If several trees fall in the forest…

We had a huge snow storm in October. 

On the first day heavy wet snow came down in giant flakes. It fell fast and the trees which hadn't yet lost their leaves were weighed down by the sticky clumps. We had a day of respite where the trees stood, just a bit hunched over. The orange and red leaves still clinging to the branches. It looked like frosted sugar icing over all the fall colors.

Snow with that degree of commitment doesn't usually come down so early in the season. Usually we have at least a few weeks of bare branches, frozen grasses and grey skies before snow fall.

But, on the third day it really came down. Again the same heavy giant flakes fell for hours and hours and hours without letting up. It fell all day and continued into the night. The trees became more and more burdened.

During the night the snapping and cracking of bark could be heard throughout the town. Many of us were awoken by the sounds of huge trees giving into the winter weight. The power went out. So many trees had fallen onto power lines that over 10 000 residents of the province woke up to a cold house and a back yard of destruction. Including us.

This weekend we volunteered to work on clearing the cross country ski trails. It was my day off and for once I wasn't on call so I dragged my arse out of bed and then dragged my hubs and pups along.

It was such a fantastic day.

It was the perfect temperature. The dogs were in heaven. It
was exhilarating just to spend a physical day outside, breathing in the scent of pine needles and spruce gum, mixed with the exhaust of the chainsaw.

Brings me ring me right back to skidooing as a kid, being pulled on toboggans, screaming with laughter and forgetting how cold my cheeks felt. Then heading home, warming up, and having the best sleep a kid could ever imagine.

Here are a couple before/after shots of our work (with Monty photobombing, of course). We finished up the 3km and the 5km loop, for now.  Nothing like a day in the woods, working until you're muscles ache, to let you forget about all the work that needs to be done everywhere else in your life.



Roads

One of my patients died today, and I feel so selfishly devastated.

B was strong, sinewy, and very alive when I met him in November of 2014.

I was a resident working in the ER and we had had a long and very messy code blue. A man found down in the cold, on the side of a quiet gravel road. It looked like he had been walking home alone and had collapsed. His knees were skinned through his faded jeans and it looked like he had vomited blood on himself, the bright red ice crystals clung to his faded grey hoodie. He was dead, frozen stiff. But, as the brutal saying goes, 'you're not dead until you're warm and dead'.

So we committed ourselves to warming this man every way possible, in the hopes that we might bring him back to life. Warm forced air under warm blankets, warm ringers into his shin bones, warm saline through a long needle into his abdominal cavity. We worked on him for a few hours, and eventually the patient was pronounced warm and dead.

My hands felt heavy as I picked up the first chart in the full rack, a glance showing all the non-emergent patients who had arrived while we were busy in the trauma bay. You can't help but think, do any of you really need to be here? That LAST guy needed to be here, HE was an emergency. I just wanted to sit down. I wanted to try and mentally file what had happened. But, there was a chart in my hand and already I was opening the door to the next room.

"Headaches"

Oh brother.

Headaches, toothaches, back aches. Drug seekers. T3 refills. I tried to shake the bias that starts creeping in the moment the presenting complaint is read.

B was sitting on the stretcher. He looked like someone who could still run a fast mile, chop more wood than a teenager or two-step until the sun started to streak across the horizon. He looked embarrassed to be there, his wife looked determined. His was an easy smile, hers was a worried face.

Headaches. Getting worse. Never had them before. Worse when he lifted something heavy at work. Feeling...cloudy. Walked around the house for ages trying to find his gloves, only to realize he was wearing them.

I tried to find something, anything on physical exam to bolster the story I was going to have to sell the radiologist in the city in order to get this guy a CT scan. Maybe some papilledema? Was I imagining that? Maybe something off with his gaze convergence? I couldn't hang my hat on anything but a hunch.

My attending was trying to clean up the waiting room full of people while I made calls to ER departments and radiology departments. He was going. He was gone.

I never talked to B again. I saw his CT that afternoon which showed a massive brain tumor, cerebral edema and a midline shift.

I ended up leaving that rotation and losing track of him. I couldn't remember which attending I'd been working with that day. I updated my phone and lost my notes, one of which was his health card number so I couldn't look up his imaging. I thought about him and his wife often and wondered what had happened and how things had gone for him.

And then I found out.

I came into work last week for hospitalist rounds and as I'm settling in to start my morning the nurse tells me, oh you had one admission during the night, a guy with a brain tumor who is here for IV steroids.

I knew it was him. I turned to the stack of charts and saw his name. I know him!

I headed down to his room and open the door. I was still in my scrubs and OR cap from an early morning case. His wife was sitting by the bed. I introduced myself and she greeted me politely.

"We've actually met before...you might not remember me..."

She slightly cocked her head before her eyes widened a bit and she replied,

"Two years to...the...day. We met you two years ago today."

I felt the hairs on my arms rise.

We exchanged stories of how we'd each lost track but hoped we'd somehow meet again. We let our eyes rim with tears at various points in the telling of the journey. B was settled in the bed and though he didn't open his eyes or say any words, his big hand squeezed mine when I grasped his. He still looked well. It was so incongruous. He didn't look faded into the bed, or sallow, or weak. He looked like he was having a quick kip before heading out to hockey practice.

I visited them daily and got to meet his kids, and hear about his grandchildren. Over the weekend he went to the city for further treatment. A hail Mary, so to speak. I kept in touch with his wife while they were out of town, just to check in. Things weren't looking good.

This morning, I woke up just after 5am. I couldn't sleep. I came into the lounge to try and get some reading done for an upcoming course. Shortly after 6am I received a text.

B had passed.

She thanked me for my part in their journey with a beautifully written note. It didn't seem right to cry, but it didn't seem right not too. As I got ready for work I tried to listen to some distracting music. Tears fell into my sink, onto my bathroom counter.

Caring for patients and their families has unexpected side roads. These paths are not on of the map of our training, and no one tells you how to navigate them. No one can guide you or tell you when the road will suddenly become bumpy, or if it will lead you to the most amazing panoramic you can imagine.

Tonight it seems those roads are often one in the same.




Heroes

A few years ago I had the (crazy, surreal, amazing) fortunate experience of spending some time with Abraham Verghese.

You know how people say you shouldn't meet your hero because they will inevitably disappoint?

That is not always true, turns out. He is actually precisely what I thought he would be; articulate, measured, polite, engaging, interesting, and a good cook. We talked a lot about books, and writing, and medicine. He even said he read my blog (!!!) which was flattering and intimidating at the same time. But he said one thing which still rings in my head, something to the effect of "I couldn't write a blog, it would take me so long to feel like something was ready to post. I'd want to edit it and rework it and I just know it would take me so long to feel like it was good enough to publish, ready to be put out there".

Shit. 

Well, I hadn't thought of blog postings that way before. I mean, sure, I hope that there are no glaring spelling mistakes or complete violations of the rules of grammar, but I had always just written something and then posted it. I also know he is a world renowned, famous author so he can't just throw a random GIF up there with "Happy Saturday" and expect his readers to appreciate it, but still.

So I currently lie awake at night thinking of things I want to write about on the blog. And then I wonder if I should write a draft then send it to my mom (retired English teacher and editor) then rework it, marinate in it for a while, rewrite, send back to mom, then post. The rumination makes me tired and by the end of this thought cycle I am asleep. Which I suppose is a good thing, since I am usually an insomniac. But it paralyses me from writing at all.

October whizzed by in a September-like fashion. I pulled a 21 day straight stint which had some ups and a few big downs. So much for "taking time for myself" etc. Why is it that when you start as an attending you're cursed? I've said, "Well I never saw THIS as a resident" more often in the past couple of months than I'd ever admit. The other new attending and I often pass each other at the hospital with mummified expressions that betray our lack of sleep muttering "curse of the new attending" between us. We tried to have wine together one night to commiserate but didn't even finish the bottle before our yawning took over the conversation completely.

Most of the time, I am just terrified. I woke up one night with a start, my heart was racing and I felt this rush of panic, "shit, I'm on call" check my phone, no missed calls, there was nothing to panic about. My breathing was fast and I couldn't seem to get myself to calm down. I thought, "Am I having a panic attack? WTF? This is awful!" My stomach was in an unrelenting knot for days and I had the worst flare up of eczema I've experienced in my life. I was actually considering blood work because I was scratching my legs so forcefully in my sleep that I developed these multicolored blooming bruises everywhere, giving the appearance of scabies AND a clotting disorder. Apthous ulcers made eating and drinking so painful I was trying to chew/slurp on one side of my mouth. Coupled with the near compulsive hand scratching (oh, the joys of dyshidrotic eczema) I am quite sure I looked like a spectacle to my new colleagues most days.

I texted one of my surgical attendings from last year. "Did you have resting tachycardia the year you were a new attending?" Her reply, "the first two years".

Great. Well, I have certainly reached the promised land of being an attending.

A nurse recently asked me (after I had scoped all day, scurried home to eat and then returned for my 12hr ER night shift), "Are you glad you went back and did medicine? I am thinking of doing that".

Cue deep intake of breath.

I remember vividly all the negative input I received from people when I told them I was thinking of going back to school to become a physician. I remember it so clearly because it occurred with monotonous regularity. I don't want to be one of those people to someone else.

"Oh you don't want to have a life?" "I wanted to do medicine but I chose a life and a family instead" "Why would you ever want to ruin your life and get that much in debt?" "Getting in is basically impossible" "Have you written the MCAT? You'll never get a high enough mark to get in". Etc. Etc. Etc. Those are just a handful of my favorites.

But looking back now, these comments weren't completely off base. I take a look at what I've gone through in the last 8 years on this tumultuous journey. I see where I am and what my life is now. I am not sure that I am glad about becoming a physician. When asked about my decision to go back and study medicine, I genuinely answer, "Ask me in 10 years" because I feel that by then I can more accurately assess the pros and cons. Right now the "cons" list is pretty heavy.

I wanted to be a doctor because my Grandad was a doctor, and he was my hero. But now that I am older and can take a wider lens to my perception of him I realize he was also a farmer, a voracious reader, a world traveller, a philosopher.

Abraham Verghese, Atul Gawande, Jerome Groopman, Walt Lillehei, and Kevin Patterson, Brian Goldman are a few more of my heroes, not because they are doctors but because they inspire me by what they've done in addition to (or despite) being doctors.


I can't ask most of my heroes how they came to find the time and energy and inspiration to do the things they've accomplished in their lives. I'm still in survival mode right now but things will hopefully settle in the next few months and I can re-calibrate and re-introduce myself to the things I enjoyed doing. If medicine remains the only thing in my now-one-dimensional life I know I'll burn out fast.  I'll find those things that inspire me again and start putting my energies into those things as well. And keep the betaderm handy.

Taking Care

One of my colleagues, Rebecca, came by last week and I think she could tell that things were a bit rocky. She took a look at my schedule and pointed out that I was working 17 days in a row without a day off. And that needed to change.

She was not wrong!

So she urged me to talk to our physician scheduler and ask for some clinic time off and to see if I could get rid of some of my ER shifts. I didn't know I could do that! She texted me on Monday and asked if I had talked to the scheduler yet. I hadn't had a chance. Then I get a sticky note on my desk from the scheduler saying to come talk to her when I have a chance.

Did Rebecca tell you to talk to me?

Sideline glance, non-committal mumble.

Riiiiiight. Okay.

So we did some tweaking and now I have a few afternoons off, and I took the last 3 days of October off. I still have 15 days in a row of surgical call but, that's the way the cookie crumbles when there is only one other GP-Surgeon in town for the time being.

I started using this app called Headspace. It's a mindfulness app. I know, it's an oxymoron to put those words together, really. But I have found it very useful and have been trying to do 10 minutes of guided meditation (or mindfulness or whatever you want to call it) daily. It's not an airy, breathy woman chanting about crystals. It's a dude talking about observing your thoughts in a very straightforward and concrete way.

Hopefully between the little pockets of protected time off, the commitment to spending some time clearing my head, writing, and scurrying around the forest with the pooch, things will start to look up and become more manageable. No one tells you how to take care of yourself. No one else cares if you disintegrate into tiny drooling shell of a person who watches Price Is Right reruns all day. So I'll start with these baby steps.

Reality Bites

Well, the shiny gloss of being an attending certainly didn't last long.

I have a new reference point for the expression "being thrown in the deep end of the pool" now. These days I feel like all I'm doing is inhaling water and pathetically thrashing around. 

I can remember rolling my eyes so many times in the past when being dragged through a long-winded seemingly redundant orientation at a new job. I would kiss the feet of someone who would orient me now.

No name tag, no hospital badge to get into the hospital. What are the codes to get into the change room, the back door of the clinic, to photocopy something? What forms do I need to fill out to book a surgery and then where do I put them? Who does the bookings? Do I need to book an anesthetist?

Where are the prescription pads? Where do I send my invoices, my day sheets, my O.R slips? What is my dictation code, do we have an ultrasound tech in the hospital, is there a pharmacy open on Sunday and when do I get paid? What times are the hospitalists on call until, do you routinely collect cord blood, what is an order set, where are the order sets? How do I empanel a patient, send a task, get an old chart?

Just a small sample of the myriad of questions I am trying to sort out while trying to actually care for patients. The cleaning staff are wiping around me an my desk every night. I make so many notes to self during the day; read up on post-kidney transplant surveillance, monitoring polymyositis, review guidelines for Barrett's esophagitis recall, post neonatal resus stabilization...remind myself how to interpret blood gases, put on casts, do fundoscopy, thrombolytics, a lumbar puncture.

But then I get home, nauseated and sweaty. Just so happy to get out of my microbe infested hospital or clinic clothing. I eat and think, "I should read up on those things now, I should work out, I should empty the dishwasher" but instead I find myself crawling into bed. Not caring that my feet probably have dried amniotic fluid on them.

And then a new day comes.

Or it doesn't. Instead the phone rings at 3am and I am driving back to the hospital for another delivery. This time the mom is fine but the baby is not fine. And I spend the next few hours talking to family members who have gone silent with fear and waking up neonatologists who are sleeping hundreds of kilometers away.

Then the night morphs into day and I am the hospitalist for the medical ward and my conversations shift to managing INR results and incontinence and wound vac dressings. A palliative patient, who I haven't met until that day has family there and they want to speak to the doctor about what is happening. My morning becomes afternoon and my lunch becomes the family meeting where I try my hardest to remember all the insightful and beautiful things that Atul Gawande talks about in Being Mortal and I try to remember to do more listening than talking.

So I leave the family meeting and fly into the clinic where on arrival my MOA throws up her hands at all the paperwork I am sending her and tells me it's not working. I duck into the first patient who wants a narcotic refill and disability form filled out and when I press him for details on the background of these requests he tells me...

you doctors are the worst...I was told how terrible the doctors are in this town, they don't care about anyone at all, even if you're dying...the worst...my old doctor cared, he prescribed me valium and dilaudid...he was a good doctor...you're a terrible doctor

And I can't help but feel the exhaustion from the night before crash over me. I can't stop the rising flush in my neck and my quickening pulse.

Where are the disability forms?