting moment, what my patient might possibly be going through...what the family might be going through. I feel borderline selfish even, getting upset over it, shaking my head over it, because it seems I am making it about me and not my patient. We're all drained, we all want to look away.

I come home, I want to talk about it yet I don't want to say a word.

The manager of the ICU sat beside me yesterday at the nursing station and said, "you are obviously passionate about your job, you obviously chose the right profession". I took it as one of the highest compliments I've received, but as she said it I nearly burst into tears. I thought about how much I hate this job sometimes and the things it shows us, about ourselves and about others. I feel weak when my work upsets me, and I feel jaded when it doesn't.

As I drove home today I felt angry about this job, I thought about what an awful line of work it can be. I watched the bobcat driver roll up and down our front yard, the heat beating down on the metal roof. Back and forth, spreading the dirt out.

My dad used to do work like that, he worked construction and road crews. As I got older I felt sorry for him, that this was his job. I continued to watch the methodical work out my front window and couldn't tell if what I felt was pity or envy.

Not Today

I do not miss my dad on Father’s Day. I miss him on all the other days. The funny days having a new puppy, the tough days struggling through nursing school, the exciting days moving to Ireland, the stressful days interviewing to come back to Canada. The boring days of car shopping, the celebratory days of graduating, the busy days of working, yes, I missed him all those days. I do not miss my dad on Father’s Day.

Skin to Skin

I meant to come home and write all about it. But of course by the time I got home my stomach was aching with hunger and I had a fridge holding wilted cilantro and questionable soy milk. So I had to make a dazed trip to the grocery store where I found myself staring at the nectarines and asking myself, "Do I really eat nectarines?" which then spiraled into an internal dialogue about the ethics of buying fruit that is shipped from a thousand miles away in order for me to have some variety in my snacks. This always happens when I am tired. I start to question everything I eat and try to convince myself that a diet of entirely chocolate and "Mary's Crackers" will suffice.

So now I am just standing there with my basket containing cheese, kale, and tuna and I am nowhere closer to having a normal dinner, showering, and writing up the day's experiences.

I did my first c-section! Let me qualify that statement. I have done all the 'steps' of a c-section in the past - but never all on one person. Usually the surgeon opens up to the uterus and then I go from there, or I open and they close. Or some other combination of events. But this one was mine from beginning to end, the reward for all my hard work, so I was told. I wanted to write it all down, remember every moment, however, many of the details are already starting to blur.

It was hard work rewarded with hard work. This was her third section which meant that the often easily identifiable tissue planes and regions become scarred down to one giant zone of adhesions. Meticulously dissecting the bladder can still result in injuring it or unknowingly cutting too low on the uterine wall. The tissue is also thinner which can be an issue when it comes to closing up, add in the friable bleeders, distorted anatomy, and the clock that is always ticking down on how long the spinal anesthesia is going to last.

My mentor was walking me through it, keeping the pressure on for time while ensuring I was being cautious yet bold. It's a weird combination. When you cut - CUT! Don't saw away taking little swipes! Go deeper...not THAT deep. 

Being new to all of this I still don't appreciate the different forces needed to cut through skin, fat, and muscle. I don't hold the cautery just right, I can't throw a fast stitch in a bleeder. I don't know when to dissect with my finger versus gauze versus a blunt end of a blade versus a blade. It's an entirely different universe suddenly, peeking out between the sterile blue drapes. I'm navigating with a mask that covers my mouth, connected to a plastic shield over my eyes.

Sweat is dotting the inside of my plastic shield and I can feel it running down my sides. The other surgeon is waiting at the dictation desk and his patient, a hernia repair, is waiting in recovery to come in. We are only a little behind schedule but the scrub nurse reminds me that the next surgery should have already started. The baby is out, I can't remember if it was a girl or boy. I can't even remember the mother's name or face. I would have never believed it if someone would have told me that I would forget the gender of the baby of my first skin to skin cesarean. But I don't. I remember green armytage forceps.

I remember being thrilled, scared, and sweaty. I remember having to change my scrubs immediately after, before going out to recovery. They were soaked from my chest down to my knees, as if someone had thrown a bucket of water at me. I remember being happy and surprised that mum and babe had an absolutely unremarkable course in hospital and that they were discharged two days later.

How could I have done that right?

May Day

Not exactly sure where April went. Well it involved a holiday to the UK, then buying a house and writing my QE1 exam. Oh, OK, that is where April (and the beginning of May) went.

Since residency started I feel that I am standing on the platform of a subway station. The days go whizzing by, past my face, at a speed that leaves everything a trailing blur. Then for a moment, the subway stops and people pour out, and pour in, bumping past me. Some linking eyes, some carrying on, some talking, some silent. I remain still and the chaos moves briefly around me, then the doors close and everything speeds up again. There are these blips of human interaction that stand out, but much of it remains a blur.

I kick myself for not writing, even just for myself, every night. I really ought to try and start doing that. Maybe that will be my mid-years resolution.

Things have been in a state of flux. I recently went through yet another soul searching time in my post-graduate training. I am gearing up to apply for my +1 year (in Canada GP's can undertake extra training in things like emergency medicine, anesthetics, surgery, obstetrics, palliative care, sports medicine, etc). I always knew I wanted to do this +1 option but I've gone around and around with what area to specialize in. I thought for a long time that it would be emergency medicine, but if I am honest I am getting to be COMPLETELY over EM. I am just tired of all the abuse that goes on in the ED, in every realm: patients abusing the system by going to emerg for non-emergent presentations, patients abusing the physicians and nurses, and then the specialists abusing us when we call to consult them. I still love a sick patient, a surgical patient, a procedure-needing patient, but that is about it. I just don't want to do it full time. A shift a week - sure! Everyday? Shoot me now.

So I thought about anesthetics. 9 months in the Big City and then 3 months in my current city. I like the procedural side of anesthetics, and I love airway management, but I am not a detail oriented, thinking person. I am a cook, not a baker, if you can appreciate the vast difference between the two personalities. I can force myself to be detail attentive but it requires a lot of mental energy. I realised that I was choosing this option more because it has greater portability and demand currently in Canada. It wasn't what I truly wanted to do in my heart of hearts.

Thus, I decided to apply for the Enhanced Surgical Skills program (ESS). It is one year of surgical training that is divided between 6 months of obstetrics and 6 months of general surgery. In the obs component you learn c-sections, essures, tubal ligations, instrumental deliveries, and other office procedures. In the general surgery component one is expected to become proficient in performing hernia repairs, appendectomies, lumps and bumps, scoping, and any other procedure you feel you ought to provide to your community (some do tonsillectomies, carpal tunnels, etc).

So now I am pumped. I have found an accepting community that will give me privileges in this scope of GP-surgeon practice. The applications are in the fall (for a July 2015 start) but I'm already trying to get as much experience as I can with these enhanced skills. It's been great, having loads of obstetrical procedures here as well as being scaffolded up on basic surgeries...all by kick-ass GP-surgeons!

It's weird feeling like things are possibly falling into place. I've had so much internal conflict and so many questions about what I ought to do with my career. I have always felt that family medicine was an uneasy fit for me since I started residency, mostly because there are many things about FM that I do not love. THIS feels like a fit, it feels like something I can hold on to and mold into what I want it to be in the future. I hope.