First Rupture

No one was in labour, we were just waiting to go for a c-section in an hour or so (after the heart they were working on). So I thought it would be safe to go for a coffee on Davie street with my friend Kai when he paged me.

Just after having sat down by the steamy window, slurping milky goodness... beeping from my pager. Annoyed, I glanced down at the number. The emergency room, probably someone with a miscarriage, and I rolled my eyes groaning. At least I can finish my coffee. I called on my cell phone and got the emerg doc directly.

There's a lady here who can't keep her pressure, we think she has a ruptured ectopic. We're really worried about her and need you to come now.

Hmmm... drop coffee.... walk briskly thru the drizzle. Stroll into the trauma room. Pristinely calm and efficient on the outside. Heart pounding, thoughts racing internally.

She is crashing and has what looks like a belly full of blood on ultrasound. I order some blood right away, call my staff, and call the OR. Things are in motion.

The part that always gets me, is the fear and pain in their eyes. She didn't know she was pregnant. Just after dinner she felt the worst pain she has ever had and then passed out, to regain consciousness in the ambulance. Her husband leans his face close to hers, eyes glazed over, brimming with tears that won't come, scared. As we flow around them in our clockwork fashion, poking, prodding, sticking needles in, wiring her for sound. I realize I have no concept of what it would be like to look into someone's eyes who I love more than anything, not knowing whether they will live or die. I ask to talk to him to get consent for the surgery. The risks and complications reel off my tongue, 'her condition is very serious' I hear myself say, 'she needs an operation right now'. I'm sure he hears nothing, just signs the paperwork, nodding, thanking me again and again for nothing that I deserve.

The elevator creaks as it sweeps us up to the operating room, she is wheeled in and asleep in minutes. Her skin white as porcelain and cool to the touch even through my sterile gloves. My hand reflexively grasping the scalpel, slicing through the skin. I look at the incision confused. The normal bright red dots that appear on the skin edge and throughout the rich shinny fat are absent. The tissues gape open moist and bloodless. She has no blood left to bleed.

Through the peritoneum and instantaneously blood is everywhere. Dark red livery clots. Bright red pulsations. We suction out three liters. Digging to find what we're looking for, its no more than three centimeters, a little blob in her left fallopian tube. We end up taking the tube out since the pregnancy has completely ruptured through, destroying it as a future egg hose to the uterus.

I marveled at it all. This tiny gestation that nearly killed her in the course of an evening. Amazing as well that we could fix it. That she is one tube down but one heart still beating. Every moment of it exhilarated me. If the outcome had been different I hope my emotions would have been appropriately altered. I wonder.

I wonder how I roll my eyes when asked to see another miscarriage but get high during critical situations. Who is this person I am becoming?

La Lecheria Esta Cerada

The fiery Aussie nurse lent over the bassinet holding the hour-old infant whose mouth was rooting around looking for some nourishment. In her slurred accent, she said smiling, "Sorry mate, the milk ba's not open yet, but your mama will be back from the operating room just as soon as she can."

The proud father, brow furrowed and eyes serious responded: "Excuse me, I'm very sorry, but he only speaks Spanish." Lifting up his child, he cupped his tiny son's head in his hand, and in a gentle flowing voice translated what the nurse had said. La lecheria esta cerada, pero ahorita viene tu mami.

I love my job.

Hairball

Pop. Through fascia. Pop. Through peritoneum. Air hissing out through the trochar in the belly button. Gratifying glide of steel as the laparoscope slides into the abdomen.

Then the cathedral lays out before you, the roof an intricate pattern of vessels. Miles of tender pink bowel, adorned with glistening golden yellow pillows of fat blobs. With a twirl of the camera the smooth moist liver edge slides into view reflecting the light, taut gall bladder cozy within its shapely lobes.

Then the pelvis, the pulpit of the cathedral. The bowel is pushed and pulled out of the way. Pesky sigmoid eternally and annoyingly unattachably in the way. Uterus gleaming into full view as it is tenderly excavated from below the bowel. On the right a spectacular contorted cyst. Triple twisting around its pedicle is the right ovary, dusky in colour and the size of the uterus itself.

Flip. Flip. Flip. Oops, wrong way. Flop. Flop. Flop. My ovary flipping skills in the cathedral are neither smooth nor nimble. And the twisted mass is eventually revived of some milky pinkness under the ever patient eyes of my attending.

Tiny scissors snip snip snip through the overlying stroma exposing the oozing speckled blood on the cyst. We decide to drain the cyst before fully freeing it from its encasement in the ovary.

Snip. Ooooooooooooooooooze. Slrurrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrp.

Creamy thick yellow custard pouring forth, forming puddles of floating fat on the mini-pools of watery blood around the peritoneum of the cathedral floor. It looks deliciously like someone is squirting out the insides of a dough nut. I insert the suction into the source of the pastry filling and pull out globs of black hair. Deliciousness immediately turns to visceral disgust to giggling. Cutting the cyst open for drainage reveals a perfectly formed incisor tooth.

Chewy hairball pudding.

The human body is spectacularly uniquely viscerally beautifully disgustingly amazing. Not gonna lie, dermoid cysts are kinda gross. The divine and the gritty sleep together.

Brilliant Rain

It was one of those consults you roll your eyes at. The emergency doc on the other end of the phone, "yeah, she's 22 and has quite a bit of vaginal bleeding, I haven't seen her yet but I was wondering if you wanted to take a look."

Uh... is she pregnant? Is it her period? Anything else you know? Maybe you could examine her and give me a call back.

I only had about 52 other things on my to-do list. It was a crazy night, several women in labour as well as a total of seven consults from the emergency department... and I didn't have a junior resident on with me... you forget how nice that is.

She was 22 but could have been 16. Terrified, and yes, bleeding heavily, passing large clots. The livery sight of which brought her to tears. She passed out from the blood loss in fact. I examined her, packed things solidly to taper the bleeding a bit and called the OR right away.

It had been her second sexual experience and she had a gruesome vaginal tear. Her first experience had been the week before, which involved a trip to the pharmacy for Plan B. Needless to say, it was a fairly critical time for us to talk about sexual practices, birth control, STDs, basically everything. Understandably she was anxious and scared, adamant that none of her friends that had brought her in find out.

After the repair in the OR, although I was saddened by the circumstances around the situation I felt like I had actually contributed something. That I had not only sewn up a physical need but soothed emotional pain as well. It was the first moment in a long long time that I was again glad I was where I was and who I was, doing this residency slog.

I crashed for most of the day. Woke feeling extraordinarily disgusting and went for an equally nauseating run in the rain. I was just going out to buy a red onion for supper (thats not the ONLY thing I ate, don't worry) and although the rain continued, the sun low on the horizon broke through the clouds. Rains drops shimmered through the air and a brilliant rainbow curved its arch across the sky. The fluorescent fuschia, orange, and yellow leaves glistened in the delicious evening light. It was a promise in the sky.

Strangely as I gazed at the sky (with red onion in hand) my exhaustion turned into a sense of accomplished contentedness.

Last Name: Mary, First Name: Virgin

There is a genuine look of intense concentration on her face.

So you've never had sexual intercourse?

No, never.

You're 25 weeks pregnant... that means...

Well... I guess maybe I've had outercourse?

Her brow is furrowed and she looks confused. Sex ed isn't what it used to be.

The Splinting of My Fractured Soul: A Case Report

"Listen, this rotation is hell, and its soul destroying, and you just have to get through it."

Why?

I don't wanna play anymore.

The end of my string is slowly approaching. I've been doing 1 in 2 call. That means every second day you stay at work for 26 hours or so. Which means everyday you go to work and it doesn't end until tomorrow. Its exhausting. Draining. Yes, it drains my very soul. So I've started a soul account. Trick is, you have to pay in more than you pay out.

You forget who you were before you were a forceps, vacuum, and C-section machine. Did I have a personality? Was I interesting? Did I care about life? Was I passionate about anything? Doubtful.

There was a big deposit into my soul fund last week. A dear friend from medical school stumbled into the Ass Room (i.e. Assesment Room at labour and delivery). His wife and him were a source of profound inspiration to me in school and all-around make me believe that there is in fact hope for the poor and marginalized in the world. They are passionate advocates of oppressed people groups, from Sudan to Kurdistan to northern Alberta. Eloquently they speak out against soulless corporations and the injustices that happen in the interest of financial gain. And they do it all with such incredible optimism and humility, all the while affirming and challenging those around them, that it makes me giddy with hope. As if that isn't enough, they throw some pretty incredible Kurdish New Year's parties!

They delivered a skwocking hairy little miracle of a guy. Rarely have felt such privilege in delivering a child as I did with them that day. It was indescribable. The lump of emotion in my throat chocked me. To deliver a new being, warm, squirming, and slimy, who, along with his two sisters will undoubtedly change the face of the world made me remember a little piece of who I am and who I want to become. It felt good to feel again. No mindless numbing, just raw and real.

Dee-der-doo-der-dee. Dee-der-doo-der-dee.

And then my pager went off. So I ran downstairs to the rotational forceps delivery in the operating room of the woman I had only met once, which failed and we had to to a C-section anyway.

Shoot. Maybe six billion little miracles is enough.

Before they were discharged from hospital my friends came to find me down at the delivery suite to give me much needed hugs and invite me over that evening. It was lovely. The nurses and attending obstetrician who were around to witness this asked me in quiet voices afterwards.

"Sheona, do your patients usually invite you over on the way home?"

Oh yeah, and I say yes every time. No professional boundaries here.

I am Convinced that Given a Cape and Tiara I Could Save the World

I broke.

Late in the afternoon after not eating since six in the morning. In the residents lounge after a hug from my fellow junior, we laughed maniacally at the craziness of the day and inexplicably, uncontrollably, the laughter turned to tears. Hot and stinging they coursed down my cheeks.

Last week a job that usually takes four people, a chief, high risk resident, low risk resident, and the elective C-section slate was left to Andrea and I. Two little second year residents. It was only for two days, but it tipped me over.

Its near impossible to put into words the intensity of it. In the delivery suite you have two complicated medical patients, one who just got off the plane from Ethiopia with pulmonary edema and on the edge of a seizure. A set of twins at 28 weeks delivering early. Then all the regular, normal, low risk women in labour. All this AND the dreaded transfer phone. It's ring heard above whatever other chaos is currently reigning, it belts out at a different tone and takes priority. BC Women's is the center for all the emergency transfers across the province for any pregnant woman anywhere who is in trouble and needs a center where premature babies and sick mom's can be handled.

Dr. McTerrified is on the phone from Fort St. Nowhere. Invariably speaking a mile a minute, sometimes a little shake in their voice. With a woman who is in preterm labour, has a blood pressure of 230/120, and is peeing out protein by the truck load. So you answer calmly (despite you own underlying terrifiedness), get all the details, make sure they have had steroids for baby lungs and douse out the fire of their blood pressure. Then you have to decide where they can go. To Prince Geoge, Kamloops, Surrey... no beds. Victoria? Nanaimo? No NICU beds. To us? No NICU beds. Edmonton? Calgary? And the last last final resort: Washington State.

All this with 8 nurses breathing down my neck to check patients, with questions and suggestions. Then one of them blew up at me, frustrated for something I thought I had already taken care of. My calm reply and innocent apology didn't seem to be received. Couldn't she see the drowning in my eyes?

I have a 'Lovely Theory'. Here's how it works. All acts of jerkdom, meaness, and ignorance can only be responded to by loveliness, humour, and humility. Theoretically, the jerk involved will eventually feel like such an idiot for being irrational that they in turn will be lovely. Alas, I'm starting to question the premise of said theory.

I talked to my incredibly wise little sister at week's end, post-call, semi-coherent. Explaining the gory details as she listened. "Rho, they broke me. And I didn't think they could. I'm not sensitive, I have thick skin!" Her reply?

Did you have your Cape? Where you wearing your tiara? I don't think they broke you, its just a chip. You're just cracked, not broken. Crying is okay. In fact, it makes you human.

Human?

Now where did I put that purple cape with green sequins?

The Baby Mill

Set the scene: a young woman lies exhausted, propped up on the bed, belly swollen, legs being held back on one side by her midwife who murmurs thoughts of focusing on the connection with her baby and on the other by her distraught and equally exhausted husband.

Enter obstetrics consult for fetal distress. Yes, you guessed it, a young resident who is about as distraught and exhausted as the poor husband after countess hours running around slightly spastically doing c-sections, and pulling out babies.

"Hi, my name's Sheona, I'm one of the obstetrics residents, and I'm going to rip open your vagina with these large metal salad tongs to get your baby out since its heart rate is lower than yours."

Don't worry, there is in fact an obstetrician around most of the time for the forceps salad tong special. As we were just finishing sewing up her sphincter a nurse sticks her head in the door. Do you mind standing by for delivery in room 10, the family doc is just on their way.

So I quickly jaunt in to 'stand by', only to be thrust some gloves as the head came out, amniotic sac and all. But the REAL kicker, the highlight of my evening, was the: Sheona, delivery in the parking lot NOW! It was my first ever parking lot baby! Now I just need an elevator one to complete the set.

I find myself running on fear, euphoria, and dread. Its a strange mix, giddy one minute and nauseas the next. Somehow its not quite what I imagined. My pager filled up twice with the amount of pages I had. Scarcely seeing a woman long enough to get their story before having to rush to the next thing. Gone in the smoke from my surgical cautery were my dreams of connecting with people, hearing their stories, and sharing the intensity of the birth experience. Instead its about survival and procedures. Learning how to operate, finding the right planes of tissue, cutting at the perfect angle, sliding on forceps smoothly.

As daylight approached I had to sit down and go through the list in my head. I didn't even know how many babies I had delivered. The tally last night: 4 C-sections, 2 forceps, 3 normal deliveries, and yes, the parking lot baby. And then I had to go round on all of them.

The breeze was fresh as I peddled home this morning,. Lovely, soul-resurrecting sunshine, blue sky with the mountains calling me to go tromping. Yeah, they didn't call loud enough. The deliciousness of my bed called louder. And I dreamed that I was a midwife, able to recall all of my patients and make home visits, dreamily catching babies as mother's calmly had water births with a massage therapist standing by as needed.

My psychosis and delusions continue...

Cold Feet

I had to do my first family meeting when I was on call last week. I'd sat through them before with senior residents and attendings and I thought I knew how it worked. I asked what they already knew. Then explained that their brother was very sick from an infection. That he was on life support, that a machine was breathing for him, that another machine was doing the work of his kidney because they had shut down, and that his heart was also broken and we had to use medications to keep it going.

He's stable right now, but he is very sick. Are there any questions you have?

Can you make sure you keep his feet warm? He always hated it when his feet got cold. And if he wakes up and asks for Julia, tell him she's just on her way down from Whitehorse. But can you wrap up his feet with blankets?

Cold feet. It made me remember what really matters. So I went and got some warmed blankets to wrap up his feet. It was the most useful thing I did that 24 hours.

Three Codes

Its a strange pager sitting on my hip. A loud, piercing BEEP-BEEP-BEEP, then it crackles with static like a CB radio and a woman's voice emerges from my scrubs' waist band: "CODE BLUE SIX BRAVO, CODE BLUE SIX BRAVO." Static, crackle, crackle.

The week started off pretty rough, I struggled to get the language down, let alone the concepts behind everything. Fortunately, ICU nurses are a special breed who ensured my actions didn't contribute to the demise of the patients. The mortality rate in our ICU is apparently 32%. 1 in 3 doesn't sound all that good to me.

On call last weekend mid-morning a code blue was called on a patient whose lung had collapsed (incidentally because of a line the internal medicine team had put in his jugular vein... oops). Sweat rolled down my face and trickled off my knee caps behind my mask, eye-shield and gown as I cut into the side of his chest, tunneled my finger through his tissue and squeezed between his ribs to tickle his lung. Air hissed out quickly as my finger wiggled around in his chest cavity and his lung re-expanded... way cool. We stabilized him and brought him to the ICU. "Good save," said the attending as he patted us on the back.

Another code was called for an SVT, a rapid heart rate causing the patient to drop their blood pressure. Hook up the defibrillator pads, a few shocks and some drugs later she was back to ticka-ti-boo. That's two saves and counting! As the day goes on I but two arterial lines and a central line in the internal jugular successfully on a few patients. My chin is held up a little bit, my walk develops a bit of a swagger. Maybe I'm not so bad at this after all, maybe this running to the rescue ain't so bad.

Its 'tuck-in rounds' at around 10pm when the third code of the day is called. The selected ICU staff drop what they are doing and run like clockwork. A small army emerging through the automatic double doors, past the ICU waiting room scattered with worried family members. There is a certain intensity and purposefulness to their gait, urgency with every movement. My senior and I walk behind the running respiratory therapists and nurses as they roll the cart down the hall. I've been told never to run to a code, you need your brain and heart rate functioning normally when you get there.

And the rest was a blur. He looked dead. I suppose he already was. We never got a pulse back on him, his heart just twitched with electrical activity. I was kneeling up on the bed, heels of my hand pounding his chest down. Sickening crunching and cracking of his ribs and sternum with each movement. I was exhausted after two minutes and we traded off and on. Nobody seemed to know much about his history and flipping through the chart wasn't helping. I botched a femoral line as his body bounced around with the CPR. Intubated and bagged, we gave him every drug we could think of, racking our brains to think of anything we were missing. The senior even stuck a needle into his heart (well, pericardium) and after 35 minutes we stopped. Everyone in the room agreed, there were probably 10 of us. And that was it. He was 58.

It was a lesson in humility and futility. We don't get decide when people live or die, we are sometimes just tricked into that illusion.

Language School

He's on pressure support at 16, his CVP is 8, PEEP of 5 and his F-eye-O-2 is 45 which is down from 55 yesterday.

Blank stare.

No hablo ICU. Ai don es-spik ICU.

Espanol. Si.

Kiswahili. Ndiyo.

ICU. Uh... no.

Bad Day

Sun streaming in the window, dancing across my wall. Suddenly jolted awake. What time is it? Where am I? Who am? My arms and shoulders ache with any movement. Crap. You slept in. Its Monday morning. You're in in bed. You're you, and you shouldn't still be in bed.

Burning coffee slopped down my shirt, inhaled cereal choking me. Bike chain clanks off in the middle of an intersection. Sweaty, soggy with coffee, hands covered in bike grease I roll into the clinic. Busy waiting room. Late late late. Rushing to change in the washroom cubicle. My hands are itching like crazy due to the THREE separate knuckles that some kind of sick evil mosquito feasted on over the weekend. Shirt, pants... no scivies... typical. One sandal off, second sandal--splash. Sandal in toilet. I'm late, I have no underwear, I'm hot and bothered and my sandal is IN THE TOILET!

This is the worst day ever.

Enter patient number one. A tall, well-built, Persian man in a stylish black leather jacket. Swollen black eye, staples across the shaved side of his scalp, arm in a sling, limps in. I saw him two weeks ago, he has been clean for seven months and moved out to Burnaby from the DTES this past weekend. He was excited about the move, and the sobriety. But on Saturday when he stopped at the pharmacy downtown he was assaulted and left on the sidewalk, where he lay unconscious for 12 hours before anyone called an ambulance. Just another passed out junkie. Quickly wiping tears away he shared how it felt... being left worthless on the street. Pain. Loneliness.

Memo to me: GET OVER YOURSELF.

The Poverty Industry

His tall, imposing figure in a thick down camouflage jacket nearly blocked the door as he stepped into the examining room. The unshaven face made a thin veil over his pock-marked, scarred cheeks. As I sat down by the desk he stood with a massive slurpie in one hand and a blue licorice strand in the other, occasionally using the licorice hand to run over the top of his head and flip his pony tail behind him, hesitant to sit down. This picture of a hardened criminal juxtaposed with a nervous child seemed strangely incongruous.

I got out of jail yesterday and I need my methadone script.
Why don't you have a seat? I venture.
All I need is my juice. Can I have all my meds daily dispensed? Its just easier for me that way. And can I get my meth script for two weeks?

Okay. No. No. Are the answers.

Have you used since coming out?
Not much.
How much is not much?
Just a couple flaps of seven and a rock or two.

Its like learning a new language. The language of drugs and poverty. His body quivered in frustration and his words were angry in response to the answers he was given. He stormed out with a two day methadone prescription in hand. Why so angry? In his eyes, this crazy doctor had just cost him $40.

$10 per week of methadone prescription, that's $20 for a two week script.
$10 per week of other prescription drugs if they are daily dispensed by the pharmacy.

Methadone and poverty are big business. Several pharmacists in the downtown East side have built empires around this. They receive ten dollars as a dispensing fee on any medication. So for methadone which needs to be witnessed daily, that's ten bucks a pop. If the patient is on six different medications and the prescription is written to be given out daily by the pharmacy, they just made sixty bucks in a few swallows. So big deal, the pharmacist is getting rich off of tax payers' dollars. Just a little entrepreneurship, right? I'm sure doctors do the same thing with 'efficient' billing and sneaky tax cuts. Right up until you start paying a person with an addiction to bring you their prescriptions. Giving them money that goes straight back to crack, heroin, booze, or crystal meth.

Then there's the recovery house business (some run jointly with a pharmacy no less!) There are a few run by the health region, but many are privately run with no restrictions to what they provide. They survive by getting most of your welfare/disability check deposited directly to them and providing you food and lodging. The worst stories are of six people crammed in small rooms, harassment, abuse, open drug use, and horrendously unhealthy cheap meals.

One of my favourite Jesus stories (other than saving the party by turning water into booze) is when he looses it in the temple courtyard where people are selling stuff. He knocks over tables in righteous anger against those who prosper from inequality and take advantage of the poor. Poverty and injustice break my heart, more than that they piss me off. Something deep down in my gut bubbles with anger. But exponentially worse in my mind at least, is those who prosper from the brokenness of others.

Here's where it all comes full circle. As a medical professional my living ultimately comes from suffering humanity. If I am not actively involved in trying to change the system, in preventing suffering and not just benefiting from it, by definition I become the oppressor. Stick that in you pipe and smoke it doc! Who are you judging anyway?

Overwhelmed by Hope

"I don't like dirty people. And I don't like people who love their drugs more than their kids."

These were the words of one of my colleagues, a good friend in fact, who I have great respect for. We do the same job yet we see the world from opposite ends of the kaleidoscope. Apparently I quite like dirty people. I've been doing an elective in addiction medicine in the Downtown Eastside and I love it. I love it so much that the question as to whether I really needed to deliver babies the rest of my life flittered across mind. Don't worry, it was only transient, I will definitely be returning to the happiness ward. However, I have worked with some passionate, maybe nearly crazy, but undoubtedly inspiring individuals who have dedicated their lives to working with a deeply vulnerable population.

Poverty, addictions, homelessness, prostitution. Words you think of when you imagine what is apparently the poorest postal code in Canada. Strange. Because its where I feel most welcomed. People talk to you on the street... granted, not always soberly or eloquently. They yell greetings at each other. They sell nick-knacks on the sidewalk: a speaker system, a pound of Starbucks coffee, 4 litres of fruit juice, an instant pawn-shop appears and disappears in minutes. They know each other by name.

I don't want to idealize things, they have more than their fair share of heart-wrenching experiences, abuse, and crippling addictions but I wonder where there's more love. In the Eastside or in lovely, sterile, rich Point Grey, closer to my residence (ouch).

They have a photo contest each year run by the Pivot Legal Society and have a book just recently published with photos called Hope in the Shadows. My heart breaks to hear my patient's stories, but somehow they reflect to me the essence of what it means to be human. In their pictures you find love and community.

My Yellow Man

A friend asked why I didn't write more posts when I was doing internal medicine since I speak about it so much. Truth is, I wrote more than ever, I just couldn't post them. To me my writing seemed crass, cynical, and unfeeling. I read them and found a part of me I didn't want to see. It was uncomfortable.

My world resembled the House of God, where instead of having names my patients were diseases. I spoke of Gomers* that I always hoped the medical students would have to admit and not me. I managed to strike a deal with my senior resident to assign me the injection drug users instead of the old people with complicated (yet boring) histories who are terribly hard to turf to another service or discharge. Stepping out of my body I saw myself as someone I wouldn't want to hang out with and didn't respect. Despite my attempts to label and depersonalize my experience, there are patients that I can't forget. Like the Yellow Man.

He was transferred from a small hospital with hepatic encephalopathy, straight to the ICU. He was a deep yellow hue. His liver presumably pickled by years and years of alcohol. He was 50 and nearly died in the ICU. But not quite. He then came to my team as my patient. His belly taut with fluid, of which 6 litres had already been drained and his limbs wasting away, his cheeks sunken. My Yellow Man couldn't talk, he moaned at times, laughed eerily occasionally, slept infrequently, and constantly chewed. On the bed sheets, on my hand when I wasn't careful, on the ear of his stuffed rabbit. His eyes darting from side to side, he squirmed to get out of bed constantly and eventually had to be restrained, his breath rasping. The treatment for hepatic encephalopathy is basically diarrhea to remove the toxins affecting his brain. It sounds inhumane but we just give laxatives everyday. The nurses tired of the constant cleaning and at some point he got a rectal tube... in addition to his catheter and feeding tube.

Truth is, my Yellow Man didn't sound like a nice guy. His partner was reluctant to visit, apparently there had been repeated abuse. His kids stayed away. He had an impressive criminal record, I guess he liked starting fires. At one point I consulted the GI service. The fellow who did the assessment told me the look in his eye was "pure evil" and recommended I consult psychiatry and not give him matches. We joked about my Yellow Man, and yeah, like psychiatry wouldn't curse me for such a lame consult, he's chewing on a stuffed animal and can't even speak.

I went in every morning each day of my rotation. Talked to him as if he knew who I was. Listened to his breathing, checked his belly, made sure he was still peeing and that he hadn't pulled the tube out of his nose that was feeding him, and tried to figure out what to do. He got a lung-full of blood at one point, went back ICU, came back to me and the ICU said they wouldn't take him back. I tried to turf him back to the peripheral hospital he came from for palliation but they wouldn't bite.

We thought he was a vegetable, and a sociopathic one at that. He repeated pulled out his feeding tube and we were at a loss of how to provide nutrition. Showing no signs at all that he wanted to live and no improvement in his condition. The family member that would always visit was his 'sister', a close cousin. She would come with her daughter, stroke his head, speak to him softly, wash his face, and claim he understood it all and responded. With her he sat up and ate an apple piece by piece. I chatted with them a lot. She called me 'Shaun' and was determined to take him home and feed him freshly squeezed organic fruit juice with this new juicer she had bought. I met her on the rooftop patio once when she was on a smoke break and offered her one of the donuts I had made for my team. As she took one her eyes welled up and she hugged me. She smelt like cigarettes and pine trees.

The last day of internal medicine I was on call and my Yellow Man started having trouble breathing, his oxygen saturation plummeted, the x-ray showed an aspirational pneumonia and he became drowsy and exhausted, gasping through his mask for air. I called the family and they came... all of them. I walked into the previously empty room now filled with a dozen people. A large native family, they sang and prayed and asked if I'd like to say a few words, Dr. Shaun.

My call ended and I left. I never say goodbye to my patients. Never let them know the new team will be by tomorrow. I can't stand the discomfort of it but I wonder if they care, if just another white coat means anything to them. I heard my Yellow Man died. His life seemed unhappy, even tortured and his end was uncomfortable. And what was my part in it all? What could I say in my last few words? I said that I knew he was loved.


*Gomer (noun: "get out of my emergency room" - a patient who is frequently admitted with complicated but uninspiring and incurable conditions)

Run Across Africa

Their names are Erin and Reuben and they are going to Run Across Africa. From the Atlantic Ocean in Namibia, through Zambia and Tanzania to Dar es Salaam and the Indian Ocean. That's a distance of 4200km so they'll average a marathon a day for 100 days. Its possible that they are in fact crazy, but they are undoubtedly passionate and dedicated. Dozens of sponsors are contributing and the money raised will go to education programs in the countries they are running through.

It makes me want to jump on a plane and go, I suppose that's rather predictable of me... jumping on a plane to Africa. But instead I get to contribute in another, positively vicarious way. I'm on the medical support team. How cool is that?!? The 'team' includes two docs from Victoria, myself, and my friend Teresa, a fellow resident at St. Paul's. We'll take turns being 'on call' for the runners and their support team as they jog across the continent. There's something rather exciting about being on call in Africa despite being planted quite firmly in Vancouver. Our 'remote' medical service will include text messages and emailed questions about diarrhea, dehydration, sprained ankles, malaria, bug bites and hopefully nothing catastrophic. It feels good to be involved in something bigger than my current world of residency, St. Paul's, and yuppie Vancouver life.

Check out the web-site.

That cracking and hissing is the sound of your fading youth

"Can we try something a bit more technical?" Fatal last words before we dropped over the edge of the mountain on those swanky full suspension mountain bikes and I launched myself over the handle bars within the first minute. It was spectacular, painfully exquisite even. Both my dramatic wipe outs and the view across Lake Atitlan as we wound our way down the mountain towards the sparkling water surrounded by volcanoes. If you're hiking and slip, you might cut yourself on the rocks but its a bit of a different story when there's a large piece of metal entwined between your legs. I was pillaged by that bicycle, worth every minute though! Gears cracking followed by the hiss of air from the back tire... either that or my knees were cracking and hissing. At the end of the day, I realized I had reached a new stage in life, where you take ibuprofen before doing ridiculous things like mountain biking down a volcano instead of after when the pain has already set in. Truth is, I'm getting old!

The biking was the culminations of an incredible week at a women's health conference in Guatemala. The content included topics like women's health and human rights as well as discussions of current challenges in sexual rights in Guatemala. It was absolutely fascinating to dialogue with Guatemalan obstetricians about their take on unsafe abortions and how to decrease maternal deaths from post-partum hemorrhage. A statistic I did not know was that abortion rates remain the same whether it is legal or illegal in the country. As usual, medical problems are often more about social and ethical issues than science.

It was delicious to all my senses to be back in Latin America. Life somehow seems more brilliant in colour, the pools are deeper, the smells more marked, life appears fuller and more vibrant to me. Spanish rolling off my tongue, gorging myself on fresh fruit and avocados the size of my head (okay, not quite). I soaked in all the colourful textiles, the familiar foods, the sounds of life and joy and pain, my soul danced again.

On a hike up Pacaya, a rather active volcano, I realized I had not forgiven my parents for something that happened in grade 8. My geology class went on a field trip to the crater of Huahua Pichincha, the volcano that towers over the city of Quito. They wouldn't let me go down the crater, ridiculous I though! So I sat on the crater's edge with the other two losers who also had been cheated out of this life changing learning experience. Oh the misery! So as I stood but a meter from the bright orange river of lava, my skin tingling and my soles melting I finally let it go. Mom, dad... you're off the hook, I got my fix!

Coning

This is something I wrote over a year ago as a medical student in Calgary and I was reminded of it being in the pediatric emergency here. I haven't edited anything, reading it now the emotions and descriptions seem so crisp and fresh and I wonder how my perspective has changed.

The Children’s Hospital emergency department. As a medical student you rotate through for a week and you either love it . . . or you really don’t. I had just finished seeing two really cute kids from Newfoundland here on holiday, one of them had fairly severe asthma and the other had, uh, a cough. I was sitting at the desk listening to one of the emergency docs ranting about people using the health system when they didn’t need to when an ambulance pulled up. The staff was pretty lackadaisical, apparently there hadn’t been a patch to let them know the ambulance was arriving which normally happens so they can be prepared. They were unsure what to expect, but didn’t seem too worried.

“3 year old boy, seizing for about 45 minutes before he got to a Medicentre clinic, given valium while 911 was called. Briefly stopped on the way here but now showing decerebrate posturing and his right pupil is blown.” The history reeled off by the paramedic. It was like an electrical shock passed through the nurses and docs who were in the area, all heads turned, and rushed with the stretcher into the trauma room. The tension was palpable, superimposed with a forced calmness. His mom following the whole procession, hand over her mouth, crying silent tears. Seemingly forgotten in the intensity of the moment. The family had moved from Vietnam 3 years previously, she spoke in faltering English, searching for words when she was asked what had happened. Flustered and crying. The doctor, put her hand on her arm, a gesture of sympathy but it seemed cold and calculated in her attempt to get any information she could out of the mom. “Page ICU, neuro, respiratory, and social work stat. Let CT know that we’ll be there in 5 minutes.” More and more bodies appeared out of nowhere. I had been told during orientation to watch the trauma rooms and get in there whenever I could so I had followed with the rest and tried to stay out of everyone’s way. It was clockwork, everyone had a role. Recording, drawing up meds, preparing to intubate, it all happened at once. I counted 17 people, all around the stretcher which laid the small body of this 3 year old little guy, Daniel. Writhing back and forth, to the untrained eye it could even look like he was just having a bad dream. To the medical professionals in the room, it mean he was ‘coning’, there was something increasing the pressure in his head and part of his brain was herniating. As if suddenly remembering something, one of the nurses turned to mom and asked if there was anyone she could call, any friends or family? No, no family in town, but the husband was on his way, he just had to pick up the 3 month old on the way.

I saw everyone buzzing around as if in a blur of activity, the only constants were Daniel on the stretcher and his mother, frozen in the same position, sobbing, hand over mouth. Clueless as to what was happening. The reality hit me, her world was ending right in front of her eyes, her pain and fear hit me in the gut. A nurse would stop once in a while put her hand on her shoulder and explain that they were going to try to stop the seizure, put a tube down his throat to help him breath, and take him to CT to get pictures of his brain. They were doing everything they could she said. The mom just shook, is shock. After what seemed like an hour but was actually a few minutes ‘social work’ arrived, apparently their job was to be with the mom. When she entered, she was the fifth person to ask if dad was on the way. Yes, yes, he’s coming. It was almost something people asked when they didn’t know what else to say and could offer no other consoling words.

In all of this I stood, an observer, a witness . . . was it possible I was invisible and had no part in what was happening? There to learn primarily, but I can never stop the feelings and thoughts that go with academia.

He was wheeled into CT, the respiratory therapist bagging him all the way. Mom sat outside CT with the social worker, a crowd of nurses and docs went in to watch the scan as it happened. There was a bleed in his right hemisphere, and yes, he was coning, uncal herniation, the bottom of his brain was squishing out below his skull. Was there trauma? Should we suspect abuse? Where’s the dad? Did he have a mass there previously? A near chorus of wild speculations. I’m with the emergency doctor and a resident, we stop on the way out as we pass her. “There’s some bleeding in your son’s brain, we’re going to take him to the ICU. Don’t worry, we’re doing all that we can for him right now. Alright? Is your husband on his way?” Yes, he coming.

The emerge doc goes to see the next patient, knowing that Daniel is now being taken care of by the intensive care physicians and the neurosurgeons. I’m full of questions and the first year emergency resident can’t hide her eagerness to use this as a teaching case. As she goes through the CT scan with me on the closest computer explaining the pathology in detail the dad walks in pushing the 3 month old daughter in a stroller in front of him. He asks where his wife and son are, the resident, immediately somber, takes him straight to his wife who is with the ICU doc. Things are explained, now in a bit more detail, the prognosis is not good. Tears well in his eyes. They assume he understands all that is happening. He too covers is face with his hands, cries out, crumpling to his knees. Sheer pain. “My son, my son . . .” his wife joins him, they cry together, sobbing uncontrollably, shaking as they embrace. My heart broke.

I was sent back to emergency to see more patients, my mind was nowhere near the child with croup, or the roller bladder who needed some stitches. The nurses stood in a group, “what could we have done differently? We didn’t get a patch from the ambulance. He really should have been intubated already by the time he got here. Why did they wait so long? They should have called EMS from their home. Is there anything else we could have done?” Constant questioning, reassuring themselves that they couldn’t have prevented this. And my role? I learn, at this point in my career I am a witness to both the functioning of the health care system and heart ache along the way. A family’s life is forever changed, we pause for but a second, and then the system keeps on clicking, like clockwork.

We've Got a Bleeder!

Helpful Hint #216

When an 8-year old zips his foreskin into his zipper there are some important points to remember:

1. Do not panic.
2. Do not just unzip it.
   
3. Do not look the father in the eye.
4. Do not make comments involving anything remotely like: 'good thing you're not Jewish, you never know what you might have caught in there!'
   
5. Give pain control (morphine, tylenol won't cut it).
6. Get bandage scissors and cut the jeans in a large semicircle starting at the waistband and going around the crotch.
7. Cut straight across the top of the zipper so the zipper easily falls open.
8. Apply pressure.
9. Suggest sweatpants for the next few days.

If gave me a flashback of the opening scene from Something About Mary. I'm just learning so many useful and relevant new things every day.

Salaam

My first shift in the pediatric emergency department. I suppose I did look the part, dressed casually in gray cords and running shoes, the standard green scrubs top and my trusty stethoscope around my neck sporting a rubber duckie key chain as the ultimate crying-kid distractor. Clipboard in hand I was wading through the crowded waiting room trying to find some vomiting child I was supposed to see. The place was swarming and loud, parents and kids covering every nook and cranny, all looking at me somewhat expectantly as if I was some kind of lifeline.

Then, a gentle hand on my arm and the Arabic greeting, "Salaam aleikum". The dull roar faded a bit and I turned to face a woman, completely veiled in the black niqab with only her smiling eyes showing, looking at me with confident familiarity. Instinctively I replied back, "aleikum salaam" with a grin and desperately searched my memory for those eyes. With a rush it came back as I caught sight of her husband sitting across the room in his prayer cap and full jet black beard. Six months ago those same eyes had held my gaze with terror and her trembling hand had grasped my arm as she lay in the operating room having a needle stuck into the jugular vein in her neck in preparation for her high risk cesarean section. Her heart was double the normal size, and was failing as it tried to cope with all the changes of pregnancy. We didn't speak the same language, but everyday, I sat and spoke with her and her husband, a deeply compassionate, sensitive, and caring man. The baby had been delivered prematurely and was born at 5 lbs, now she was a thumping 6 month old... granted she did have a bit of a cough, but had her mothers big dark eyes that peered at me solemnly and intently.

Its amazing how powerful one look can be. In a moment, salaam, peace, is exactly what I felt. The next moment, the roar rose again, the vomiting child had heard their name and I ushered this new family into a room to be seen. Strange. Some patients impact me so powerfully that I can remember the exact emotions that coursed through me, the thoughts I had as I anticipated seeing them each day, and the way they stuck in my heart. But it never crosses my mind that they will remember me, that I was someone in green scrubs who looked different to them. It gave me shivers down my spine and warmth in my belly.

Other lovely feelings I'm having are related to ridiculously cute kids (granted, some slightly neurotic parents... why can't they just vaccinate their kids?!?) as well as my work week now being around 30 hours instead of 80. Last night I got to put a bright pink cast on a giggling two year old's leg, saw my first ever case of mumps (uh... yeah, there is in fact a vaccine for that FYI), and got to make funny faces at all but one of my patients (the exception was a 15 year old with a hole in his finger, I just didn't think he'd be that into it).

After explaining to my sister how I only have 12 shifts in four weeks and that I get to play with cute kids all day, she asked quite a profound question. "Well, why wouldn't everybody want to be a children's emergency doctor?" Good question. It stopped me in my tracts. The answer didn't take me too long. Well, clearly, its because you don't get to delivery babies and be at birthday parties everyday, that's why.

Good People

He purposefully walked towards the podium, then stood before us, his figure tall and imposing. Starting on the left of the room his gaze washed over us, gentle and intentional. Silence descended like a warm blanket over us, somehow safe and exposed simultaneously by his eyes. Then he spoke, a voice in one breath peaceful and powerful: You all look like good people.

I was at a talk organized by a group called Streams of Justice and we had just heard a presentation on the gruesome history of residential schools in Canada run by the church and the recent recompensing that the government was making. Aboriginal children removed from their communities and families to be socialized and reformed. Their language and culture was to be educated out of them and the even greater tragedy was the rampant abuse and neglect that occurred while attending residential schools. The monetary settlements themselves sounded gruesome to me. They give different forms of abuse a different value, so many dollars for being beaten, a different amount for anal penetration, and the list continues.

We put numbers and dollar amounts on people's pain . . . on people's lives.

Evil happens because good people sit back and do absolutely nothing. His gentle words cut straight to my heart.

He shared with passion how his sisters and brothers had been affected and are now further wounded by the settlements that are being proposed. One hundred years of children affected. I hurt, I hurt because who we are is beautiful human beings, as beautiful and precious as anyone else. What we need to understand is how to heal. We need to heal.

The first step in the oppression of other people is that we objectify them and they are no longer people. 'Indians', not human beings, the 'Indian problem.'

So, good people, are we to continue to do nothing? To walk by the human beings who sit on the street who cannot heal themselves. Are we to continue to do that as good people?

As I left, I told myself in no uncertain terms: I don't ever want to be one of those good people who does nothing.

Acidosis

soul crushing
guilt
a sick sick mom
gorked baby?

how can my omission cause such catastrophe?
why did it happen?
a sleepless 32 hours
I had to talk to another family
whose brother's lung was full of blood
whose liver had failed
heading to the ICU

maybe excuses
maybe justification

stumbling from hospital in a daze
I didn't check on her
I went and slept
and woke
and dreamed
of people drowning in their lungs while I watched helpless

tragedy happens
and I have often stood and witnessed
counseled
listened
discussed
even helped
but not caused

I don't want my actions to matter this much
don't want my life to make a difference
my being has deadened

The Harvest

Its strange that we call it harvesting. Harvest makes me think of golden wheat fields, rich green maize fields, piles of potatoes, or stacks of pumpkins. The end of a growing season, a time of plenty. This harvest was different. She was young, a mother, a wife, a daughter, a sister. Only in her thirties, with a bleed of unknown cause in her brain. On the medi-vac flight down from northern BC she had an uncal herniation, where your brain squishes out the bottom of your skull from the increasing pressure. Technically she was dead, although her heart was still beating and blood pumped through her body. Her family agreed to donate her organs so she came to St. Paul's to be kept alive for the harvest. Corneas, liver, kidneys, heart. I suppose it was the end of a growing season in a way.

I don't know who got the other organs, but I know who got one of the kidneys. It was a guy in end stage renal failure, living on dialysis. To me watching a kidney transplant is a miraculous process. It sits cold in fluid, grayish white, in a specimen container that I've only seen in the anatomy lab. Just a dead piece of tissue to my eyes. But the vein is delicately sewn into the belly of the recipient, the artery perfectly attached and then this dead flesh goes dusky and slowly pinks up, pulsating with blood and life. Warm and slimy wet under my sterile gloved hand and suddenly the worm-like ureter squirts out pee like cold air hitting a diaperless baby boy. Its nothing less than magical.

Of course, kidneys don't only come from cadavers or people with brain death, they come from living donors as well. Like sisters. There were two sisters this week who donated to their siblings. It made me grateful for my sisters, you never know when you'll need a spare part... in fact, I should probably call them more often anyway.

There's a novel by Kazuo Ishiguro called Never Let Me Go. It takes place in a dystopian Britain where humans are cloned to be organ donors, and they slowly donate until they 'complete' and die. I found it deeply haunting in its suggestions about what makes people human. I'm awed by how life can give life and death can also give life. I hope my life and death bring both the beginning and end of a growing season. Just for the record, when I die, at least stick a mango seed in my mouth and bury me somewhere fertile.