Spirit & Flesh: Confessions of a Baby-Catcher

A Hint of an Existential Crisis

2012-02-01T10:19:00.000-08:00

The final hint of tropical moisture was removed from the air with a fine chemical mist as the flight attendants emptied their aerosol cans into the air to sterilize any hitchhiking mosquitoes. As the air-conditioned plane lifted off from the Entebbe airport I felt a mixture of relief, nostalgia and regret. I couldn’t help but feel just a hint of an existential crisis in the residual mixture of emotions left behind after spending August to December in Kampala. Although my expectations may have been unrealistic, on many levels, both personal and professional I question if there was any point to the exercise and whether the balance of good and bad, frustration and hope leveled out to a positive balance. The truth as, looking at the history of ASPIRE, a huge amount of progress has been made this year despite my questions as to the sustainability and local investment. Perhaps my goals for my time in Kisenyi were somewhat unrealistic.

After a few weeks in Europe for some much needed rumination and healing I found myself back at Hopkins, trying to drink in some knowledge from the Public Health fire hydrant. Its always an intense and exhausting experience but I found myself searching for mentors and perspective on how to direct my vocation in a way that will both be personally rewarding but actually contribute in a way other that just catching individual babies. Don’t get me wrong, I don’t need to save live ‘a million at a time’ like Hopkins claims to. As my wise spouse often quotes, “its not important to be important, its important to be useful.”

Christmas Around the World

2011-12-25T04:42:00.000-08:00

Christmas Day finds my family on three different continents, what's new? We're in Barcelona, the sun is shining and the sky bright blue over the Mediterranean Sea. Our Christmas dinner will likely consist of tapas instead of turkey. My older sister is in the midst of an Australian summer while the younger one is on a local boat somewhere on the Amazon between Pucalpa and Iquitos in Peru, a few cows are penned on the boat deck and apparently there was potential for one of the chickens to turn into Christmas Eve dinner! Mom and dad are staying in Calgary this Christmas, celebrating with old friends while my in-laws are having a feast in a brown and snowless Manitoba...what a family it is!

Of course, Christmas in much of the world is very different than the shimmering lights, Christmas markets and designer boots we find ourselves surrounded by here in Spain. I love the public health messaging campaign below about the 'festive season'. The gift of health for Christmas is priceless but as 'cheap' as two doses of antimalarials for some!

Wishing you all the best of Christmases, may you know hope and peace, and share some of it around.

Tanzanian Nostalgia

2011-11-08T04:31:00.001-08:00

I recently went on a rather nostalgic trip to Tanzania to climb Kilimanjaro (an epic tale told elsewhere). Let me be clear, it wasn’t nostalgic because I’d climbed the mountain so many times before! The truth is, I really like Uganda. It’s a country with a dark and violent past where (for the most part) people have chosen reconciliation over judgment and much about the nation and its people fascinate me. But I LOVE Tanzania, perhaps because I speak the language, I can interact on a different level, joking and teasing. Undoubtedly it is because I spend a very formative year of my life there. Immersed in Tanzanian food, culture, language and families. I will forever think their elephants are larger, their hearts are bigger and their language more beautiful. There’s no questions I’ve left a chunk of my heart there. The nuances of Ugandan work culture and language are to some extent wasted on me. Tanzania was my first African love, I can’t help it!

I miss Tz.

Cervical Cancer History

2011-09-29T10:52:00.000-07:00

As we wind our way deeper into Kisenyi II past the pungent aroma of fermenting millet, down a steep alley, through a door that opens onto a dirt courtyard of children playing and women washing clothes, around the corner of a block of latrines you can see how a child could get washed away in a downpour. We edge along narrow ledges between houses, the drop-off off to deep open sewers inches from my toes. I duck my head to follow Veronica into a house, a sheer piece of cloth is the door. We are welcomed and a colouful woven mat is layed on the floor where I sit, legs bend beneath me next to Hadija, a wide-eyed 2-year old chewing on her breakfast chapatti. The morning sun glows through the curtain as Veronica explains what we're doing and asks if the woman would like to participate. She's keen to get tested only after she is reassured that she won't have to 'open her legs for an exam like they do at the hospital' unless the test is positive.

Although I am obviously deeply invested in the project and passionate about working towards preventing women dying of something so incredibly preventable it still boggles my mind that women are so open to collecting their own samples and being screened for HPV. On our first day of testing, one of the teachers at the primary school heard we were testing for cervical cancer and ran over to find us during recess so she could get tested. They take the swabs, go behind a curtain or to the latrine, and come back with the specimens for the research assistants to label then ferry to the lab for analysis. To be honest, if someone showed up at my door with a cooler full of swabs and asked if I wanted 'do-it-yourself' cervical cancer screening I might just shut the door. Although the logistics of a truly community-based screening program can seem intimidating, I can't help but be encouraged by how eager women are to be involved.

I remember an impassioned speech by Stephen Lewis at a huge HPV conference in Montreal last year. His usual topic is HIV but he spoke about cervical cancer that night, and the tragedy of something that is completely preventable, not only with screening, but with an effective and safe vaccine that is responsible for the death hundreds of thousands of women across the world. Over 85% of those deaths occur in the developing world where there is no infrastructure for effective screening programs.

I heard Stephen Lewis again more recently, on a CBC podcast interrupted by haltering internet when he spoke at the funeral of Jack Layton, previous leader of the opposition. The quote of Jack Layton's that stuck with me was 'Always have a dream that's longer than your lifetime'. Today, my dream is to make cervical cancer a historic disease, this disease that is often called a case study in health equity has no right to take the lives of young women, regardless of where they are on the planet. Check in with me in a decade to see how we're doing.

Blatantly Obvious

2011-09-03T23:29:00.000-07:00

The sound of my feet pounding the path was the only rhythm I was aware of as I slowly climbed the incline of the Kololo hills in the rising early morning mist, past embassies and houses that would put the mansions of Shawnessey in Vancouver to shame. As I pass Kololo Heights and start my descent back home, the orange ball of the sun peaks out from behind Ntinda hill sending sunbeams shooting through the low lying clouds in a brilliant peachy fan. Running is good for the soul. A nearby mosque emanates sing-song prayers out into the waking world. Funny, I think to myself, normally their morning prayers are done by this time.

As I drink my coffee, the plan for the day goes through my head, meeting with PATH (an NGO with offices nearby at the WHO building). Then Michael (Doreen’s replacement) and I had a long to do list, check-out labs for processing cervical biopsies, buying a specimen carrier, editing and printing surveys and educational material, we had discussed it all just yesterday.

I show up at the gate of the WHO offices at the appointed time, but have an intriguing discussion with the guards at the gate. No, no one is in the office today. Why? They give me a strange look, a bit confused even. Well, its Eid.

Of course, Eid, silly me, oh well. Having not learnt my lesson I tromp down the hill to Mulago Hospital, get to the office to find the place a bit deserted. That’s funny, Mike and I had this work plan, oh well. When I call him (he’s a good Catholic boy by the way), he says: Sheona, it is Eid, we cannot work today!

I now recalled our scheduling challenges with the outreach workers in Kisenyi:

Does Monday work? No, Veronica’s church has to help distribute the World Food Program food.
Tuesday? Well, Esther is a Muslim, it could be Eid.
Wednesday? Well, it could be Eid.

Of course no one had thought to tell me, its obvious to the rest of the world, the date of the huge celebrations of Eid marking the end of Ramadan can’t be announced until the Imam sights the new moon.

It reminded my of a lovely family from Kerala, India who after recently moving to Calgary experienced their first Halloween. Of course, no one had thought to mention to them that children in their neighbourhood would be coming by, ringing the doorbell, yelling ‘trick or treat’ and asking for candy. Its so obvious, isn’t it?

So I spent the day immersed in epidemiology and statistics, catching up on courses instead. I have to say, I was grateful for Eid!

Debt Perspective

2011-08-20T03:00:00.000-07:00

From The East African Newspaper August 15-21, 2011

Kampala Calling

2011-08-19T12:28:00.000-07:00

After an unplanned, frustratingly exhausting 30 hour tour of Africa courtesy of Egypt Air which included such notorious airports as Cairo, Dar es Salaam, Kilimanjaro and yes, eventually Entebbe I am now back in Uganda! I had the most surreal experience during my 5 hour tour of the Dar es Salaam airport. Having come through Madrid in Europe, many of my fellow diverted continent-touring comrades were from Spain. So when we were grumbling and groaning about our predicament, naturally, I spoke Spanish, however, when we were given our breakfast coupons (yeah for chips and chicken as the only option for breakfast at 5am!) I ended up sitting with a lovely Tanzanian bloke who works as a lawyer at the Arusha Human Rights Tribunal who had also come from Madrid, so naturally, I switched to Kiswahili….much to the confusion of my newly acquired buddies from Barcelona who hadn’t been able to place my Spanish accent to start with. Surreal. I was post-call equivalent as it was which probably heightened the dream-like nature of the event.

I got to the guesthouse from the airport at 3pm, showered and dropped by the office to check in with our research program assistant. Our to do list was long and I just wanted to pop by, say hi and outline our plan of attack. I found not the woman I had seen in January, no, alas, there was a very very pregnant woman sitting at the desk….very. The baby squirmed visibly across the tautness of her belly beneath her clothes. Although she was expecting me, she looked rather….well, sheepish I suppose. My mzungu self blew up inside of me, why on EARTH would this not be something you would mention to the research program so they could make some adjustments?! But FORTUNATELY, the lovely culturally sensitive, accepting inner being took over, congratulated her exhuberantly and enveloped her sheepishness in a hug. I need to zen out and get with the African way of doing things. When I asked how the pregnancy was going she said “Sheona, why do I feel these contractions every 20 minutes, I don’t understand?” She’s due in three days…life happens, awesome, complicated, real.

As I sit writing this the clatter of the monkeys scurrying mischievously across the tin roof startles me occasionally. I’m staying at the Mulago Hospital guesthouse for a few days before moving into my apartment. The guesthouse consists of two, not quite rustic, not quite luxurious house-like structures set on the slope of Mulago hill surrounded by deep green grass scattered with brilliant purple jacaranda blossoms fallen from the trees and the occasional sharply textured globular Jack fruit, cracked and oozing its sweet white nectar onto the surrounding celebrating ants. In addition to the resident monkeys there are a few large Ibis who wander, searching for bugs in the grass with their long smooth beaks. I’m exhausted, overwhelmed by both the logistics of research and the epi and stats MPH courses that I’m starting. But I’m also overwhelmed by gratefulness, for the opportunity to be here, the thrill of the daily realities of life in Uganda and excitement for the next phase of the project. Life is crazy, but good.

MIA for a Year

2011-08-01T13:15:00.001-07:00

There was an intense yet fascinating two week at Hopkins. I’m taking a part-time Master’s of Public Health that will allow me to spend the majority of the year between Uganda and Ecuador working on a cervical cancer research project. The John Hopkins School of Public Health turned 95 years old this year. A world-revered institution that churns out research at an incredible rate and who’s motto is (seriously folks) “promoting health, saving lives….millions at a time.” I can’t take them seriously. The Hopkins medical center is a state of the art institute of modern medicine situated splat in the middle of a ghetto. They shuttle us back and forth from the residence to the medical campus for safety reasons. Looking out the smudged window of the bus I see row after row of brick houses with boarded windows. Is it not a deep irony that this desperately poor and crime ridden community, somewhat of a public health disaster, surrounds one of the world’s leading school’s of public health? With disproportionately high rates of HIV in the African American population that lives there and statistics that show if you are an African American man you will die 30 years before your Caucasian counterpart it makes me suspicious of the program I’ve just signed on for.

Regardless of all the irony and healthy ego of the institution, I am awed by my classmates. I become quick friends with Sara, a young soft-spoken Southeast Asian pediatric ICU physician from Stanford who loves climbing and road biking and has set up a peds ICU in Kathmandu. One of my small group members was an adviser on the Bush administration’s bioethics committee, needless to say he had to find a new job when Obama came in and is now a health policy analyst at the NIH (National Institute for Health). The list goes on, but I quickly learn that those who surround me are without a doubt the biggest resource I have.

I returned to Vancouver for a frantic two weeks of baby catching which completed the requirements for my Baby Mill Chief rotation! Although unlike gyne oncology, it was far from passing with flying colours, I met expectations. I’ll take that and run. I pray that I never eat my words in the future but if I EVER sign up to work at the Baby Mill when I’m done residency someone please slap me, churning out babies at that pace isn’t good for my soul. July 1st was my last day of call at the Mill. A few of my favourite nurses took me out on the weekend and said the loveliest of things about how much they liked working with me, they can’t possibly have any idea how much it meant to hear that.

And now for a year that will beat to a different drum, I won’t hear the rhythmic thumping of the fetal heart Doppler, the reassuring snapping of sterile gloves on my hands or the smoothness of a scalpel sliding through skin. I’m excited, ungrounded and apprehensive all at once. Uganda, Ecuador, Egypt, Spain…oh yeah, and Baltimore, here I come.

Maternal Death and iPhone 4s

2011-06-06T09:46:00.000-07:00

It was a standard beginning to Sheona-style traveling. I book a flight post-call…why not, it’s a wasted day anyway, right? Packing in a mad rush, semi-comatose through security and then exhausted I finally slide into my seat on the plane. Complete relief envelops me and I promptly pass out. I awake foggy brained, dry mouthed and with drool caked down the side of my cheek as we begin descent into Toronto. The perfect opportunity for the lovely Nigerian couple (of ‘traditional African build’ as Mma Ramostwe would say) beside me to engage in conversation. They are profs in Washington DC and think Hopkins isn’t such a bad school for me to go to.

After a short flight on a plane smaller than the ones they use to fly to Yellowknife I find myself in a taxi in Baltimore. Ayaad, the driver, is originally from Eritrea.

You know where that is? He turns with a wide smile of surprise on his face.

Ayaad is driving taxi part-time while finishing his engineering degree. We discuss East African politics, Somali-Ethiopian relations and after discovering my profession he tells me the story of how his mother died while birthing his younger sister.

You see, they just don’t have the technology… so women die during childbirth. He explains.

I suggested it is perhaps not the technology at issue but access to it.

We reach the hotel and I hand him my credit card. He pulls out his iPhone, plugs in a little white box to the top and swipes my credit card. I sign the screen with my finger and he emails me the receipt. He notices that I’m quite impressed by the transaction.

You haven’t seen this before? Oh, you much not travel much!

Oh Ayaad, if you only knew.

I need to download the Preventing Maternal Death App.

Chief what?!?

2011-05-17T21:45:00.000-07:00

Their times of birth were 1526h, 1527h and 1528h. Three babies in three minutes. Her life has been suddenly changed from the quiet days of strict bed rest up on the ante-partum ward were she was learning to knit and working on putting a quilt together. Now hurled into the reality of having three premature babies, one of which weighs less than a kilogram. She is a recent immigrant to Canada, trained as a nurse. She and her husband have a one bedroom basement suite and he works the graveyard shift at Tim Hortons every night. The Canadian dream, eh?

Somehow I have become a chief resident. No, contrary to life on Grey’s Anatomy, this is not a prestigious position you apply for, it’s a mandatory part of a residency in obstetrics and for the most part I hate it. Your junior residents have an obligation to dislike you because you make the call schedule, and no matter what, it will be horrible because of the sheer volume of hours they have to work. They will always consider it unfair, regardless of how many hours you invest in planning ahead, spreading out their call days and weekends. Your attendings somehow hold you responsible for any case that goes awry, either because you didn’t show up for it, or because you did. Oh yeah, and they don’t like how you make the call schedule either. Nobody is happy.

But enough whining, what I love about being a chief resident is the staff clinic. A clinic run by the chief residents for women who don’t yet have health care coverage. The women are mostly recent immigrants and refugees who go through a financial assessment to qualify to be there. Occasionally they manage to jump through the hoops and a patient shows up with a purse worth several weeks salary but for the most part these women are facing huge barriers to getting care. Not only financial stress but imagine the terror of arriving at a hospital in labour and not speaking a word of English. I love the colourful spectrum of languages and cultures that traipse through the clinic, their faces containing such depth of heartache and hope that it fills me with both. This clinic is a glimpse of why I chose to embark on this journey.

The obstetrician who oversees staff clinic asked what type of patients we would like to see referred, then she laughed as she remembered, “That’s right, you don’t like rich people at all, I’ll try to screen them a bit better!”

Orchids, 70-year olds and Dengue Fever

2011-03-17T08:45:00.000-07:00

And then I went from -32 to +37. Ten and a half hours driving through blizzards and freezing rain with logging trucks, not everyone’s idea of a fun day. Then it was my mom’s 70th birthday. She is a phenomenal woman my mother. Its hard to put into words the mentorship she has provided to dozens of people over her career. Her passion for the marginalized often setting her apart from the right wing Calgary community she worked within, who often preferred to turn a blind eye in self-righteous indignation to the needs of the global poor as well as those on their own front step instead of being faced with the discomfort of inequality. But I digress, point is, she’s amazing. After the big party we hopped on a plane together, through Bogota to Guayaquil in Ecuador and then on a bus to Machala, the malaria and dengue capital of Ecuador! Then with some trepidation we put mom on a bus to the Peruvian border, where she caused a minor riot, watched the bus drive off with her luggage and eventually got to the airport in Tumbes to get on the newly minted Peruvian airlines on a flight to Lima for another birthday celebration with my sister. She’s decided to celebrate turning 70 all year, this seems like a good start.

Why come to Machala you ask? Well, the spousal-unit does Dengue fever research here. People describe it as Donde el Diablo perdio su poncho (where the devil lost his poncho). But I must say, it does have a certain sweaty-banana plantation-mango paradise-type of charm once you get a handle on the 37 degrees part. Last weekend we went on a hiking trip through Podocarpus National Park. In the lowlands of the park there were hundreds of orchids in dense humid forests, with plentiful rivers and waterfalls to jump in for refreshment from the oppressive heat. The highlands had amazing bird life and a bit too much of an adrenaline rush in a climb and descent along a steep ridge for several kilometers. Although the view was breathtaking on both days we hiked about 8 km longer than our legs were happy with. We’re turning into old farts.

Back at work this week in Machala, I’m working on a manuscript but did get the opportunity to go to a Dengue community meeting in one of the communities the TDR project is being run in. There was a certain irony in the fact that I got eaten by mosquitoes for the duration of the evening meeting…oh dear. Amazing to see how the project actually works on the ground though.

Eau De Prince George

2011-02-28T16:53:00.000-08:00

The sweet yet sour smell of skim milk powder, part chemical, part organic. It wafts across the valley and settles thinly over everything, permeating the environment. Apparently its from the pulp mill, the billowing towers you can see from most parts of town. As I open my front door in the darkness of early morning I get smacked in the gizzard both by the sharp, biting cold accompanied by the tangy odour singeing my nostrils. I've nearly been up here three months now, granted with a short interlude in Uganda, but it will rank among the best rotations of residency.

Its a strange medical community Prince George, like none other I've seen, they may have missed a memo. There's no open shaming and ridiculing of residents. No pointless scut work to help you build character. The attendings genuinely seem to care about your learning. Strange, very strange. Invites to obstetricians' houses to 'drop by whenever just to hang out', you tend to see your attendings in a different light after competing against them and their kids in Wii dancing.

I didn't know why everyone seemed to care about the HUGE solar flare that happened last week. Northern lights dumb city kid. Shimmering fluidly across the sky, only fading next to the full moon. PG is positively charming, I listetned to a home grown white boy reggae band on Friday night, not something I would have done in Vancouver. Although, unfortunately I started mocking them with the lead guitarist standing right behind me...shoot. Next to my front door are a pair of Sorel boots, snowshoes, hockey skates and cross-country skis...it just depends how much time I have and how cold it is.

The cold was a shock to my now pansy-fied Vancouver-accustomed system and the irony of spending an hour digging my car out of a snowdrift so I could go for a swim in the local pool was not lost on me. Also, FYI, snowshoeing at -32 C is not recommended without significant toe frostbite protection, my eyelashes were fluttering with ice at the end of it. But the benefit of the all too accessibly snow is that 15 minutes after you get off work you can be out at Otway skiing for a few hours, either as the sun sets, turning the clouds yellow to peach to brilliant orange or under the brightness of the stars above.

Whereas at other community rotation sites where residents have the highest chance of being called a ‘tard’ (as in retard) or ‘cretin’ for their OR skills, in PG you have the highest chance of being called ‘sweetie’, ‘buddy’ or ‘love’ and fed by the frequent OR ‘food fests’ to within inches of your life with delicious homemade dishes. I felt affirmed, respected and embraced as part of a team. Although I didn’t expect it, I would absolutely work here in the future if given a chance, my soul fund has been topped up.

And now back to the big smoke and the baby mill…well, with an Ecuadorian interlude that is.

My Screaming Ovaries

2011-02-23T20:20:00.000-08:00

There is a divine and messy moment after birth. I peeked my head around the door to see if the baby had been born yet. It was one of those consults that causes obstetricians to go into early retirement. A recommendation for assisted delivery had been made, and it had been declined. One can only step away and wait. Regardless, the parents were lovely, both well along in successful careers.

So it was with a wave of relief that I witnessed this tender moment. An exhausted but exhilarated mother holding her naked child against her chest, the father leaned in close, tears streaming down his face, tenderly kissing the top of his daughter's head, telling his partner how much he loved them both.

But the pediatrician walked back and forth restlessly, the babe had to go to NICU. She was much sicker than expected and needed multiple interventions. Later that night I found out baby had been urgently flown down south for further care. Mom and dad were going with.

Dread. Nausea. Sadness. Guilt. I can't find words to describe the feeling. Should I have made a fuss? Demanded delivery? Pulled the "your baby will be gorked if we don't deliver it now" line? Would that have made any difference? No one can say.

The next day I called the NICU down south to see how baby was doing. Not good. On ECMO (a heart-lung machine for babies) with uncontrolled pulmonary hypertension. The baby had a common trisomy and the parents were giving her up for adoption.

My ovaries screamed in unison and my heart exploded. I jumped in my car, drove the 10 hours down to Vancouver in the snow, only wanting to wrap that baby in my arms and love her for however long her life might be. My soul aching, thinking of that tiny baby all alone in a NICU far away.

Okay, I didn't actually get in the car. More just a compulsion to do so.

Damn ovaries.

Unsettlingly Serious

2011-02-11T20:55:00.000-08:00

There was a gnawing unrest somewhere deep in my belly as I walked out of the hospital tonight, and I'm not talking overdosing on Timmy's coffee unrest. I could chalk it up to the communal grief of the seven family members crowded into the small assessment room after they found out the baby had died at 33 weeks gestation. A familiar wave of nausea and dread swept over me as I sat on the edge of the bed, searching desperately with the ultrasound for the flapping heart in the grainy picture. The cardiac anatomy was outlined clearly, sitting eerily still and unfamiliar under the railroad tracts of the spine as the taut belly shook with sobbing.

But if I'm truthful, it wasn't just fetal demise that has unsettled me, its that things are getting serious. The weight has gradually but solidly settled on my shoulders. Surgery isn't just cutting and fun anymore...well, its still fun, but serious fun. I did surgery on a woman for uterine cancer last week, who made zero urine the next day. Zero. Oh, and developed a sky high creatinine (that means renal failure). I felt sick. My night was spent tossing and turning, in my mind replacing every single suture I had placed, each vessel I had cauterized, trying to figure out how I had tied off her ureter or cut an unrecognized hole in her bladder. I woke up soaked in sweat and nauseous (no, I don't have cancer and I'm not pregnant if you're symptom fishing).

Last night I had to deliver a distressed baby by forceps before the attending could make it, egged on by an anxious GP. As the fetal heart rate tapped out ominously, I did the pudendal block, then slid on the forceps smoothly, double checking their placement. Perfect application as the silver salad tong suctioned into place creating the baby's ergonomically designed helmet. Beautiful delivery over two pushes. Perineum INTACT. Impressive, no? No, not at all, you're not SUPPOSED to pull babies out with forceps sunny-side up Einstein, its not AS ergonomical to wear your helmet backwards. Not a delivery I was proud of. The baby went to NICU, not because of the forceps, because of a fever. Obstetrics can be humbling.

The responsibility of the vocation I'm training for is becoming clearer. An obvious result of the increased autonomy I'm given here. I hope I find the balance between the fun and the fear. You see, I've just never been described as serious before, but I haven't been joking as much lately either. My renal failure lady had an intact bladder and ureters and turned the corner just fine, the nurses went out of their way to care for the grieving family and my sunny-side up baby is breastfeeding with mama now.

P.S. I know unsettlingly isn't a word.

Breech Baby Breech!

2011-02-05T21:04:00.000-08:00

Beeeeeeeep beeeeeeeeeep beeeeeeeeeeep.

My phone call to an old friend is rudely interrupted and I go into the kitchen and grab the phone to answer the page.

Code pink, vaginal breech, primip with meconium.

At first I think the maternity nurses are playing a joke on me, knowing what the wet dreams of OB residents are made of. But no joke, its for real.

Everyone is there, the OR staff, several dozen folks from NICU (it seemed) and no obstetrician (yet). The baby's heart rate looks lovely, so I consent the mom for a STAT C-section just in case and tell her all about breech deliveries...truth is, we can see a scrotum coming out each time she pushes which would make a C-section quite challenging at this point.

The Grandfather of obstetrics rolls in calmly, shirt and tie with scrubs top over top as his signature outfit, and peaks over my shoulder. His only words, in his usual unflappable manner and quiet voice:

Looks like the little guy's pecker is pointing up there, I suppose you'll be getting ready for an episiotomy.

Right, of course...as I scramble to get some local anesthetic. The delivery is beautiful, the kid starts screaming and the crowd disperses fairly quickly.

I notice a huge blood clot has dolloped onto my jeans during the process, which I hadn't had time to change on the way in. Well, in the grand scheme of things, that delivery was worth a good pair of jeans!

As I head to the nurses' station to do the paper work feeling rather exhilarated, the Grandfather says: Great job, now you can do them in your practice, right?

Right.

Uganda's Top Five

2011-01-29T21:47:00.000-08:00

5. Sam Luboga - His gentle manner and soft voice win you over in seconds. He has every right to be a successful academic general surgeon with a healthy ego to boot but his humility is palpable. As we sit around a table in the now empty waiting room of St. Stephen's hospital he tells us the story of how the small community hospital came to be.

You see, they would come and knock on my door, I would spend the day working and then come home to a line-up of patients. It started in my office at home... I simply could not ignore the need. So we started St. Stephens.

His young protege gives us a tour of the small but clean and organized hospital, we all agree we'd rather deliver here than as part of the mass of humanity at Mulago. Sam's hair is now mostly white, his smile gentle and his laugh genuine. His clerical collar (since he has also trained as an Anglican priest) seems to make him even more approachable instead of unattainable and intimidating. He has 'adopted' over a dozen children, mostly from his siblings who have passed away, from AIDS and other life circumstances. I have no doubt he has made more of an impact on this community than the most well-published of academic general surgeons could ever hope to.

4. Jean Chaimberlain - They told me she was a spit-fire but I must say seeing is believing, (I briefly may have even mistaken her passion for hypomania at one point). An obstetrician originally from Ontario, she has dedicated her life to developing a Masters of Public Health in Maternal Mortality at Uganda Christian University where currently professionals from across East Africa are being trained. I felt privileged to meet some of her students and was blown away by their dedication and passion, some were government health officials, nurses, social workers and business people who all work full time in addition to taking the course. She makes no excuses. Not for her faith, nor for the relentless drive she has to affect change in a world where a woman dies needlessly every minute of everyday from a pregnancy related cause.

3. Veronica Najjuma - She must be nearly 60 but to me her wrinkled face seems ageless. Rarely without a smile, always some type of floppy hat on her head as she sets out into her community of Kisenyi with a message. Whether related to cervical cancer or a town meeting, she spreads the word with determination. She's a village chairperson and one of the research assistants that I've written about previously. In January of this year, I visited Kisenyi again, but this time with an entourage from UBC. Among them, the head of gyne oncology, the Canadian infectious disease in pregnancy guru and of course my fearless research supervisor herself! I have worked with these attendings in a very different context than the dust and garbage that surrounded us in the slum.

Veronica had been charged with a tour of Kisenyi which she took seriously. First to the houses that had been burned down just three days before, two children had died. The wooden shacks are crowded so close together that the fire had destroyed a dozen houses within only a few square meters. Next she lead us to the brothels. We sat in a tiny courtyard, crowded on tiny wooden stools as Veronica chatted with these women about HPV self-collection. To be there, having my attendings, a group of driven women who are leaders in their fields, sit and witness the stories of a group of women so different from themselves, some of the most marginalized, was a powerful and moving experience. They had recently been involved in an HIV microbicide trial and were wary of pelvic exams, saying speculums had caused HIV in some of their friends. Veronica engaged them in conversation, her openness drawing them in.

2. Florence Mirembe - aka The Queen of Africa. Previously the head of the department of Obstetrics and Gynecology. She may have done more than any other woman in Uganda to forward women's health. She is a trained obstetrician-gynecologist and a long-standing professor at Mulago Hospital. I remember going to morning rounds before I had met her and leaning over to ask one of the junior doctors in a whisper what her name was. He looked back at me incredulously, "that is Prof Mirembe!" She certainly had a presence in the room, admonishing the interns and registrars to higher standards

"you knew she had a previous Ceasar when she came in in labour, and now you have risked her life and taken her baby's life from her because you waited for her uterus to rupture before going to theater!"

No apologies, just pure passion, decrying the injustices of a system without resources. How can a woman who has not only lived through the dark times of Idi Amin but also witnesses unspeakable tragedy at the loss of women's lives not have become jaded? Not have come to lower her standards of care? How does she maintain that fiery compassion in the twilight years of her career when she could be relaxing a bit more? I have trouble not getting jaded and I'm only partway through residency!

1. Allan Ronald - In all honestly I didn't fully realize who was coming over for dinner, over the past two weeks we had innumerable meetings with a variety of phenomenal individuals and names were all starting to blend into each other. So Allan Ronald took me off guard. He is humble to a fault, down-playing his involvement in a massive HIV trial currently taking place. He is somehow able to connect personally with everyone in the room, he leans forward engaging me in conversation, interested in what my plans are. Then, looking me straight in the eye puts the entire responsibility of saving the world squarely on my shoulders. "You need to change how CIDA works, you need to transform the way health research and development are done, its up to driven young people to do it."

As it turns out Allan Ronald has not only received the Order of Canada and been inducted in to the Medical Hall of Fame, but he is the foremost infectious disease physician and microbiologist in Canada and was at the forefront of developing the infrastructure for the hundreds of thousands of Ugandan's who have received antiretroviral medication. He is a leading HIV researcher who spent 30 years involved in research in Africa. Sadly, I heard he has been diagnosed with advanced stage cancer, something you would not have know by the hope and inspiration oozing out of his every word as we sat and discussed international development over dinner. Everyone was a bit starry-eyed as he left that night.

The Top Five have left me humbled, inspired and unapologetic about what drives me. As the slog of residency continues, the day to day of baby-catching, sleepless nights, coffee-jittered days. The endless learning of surgical techniques and the challenges of clinical decision-making threatens to convince me that all there is to my vocation is getting babies born safely and hysterectomies done properly. Not to sound cliche, but these individuals, all in different ways, have been a thundering waterfall on a parched and disillusioned soul, overwhelmed by hope in the face of a much greater need than someone with painful periods wanting a hysterectomy.

OB/GYN Residency

Family Feuds and Cancer Survivors

2010-12-13T19:04:00.000-08:00

I make no claim to have battled the Emperor of All Maladies, I have merely doggedly walked under the feet of the insurgents who attempt to stand in the way of the Emperor's tank as it rolls into the square. I loved and resented the experience, captured by their vision and passion, I may even make a career of anti-tank mines myself.

Its a fascinating family dynamic. At its head is the Matriarch, simultaneously commanding, inspiring and terrifying, all the while deeply proud of her brood and how far they've come. The fatherly and jovial Uncle at the height of his career, confident in his inside knowledge of how the whole machinery works, with only occasional sexually inappropriate jokes. Then there's Diva, the sometimes moody and generally demanding teenager. The Adopted Child, sweetly cerebral but easily the brunt of the family's jokes. The Distracted Godfather, now moved on to faster moving races, still an efficient and skilled surgeon but detached from family functions. Last comes the Runt, once dotted upon but now pressured to prove that she can play with the big kids. As a family they can be inspiring, compassionate, blood-thirsty, passionate, and heartless all at once. If you succeed they applaud you loudly, taking credit for having painstakingly formed your skill. If you fail, they step back disgusted at your weakness, sure it is no fault of theirs.

It is one of those rotations in residency that seems like an initiation, a gauntlet designed to prove your worth at every turn. Having survived you now breath easier, knowing comrades have fallen before you, switched to other specialties, left without mental health intact.

Despite the incredibly melodramatic picture I've painted, I'm grateful to the Emperor and the Insurgents for lessons learned...I can say that from the other side.

Good news! You have lymphoma!

2010-10-30T22:13:00.000-07:00

Well, I have some good news and some bad news... The bad news: you cancer, but the good news is that its lymphoma!

I recall standing next to my attending at the gyne oncology clinic as an elective medical student in complete disbelief at the words that had just come out of her mouth. The poor patient dissolved into tears. She had been pacing back and forth with too much back pain to sit in the chair next to her husband, a result of massive lymph nodes pressing on her psoas muscles.

A hideously awkward discussion ensued where the attending (sickeningly upbeat and logically) explained that lymphoma had a drastically better prognosis than ovarian cancer, so it was a better cancer to have really. The whole time the poor patient's husband tried to refrain himself from punching said attending in the face. Or maybe that's just the fly-on-the-wall little medical student's interpretation of what happened. My attending then did a smooth punt and turf to medical oncology despite the sobbing patients request for answers.

I remember feelings of helplessness washing over me, overcome with empathy for this hurting woman and anger towards a frankly ridiculous attending. It was in the midst of a frigidly cold elective in Ontario during which I was supposed to be impressing people but felt achingly lonely and completely incompetent for the entirety of the rotation.

Last night I had a vivid flashback on call at the Death Star. The emergency physician called me to see a woman with "new onset metastatic ovarian cancer" who had recent growth of parotid (jaw), neck and axillary lymph nodes (and of course, a mass in her pelvis). It felt like a case of: "patient has vagina, please see in consult." She was young, and as I spoke with her and her husband the fear was palpable. A single tear slipped down her cheek as she answered my questions. The truth was, the chance of her having ovarian cancer was slim to none as further investigations confirmed, gyne oncology was not the service that could help her. Unfortunately Dr. DoucheBag McEgo was the internal medicine Sr resident and it took three heated discussion, four hours and a (useless) consult with hematology for him to admit the patient. My blood was boiling with Dr. McEgo's passion and determination to turf this lovely patient to anyone but his team.

Hours passed, internal med finally saw her but as I walked by to see another patient, her husband grabbed my arm, looking for answers. What's going on? Does she have cancer? Is she going to die?

Leaving the post-partum lady with a fever and the palliative patient with metastatic uterine cancer who now had a lung full of fluid, I sat on her stretcher and laid it all out for them. Yes, right now it looks like lymphoma, but there's treatment for this. The husband curled up in fetal position crying. My heart broke a little...maybe a lot, but it felt like I was actually doing something useful. Not turfing, not fighting to get rid of patients, but being present in the pain, messy as it is. I'm not scared of tears anymore and I'm no longer just a witness to it all.

Full Circle

2010-10-01T20:48:00.000-07:00

February 14th, 2008 Vancouver was enveloped in its standard winter cloak of gray clouds and cold rain. Although, even that I was only aware of cycling in the drizzle to work in the dark mornings for 6:30am rounds, leaving as light left the sky in the evenings. Exhausted and drained from another day at the Death Star. There was a haze in my eyes and my head ached, I was on call that night and groaned inwardly when the oncology fellow paged me to go to Emergency to see a patient.

She was a woman in her early 50s, who after a long post-operative recovery from ovarian cancer debulking surgery had now developed an abscess. She was febrile and in significant pain, accompanied by her husband. She was also a physician, as was her husband a fact I knew from her lengthy admission to the service.

The most amazing thing happened that night. Though her own pain and fear, she focused on me as a person. How is residency going? What type of practice are you considering? What are you struggling with? What do you love about the specialty? I stood next to her stretcher in the emergency department, examining her, explaining the CT scan she would get and the antibiotics she would be on, all the while completely floored. Here was my patient, a physician no less, taking the time to recognize my humanity, something no one else had taken the time to do that whole year. I remember the night vividly.

September, 2010 Why don't you see the next patient? She's a doc so make sure she's okay seeing residents first. And there she is as I walk in the room. A warm smile on her face, her arms tanned from the sun, positively glowing despite a recent recurrence and chemotherapy. Hey! I know you, February 14th. Were her first words to me. You saw me on the night I was readmitted to hospital!

I couldn't help but recount to her how she had recognized the person-hood of a junior resident in the middle of the night in the emergency department and in doing so had renewed my faith in a healing vocation. We can't cure her cancer, but nothing about her suggests a dying woman, she is living and vibrant, full of hope and laughter. And so I come full circle.

Doctor in Denial

2010-09-13T15:15:00.001-07:00

There comes a time in every kid's life when they realize something about themselves that has become too obvious to deny. This has happened on many levels for me, and now, there's no denying it, its been four years, lets face it, I'm a doctor. No more denial.

The challenge comes when trying to find a new blog title though, something that portrays a journeyer, some humility, faith, a learner, open-mindedness, and yes, something related to obstetrics and gynecology. A list of hilarity ensued:

Hippocratic Acrobatics

Chicken Soup for the Vagina [lets get all spiritual]

Vaginal Soup for the Soul [that's going too far]

Vaginal Surrender: Gynecology on its Knees [an attempt at the humble part gone oh so wrong...]

Vagina Smagina [not quite profound enough]

Confessions of a Passionate Nomad [sounds like a travel blog, although a friend once told me she could see me 'saving the world, one vagina at a time'...]

Confessions of an Aspiring Mid-wife [might get doula-wacked, better watch out]

Dr. Mister the Gynecologist [insert inside joke here]

God, Boob-juice and Hysterectomies [stop while you were ahead]

Eventually, after several episodes of gut wrenching, eye-watering laughter, here's the new title, comments welcome.

Informed Consent, the Lion King and Cholestasis

2010-07-26T11:45:00.000-07:00

So...what you're saying is that there's a risk of stillbirth so that's why you recommend getting labour started now?

This was after a thirty minute discussion on cholestasis of pregnancy which is associated with a 1-3% risk of stillbirth at term. The poor woman came in as itchy as a bed bug infested child, going a bit nuts scratching her skin off. There's no need for an urgent induction, but we do tend to recommend proceeding with a birthday party if the baby is already fully cooked in there.

Well, this is a miracle baby you know, it was an IVF pregnancy and we're really quite nervous about it...but...its just...well...

Understanding where people are coming from is crucial, we get taught to ask how people feel about treatments, what their perceptions are yada yada yada, but I couldn't quite get inside this woman's head.

We had tickets for the Lion King this weekend, couldn't we have the baby next week instead?

Then it all made sense. We're not in Uganda any more kid, there's more important things than life and death you know, there's the Lion King. [Insert irony here.]

Off to Amsterdam Again

2010-05-05T00:11:00.000-07:00

My time is drawing to a close. I’m going to miss things. I’ll miss the carpenters saying good morning and greeting the chapatti lady as I wind through the neighborhood, past plantain trees, scattered maize and jack fruit trees on the way to catch the matatu every morning (I live behind a petrol station you see). I’ll miss the milky chai, fresh pineapple and mango breakfasts. I’ll miss my chats with Veronica every morning in Kisenyi before we start our surveys as we sit in her somewhat derelict hair salon, the world passing us by on the dusty street outside. She loves reading, and although she has no books, she budgets to gets the local Luganda paper every morning and as she sips her chai she translates the stories for me.

She this man! Ah! He was to marry this woman, but then at the wedding day, this woman here came into the church and said that he was already married to HER and had three children! These people…

The last page of the paper always has an update on the soaps. Most are dubbed Brazilian soap operas (not quite sure why), sheer cheesy hilarity to watch. Apparently everyone says I look like the character ‘Ina’. Veronica points at the pictures as she explains:

Shona, have to seen it yet? On TV? Well you see this man, he is in love with Ina but they forced him to marry this woman, see? Can you see even the tears in his eyes? Oh it is so good this show.

She’s an amazing woman, she’s 55 and has had seven kids, four of whom are alive. In addition to being village chairperson, it sounds like she helps support about 10 grandchildren. Two of her children are working in Iraq and she wants to send her other daughter as well, the money is good she says. It blows my mind. They mostly work in security and when they are there everything is provided, their salary goes directly into a Ugandan bank account. Perfect scenario, no? Except for the getting blown up part I suppose.

I’ll miss the vitality of life, the gratefulness for each day that people have. The vivid colours of clothing, the smiles in response to my attempts at Luganda, the very grittiness of life. As my mom says of life in the developing world, the colours are brighter and the pools are deeper. It strikes me also that heartache is closer to the surface, each moment of life is more precious, it can come and go so quickly after all.

I’ll miss my Ugandan family, the sometimes profound, sometimes hilarious dinnertime conversations. They are middle class Ugandans who are deeply generous, taking in all sorts of strays in need (mzungu and Ugandan alike!) I’ll miss groundnut sauce…but I suspect I won’t miss the matoke (steamed and mashed plantains) for every meal. After some deliberation, I don’t think I’ll miss the Lugandan gospel music piped through the household sound system at 7am every single morning. I vaguely recall initially finding it a lovely part of the whole Ugandan experience… naive rookie!

I may even miss the tachycardia-inducing bodaboda rides. The first day I was sure I would not die, instead I would be smeared on the road between a matatu, a large truck and a bicycle overloaded with plantains, maimed for life. After that it turned out to be a fun part of the daily routine.

I’ll definitely miss not being on call…two months with no call has been soul restoring. Although my soul has been restored by much more than that. I’ve found passion for my vocation again, or it has found me. Instead of pulling myself out of bed each morning to do something interesting that I feel privileged to do, the work itself pulls me out of bed and drives me through the day. I feel empathy again, compassion, my jaded attitude has dissolved in the mud of Kisenyi and in the eyes of the women who have shared their stories with me. I’ve lost the sense of overwhelming helplessness in the face of human need and again am ready to hurl myself indignantly at injustice.

I’m reminded of a quote that a physician read out to our class on the first day of medical school, as we sat packed into our seats in Libin theatre, naively full of apprehension, dreams and ready to take on the world.

Do justice,
Love mercy,
Walk humbly.

Of course, these were familiar words, as I was raised on them.

A Love Affair

2010-05-03T00:21:00.000-07:00

I’ve been having a love affair with Jinja.

Who’s Jinja you say? Fine, I’ll admit it, not a person but a place. The source of the Nile. It was the third weekend I had been up there, the first time for rafting, the rest to kayak.

The kayak skirt tucked tightly around me, my red Spice playboat responding to every movement of my hips as we paddled along. I feel a bit guilty, you know, with the water shortages in this part of the world, that I should be inhaling so much of the Nile into my sinuses…so wasteful.

My teacher David and I had spent hours working on my rolling, you know, the second 180 degrees that gets your head OUT of the water. As I feel I have a gift for easily accomplishing the first 180.

We now paddled down the river to approaching rapids. The sky was bright above us, the sun beating down, but ahead huge dark clouds loomed. Like a prairie thunderstorm on a steaming summer day, we could see a sheet of rain approaching in the distance. The clouds flashed like fluorescent bulbs, trying to flicker to life and I heard deep grumbling in the distance. I cursed myself for not having invested in a waterproof digital camera as the light show was breathtaking.

It was exhilarating. The pounding waves, spray and foam of the rapids, David convinced I was capable of turning my kayak backwards and surfing the wave. Of course I was, but it took few runs to maximize the percentage of time my head was out of the water.

Then the storm hit us, pelting down, the rain seemed to have the force of a waterfall. Powerful, overwhelmed equally by beauty and adrenaline.

An affair I won’t easily forget.

Sorry, No Cervix, No Survey

2010-04-28T23:36:00.000-07:00

But what about the men? What about us? We are important also! He was about the fifth Somali man who had interrupted us with the same question.

I paused as I tilted my head to the side and studied him thoughtfully from the rickety stool I sat on, my brow furrowed. Tall and lean, loose black curls on his head his skin nearly golden brown.

Do you have a uterus?

A what?

A uterus. A womb. Have you given birth to any children?

He laughed and shook his head. What was this crazy mzungu all about anyway talking only to women and not to men?

Surveying Somali women has been a challenge for us all along. Not only are we limited by our abysmal Somali language skills, but they are a relatively closed community. As refugees living in a poor neighborhood, they are as suspicious of Ugandans as Ugandans are of them and speak no Luganda. Unlike Ugandans, who approach with friendly greetings, Somalis have a direct, blunt approach. What is happening here? Who are you?

We had occasionally struggled through some surveys in Kiswahili, as a few of them have learned a bit along the way. A survival skill on their tragic pilgrimage across East Africa. But today we hunkered down at a fruit stand, owned by a Somali woman we had interviewed last week, who invited us back. At first, things were a bit rough. What?!? All I get is a piece of soap? Give me another one! But slowly women gathered, curious as to what was going on. All covered in various colours of flowing veils, a circle of cloth framing their faces, others with only their eyes visible. Rarely you catch a glimpse of an ankle, or a toe through a worn through sock.

We had a young Somali woman helping to translate. Her English was good and she reported being an avid BBC World News fan. As a diaperless 14 month-old crawled around a huge basket of papayas under the fruit stand and with flies buzzing around, we heard the now familiar stories. Married at 14 years old. Of course they had never had sex with anyone but their husband, they indignantly reassured us.

You don’t understand, we are Somali women! No boyfriends, only our husbands. We are clean down there! If not… She made a gesture with her finger across her neck. Doreen asked, but what about the men?

Ech, the men, they do what they want. Who knows about the men, you cannot control them! What I did know, is that the men found it was miserably unfair that we only wanted to talk to the women.

The women were confused by some questions. Yes, of course I go to the hospital when I am sick, yes, I am Somali, I must go. Always statements with pride in who they are. But the idea of going for screening, of checking something when you had no symptoms, no pain, no bleeding. No. You go when you are sick. Silly mzungu with the crazy questions.

A cheeky Oxfam gender adviser (my sister) I know added her two bits, "as a gender adviser, i would like to advise you about the issue of gender equality. I am concerned that your research is not addressing the issue in a balanced fashion and seem to prioritize one gender over the other. Concerning to say the least, especially in this day and age."

Money Can Buy Bliss

2010-04-23T05:33:00.000-07:00

Knock off pink Speedo swim goggles: 8,000 Shillings

Matatu fare: 200 Shillings

Bodaboda (motorcycle) ride: 2500 Shillings

Munyonyo resort admission: 20,000 Shillings

Swimming in an Olympic-size pool surrounded by palm trees: Priceless

How much does sex cost?

2010-04-22T03:03:00.000-07:00

Well that depends. On the time of day. Whose asking. What the ‘guest’ is after. If your kids school fees are due. That turns into between 50 and 1000 Ugandan shillings they tell me (a few cents up to fifty cents), that is, if you’re not looking to spend too much time there. The councilman turned to me and said, you know these women get very rich, see they are fat and healthy.

Hmm. It was the only answer I could muster. The calculations cranked slowly in my head, from the surveys we’d done these women have sex with between 10 and 40 men per week. My math skills have never been spectacular, but that’s not much above extreme poverty as an income.

We had slipped through narrow muddy alleys that morning, the stench of chicken manure permeated everything, apparently this is where you get all things ‘chicken’ in Kampala. Crouching through a low door jam, down a muddy hallway, puddle hopping across a tiny courtyard surrounded by doors. Women in various outfits, most quite simple. All of them with different hairstyles, the diversity of hair extensions in Kampala is truly spectacular. In general most of the women had slightly lighter skin, many had scars across their arms and legs. We were at three different ‘houses’ during the day and the women warmly welcomed us. It took some getting used to. Of course we’re used to pausing the survey when a woman has to go grab some tomatoes to cut into her sizzling pot of onions, or sometimes serve a customer some cassava, or a chapatti. But instead we paused so the women could slip off into a room to do their work. They were generally quite jocular and at the second place we visited, after doing three surveys and teasing each other back and forth they planned a joke on the next client that came in about how much the mzungu would cost. I just had to laugh along with them, the alternative was crying I suppose.

All their stories were different, some had finished secondary school, others could not read. The majority of them had children, a few were married still. Several of them had received screening for cervical cancer, something the majority of the women we’ve talked to had never had. And all these women used condoms every time. No question.

They were hard working women. The only time I glimpsed apology in one of their eyes was when we asked about religion. She said she was a Muslim. Veronica, the research assistant paused. Muslim? But your name isn’t Muslim.

She looked down, embarrassed. Well, I’m actually Pentacostal but you see… her voice trailed off. Veronica just picked up where she left off, putting a hand on her arm. You are what you are, and that’s just fine. It seemed a profoundly affirming statement.

There are many things in our world that are heartbreaking and unjust. But we live our lives everyday, able to live in our broken world without it crossing our minds. We sterilize our lives, separate our daily living from the realities of so many. Whether in Vancouver or Kampala. But when it is thrown in your face, when it happens as you look into a woman’s eyes, you can’t just turn around and pretend you never saw it.

God Lives in Africa

2010-04-20T03:26:00.000-07:00

Doreen, is that man crazy or does he just really love Jesus?

She laughed. Maybe both, but I think he's just a Christian Sheona.

The street preachers in Kampala are phenomenal. Seriously. They spend hours and hours eveyday in the scorching sun and pouring rain. There’s the skinny guy who brings his own pulpit and megaphone. He stands on the side of the bustling Entebbe Road going into Kampala yelling at passersby and matatus then intermittently staring intently at the bible on his wooden pulpit, recenlty I think he's run out of batteries for his megaphone. Then there’s the lady with shoulder-length braids who was next to the Nakasero market yesterday when I was buying a pineapple. Her brow furrowed with intensity, she appeared furious as she preached, suddenly whomping her bible against the tailgate of the little Toyota pick-up truck next to her with a loud metallic clank. They just seem so angry, I don’t understand what story they’re telling. Where's all the peace and love folks? I hope they’re describing Jesus getting angry in the Temple about injustice and the rich ripping off the poor…I’m not convinced.

My all-time favourite Kampala street preacher has got to be the guy who strolls around by Shoprite [a South African grocery store]. The same angry, passionate preaching, waving bible in hand. But this guy has a follower…so to speak. He’s a tall Ugandan wearing the long white Muslim dress with the traditional embroidered cap. His face is equally intense but he looks like he has some kind of transcending knowledge. He raises his right hand, his elbow bent at a right angle with each movement and he repeats again and again, “Allah akbar….Allah akbar….Allah akbar….” Whether it’s in response or in harmony with Shoprite man I don’t know. I wonder what God thinks, all these folks fighting for his attention.

I was chatting with my Ugandan family about it, who have been described as ‘serious Christians.’ They likewise think its hilarious and shared a story of a preacher waving his bible chasing a naked man around the central clock tower one day shrieking as he cast out demons from the naked running man.

Faith is everywhere around here.

Sticky Fingers

2010-04-15T07:34:00.000-07:00

There are children everywhere in Kisenyi, but usually they’re scared of me and hesitantly curious, never wanting to get too close. But today, in a rather dodgy area of Kisenyi II, a 2 year old little guy spotted me in a store where we were doing a survey. He yelled out, “Mama! Mama, mzungu!!!” And from then on I was his property. He would let no other kid touch me, screaming at them when they got close. Under the beating sun, his sticky, sandy hand grasped tightly onto mine. He laid his sweaty cheek against my hand, his face covered in varying degrees of dried snot. My heart melted, I couldn’t help it. I guess its not made out of stone after all.

Tears

2010-04-13T08:24:00.000-07:00

I was with Dr. C today for colpo, one of the gyne oncologists. She’s tall and slim with flowing braids always arranged elegantly. Her belly is unmistakably swollen with pregnancy. She a bit more gentle than some of the other straight-to-business gyne oncs. However, as it is with doctors across the planet, everyone is always rushed and has an important meeting they need to rush off to. All the patients today were HIV positive, not uncommon as cervical cancer is much more prevalent in these women. The first woman was a 32 year-old, here for cryotherapy for her CIN II. It was my first cryo experience and I know they say one of the benefits is that you don’t need any anesthetic, but dang that looked uncomfortable! Tears rolled silently down her cheeks, then weakly she asked us to stop. She lay there dazed afterwards. It must seem rather barbaric. Someone putting a gun shaped instrument in your vagina, which is attached by a tube to a huge CO2 cylinder with a massive monkey wrench on the top to turn it on and off. I knew exactly what was going on and I couldn’t help but envision a medieval torture chamber with a few modern gadgets.

The second woman was slight, her bright turquoise dress flowed to the floor and her hair was combed up into an Afro twice the size of her head. As we broke the news that the biopsy had shown no cancer she clapped her hands together twice and hooted with joy. Her wide smile transformed her face. Her tears were not silent, she thanked us and thanked us and thanked us again. Dancing as she left.

The next came in shimmering in a dress of gold rimmed yellow, black and white. Her news was not as good. Infiltrative carcinoma. We admitted her for a work-up and to set her up for the OR if she was an operative case or for palliative care if not. She just sat in shock. Then tears came with anger as she was shuffled out of the room. I asked about radiation and chemotherapy, Dr. C explained that those were treatments you had to pay for so they were rarely an option.

The next three women played out the same scene, almost exactly the same story. There were no more tears of joy today.

I plodded out of the hospital in the afternoon, turned up the hill and along the dusty road under the sweltering sun. A bit defeated. Sometimes you have the emotional energy to process it all. To fight overwhelming despair. Other days, you can’t. So you just escape.

I had a beautiful cappuccino. Sitting at a café in the shade with a warm breeze, watching the world go by. Overcome by gratefulness. For espresso. For shade. For such resilient, brave women. For the privilege I have to witness their stories. For the hope that I have.

Tomorrow I’ll yell indignantly at injustice again.

Dancing Pea Pods

2010-04-10T01:39:00.000-07:00

Yesterday we came upon a group of four women shelling peas outside their home. We stopped to interview one of them as she continued her work. There were a few toddlers around laughing, screaming and occasionally throwing pea pods at each other.

As we stepped closer I noticed the large sac from where the bright green un-shelled peas were being pulled appeared to be gently undulating. Must be the heat I though. A wave of nostalgic memories washed over me, of shelling peas at my grandparents farm with my cousins...our payment for getting to watch Mr. Dress-up.

I looked into one of the pots and realized these were long peas...and they were wiggling. My 'peas' were grasshoppers. Its grasshopper season! The women pull off the legs, wings and antennae before throwing them in the pot and frying them to be sold as a snack. Just like peanuts, they explained.

When I told my Ugandan family of my learning for the day they insisted I have to try them. Now, they're best fresh, we'll get Annette to buy some tomorrow morning and prepare them for you.

Yum.

Laughing Sisters

2010-04-09T08:51:00.000-07:00

The breeze blew into the room, gently shifting the lace curtain covering the doorway to reveal the two cow knees roasting on the charcoal jiko. A toddler sat naked next to the smoking stove, using charcoal bits as building blocks and giggling to himself, as if there was nothing in the world more fantastic than his architectural plans. Our laughter from within made him look towards us. I was in a tiny living room sitting on a sagging sofa with Veronica (one of the research assistants) and two sisters. The older sister sat on the floor while we did the survey, she had insisted there was nothing to hide from her sister and she wanted her to stay. She sat on a woven mat, leaning against the wall with her legs folded beneath her and thought our survey was fantastic entertainment.

One of the questions we ask is whether they’ve had sexual intercourse, the research assistants hate asking this one, preferring just to tick off the ‘yes’ box. She smiled as she answered: “Well…you know...I am Catholic, but I’m not the virgin Mary! Where do you think my four children came from? The Holy Spirit?” When asked if she’d be up for doing self-collection for HPV with a swab in her vagina, she said sputtering with laughter, “why not? There’s much bigger things than that been in there!” My favourite answer however, when asked if she would need her partner’s approval to do the self-collection. Veronica pausing for breath attempting to translate for me, “You’re joking! What do men know about vaginas anyway? What he doesn’t know hasn’t hurt him so far!” The sisters shot jokes back and forth the whole time, it may have been the most entertaining interview so far. They were both intelligent, well-spoken, hilarious women. The laughter in their eyes and bursting out every pore lightened the sometimes intense days we’d been having. It was refreshing. Joy in the slum.

At some point that afternoon Doreen the program coordinator caught sight of my feet. “Sheona!” What?!? I assumed I had just made some kind of terrible cultural faux pas. “Your feet!” A bit of relief, she was just appalled at the state of what Kisenyi had done to my feet and declared that Friday afternoon she was taking me for a pedicure. We laughed some more. It was a good day.

April Fools

2010-04-07T02:18:00.001-07:00

Written from one doctor to another on their Facebook Wall:

"We have oxygen in the hospital now!"

A Poverty Spectrum

2010-03-31T08:10:00.000-07:00

Pouring rain again today. Kisenyi was a bog, we slipped around for the first several hours. Red mud caked in inches on my flip flops and splattered up the back of my legs. The first house we went to was the poorest I’ve seen yet. We approached the wooden shack hearing voices within. The inside room was pitch black save for a single candle, next to the empty chai cups left from breakfast. Two single beds lined the walls and the uneven dirt floor was covered with thin, ragged mattresses. The walls black from smoke from the charcoal jiko. We interviewed a 65 year old woman who thanked us profusely for visiting. She was endlessly apologetic for the pungent smell of urine emanating from the mattresses on the floor where one of her young grandsons had an accident overnight. She’s had 16 pregnancies, six children and eight grandchildren. Seven people live in this room, smaller than my own bedroom.

Yesterday we had approached a similarly crowded part of Kisenyi, simple brick buildings, the open sewers trickling by. Kisenyi has sporadic patchy electricity but no in-house plumbing. Water is collected from taps spread throughout the community at a cost of 50 Ugandan shillings per 20 liter Gerri can. As we ducked in the short doorway between curtains I stopped, confused. From dirt to a carpeted floor. A couch lined one wall, directly across from the large TV, with DVD and VHS sitting below it next to a huge speaker. In the corner was a flat screen computer monitor, keyboard and computer. But the thing that I couldn’t take my eyes off, was the massive fish tank bubbling away, spanning half the length of the room with tropical little fishies shooting back and forth. As we started the interview a stark naked 3 year-old shot screaming into the room, soaking wet from her bath she ran around oblivious to us. Finally noticing me she burst into tears and buried herself next to her mother’s pregnant belly. We all had a good laugh.

Last weekend I took off to Jinja, just north of Kampala to go whitewater rafting on the Nile with some other folks working at the hospital. It was unbelievable. Spectacular scenery and exhilarating rapids (obviously). I felt refreshed and renewed after the weekend, ready for another week of witnessing human stories. I had a mildly profound conversation with an internal medicine resident from Yale, as we sat sipping tea, and looking out across the Nile. We were discussing how we, as residents, are abysmally trained on how to be present for patients in the midst of suffering and death. We neither have the vocabulary, or the emotional and spiritual skills to respond to a suffering human being in the face of no treatment options we can offer them. And that is exactly the situation we find ourselves in everyday at the hospital here. There are no ICU beds for the gasping patient with agonal breathing, so we either go home for supper and return to an empty bed the next morning, or watch him die. Similarly in obstetrics, a woman in hemorrhagic shock, despite the medication and resucitation that are available to give her, but there is no anesthetist available to take her to the operating room. We can stay and be present, or leave. Either way the woman has passed away by morning. Helplessness in the face of suffering and death is the most uncomfortable place I've ever been.

Perspective

2010-03-26T08:47:00.000-07:00

I crawled out of bed feeling achy this morning, my throat was parched and sore. There are these ridiculously vicious guard dogs that yowl miserably all night and I hadn’t slept well. Grumpy, tired and sick…oh and it was cloudy outside. I felt down-right sorry for myself, this was not going to be a good day. I fought myself into the crowded minivan, then onto the bodaboda swerving taxis, bumping through muddy potholes to get to Kisenyi to start the surveys with the research assistants.

It was an ‘outreach’ day, free HIV testing for kids today so folks came from all over. Instead of going to women’s homes, we talked to those who were attending the clinic. The first interview of the day was with a 39 year-old woman. Her outfit was swirls of peach, yellow and green with an elegant matching headdress. She walked slowly and appeared weary. Her voice was soft as she eagerly agreed to complete the survey with us, despite the fact that it would slow her down in getting to see the nurse. As the story unfurled, she described her painful two-hour journey on swollen tender feet. She was HIV positive and here to get her children tested for HIV. When we were finished, she gently took my hand and thanked me in her soft voice, not letting go. She said it was so good we were starting this program, because she definitely needed to be screened for cervical cancer since she was HIV positive… when our program got started, and if she was still alive, like in a year or two, she would do the screening she said. Her sincere, dark eyes spoke volumes of hope.

Perspective. My throat suddenly felt better and my heart was humbled. This was thanks I did not deserve.

As my wise slum-dwelling little sister says, "I am glad that you are having a back to the basics time in Uganda (oops, I mean, the country of Africa). I find spending some time acompañando a mujeres [walking with women] in a slum is good for the soul. Brings you back to what the world is about, to why you do what you do and helps realign priorities.

Plantains, Mud and Cervical Cancer

2010-03-23T11:49:00.000-07:00

We started down a muddy alley where several women ran a row of cooking stalls, little shacks made from old planks and recycled car parts. Huge pots on charcoal jikos with piles of plantains steaming covered in banana leaves, beans boiling and peanut sauce simmering. Once we started doing a few surveys word spread among women, cervical cancer is all too common yet women know little about it. Confidentiality turned out to be challenging as women and men endlessly sauntered close wanting to know what the muzungu was at, could they do it too? One woman was persistent, popping back to see if we were done so she could go next. She started reeling off questions, what if she had a lot of pain, what if things didn’t smell right, what if there was this chunky foul discharge? Her symptoms could mean a dozen different things, from benign to well, terminal I suppose. Had she been to a doctor? No, there was no time, she had to work to feed her kids. Her eyes were worried and sincere. We went through the survey and found she was HIV positive. She was 38 and had never had a pelvic examination, an incredibly common situation in most of the world.

There we stood, next to an old converted container that smelled faintly of urine, mud and broken glass at our feet, in an alleyway buzzing with people, the sweet smell of steamed plantains mixing with the human odours of sweat and engine oil. She looked into my eyes, asking for help. I stared back humbled. Completely helpless, overwhelmed by my knowledge and unable to convert my skills and training into the real help that she needed. Yes, the project we’re doing will eventually provide proper screening but we’re just getting started.

I urged her to see a doctor, told her where she could go, and gave her some names of medications she could try (for the benign options, obviously).

Last week at rounds we had discussed a woman who had cervical cancer and was HIV positive. Initially her cancer was treated successfully but it soon returned, metastasized and took her life last Thursday. A combination of underlying cancer allowed to rampage through her body in the setting of an immune system ravaged by AIDS.

This isn’t fair. But this is life, in all its grittiness, that’s what I asked for, wasn’t it?

It feels like such a privilege to be able to see people in their environment. Whether it was the chai/chapatti stall girl who took a break and sat in the alley with us, the mama lishe who sorted the rice for lunch which searching our faces inquisitively wondering about this ‘HPV’ thing we were talking about, or the 60year old woman who is currently having post-menopausal bleeding fumbling nervously and with fear as she asked questions about whether she had cancer…the tethered goat in the background gently chewing on her 2 year-old grandson’s shirt in the shade of a tree. The suvey is going well, it gives me hope in the midst of such raw human need.

The Baby Mill's Got Nothing on This!

2010-03-16T23:28:00.000-07:00

Mulago Hospital, Kampala, Uganda

Morning report this morning. Sixty or so residents, medical students, midwives and attendings cram onto benches as the suns rays begin to creep through the window raising the temperature by the minute. All the house staff in crisp white coats, the nurse-midwives equally crisp in their light dresses, knee-high socks and nursing caps pinned meticulously on their heads. An exhausted resident lists off the happenings on labour and delivery in the last 24 hours.

Total women in labour: 73, vaginal deliveries: 48, C-sections: 17, stillborn: 2. The special teaching case is a woman of 28 years old, gravida 4, plus 1 (apparently that means one kid), previous Ceasar. Presented in active labour for 34 hours. Became fully dilated and the fetal heart was 166 at this time. After 3 hours of pushing there was no fetal heart found and fetal parts were palpated abdominally. Uterine rupture was diagnosed and a c-section was arranged, this happened 3 hours later. The baby was stillborn and a hysterectomy was performed due to bleeding. She became anemic with a hemoglobin of 50 and was transfused two units. We are continuing to give her more fluid.

Wow. BC Women’s is a quiet country hospital compared to this. Our morning rounds include pedantic scientific details of preeclampsia for the most part. We ONLY have about 8000 deliveries a year. Of course, they ARE beating us with the c-section rate, 25% isn’t too bad…but then you have more dead babies and mothers losing a uterus they might have otherwise wanted to use again.

The discussion was stimulating and passionate. How could we not prioritize a woman who had a previous c-section and let her labour this long? We have condemened her to infection, she may get a fistula down the road, we took away her baby. What can we change for next time? They know what care they want to be giving, but are bound by the resources they have. I felt for the poor, haggard-looking resident presenting the case, having felt the wrath of attendings in a sleep-deprived state at morning rounds myself.

Next the NICU gives their 24 hour update. Eight neonatal deaths, 6 pre-term, and 2 at term. One may have had a congenital heart defect.

It all left me a little numb, and it was only 9am.

We were going to head out to Kisenyi, the community where the surveys are going to be done. As we were about to leave, Doreen, the project coordinator, got a call on her mobile. There was an emotional jabber of Luganda and she ran out of the room. She returned after a few minutes, with red eyes. “I’m sorry, it seems my brother is dead.”

WHAT?!?

There had been clashes between university students who opposed one of the candidates being proposed as the new president of Makerere University. Things escalated and a security guard shot two students. As it turned out her brother (cousin) had been shot in the neck and was now in ICU. I’m no trauma surgeon, but things didn’t sound good.

It was 11am… maybe it was just the jet-lagged, but it seemed like a disproportionate amount of death and suffering before lunch.

Sex is Complex

2010-02-01T19:53:00.000-08:00

Her soft voice in an English accent floats across the room as I struggle to focus and keep my eyes open.

So are you firm in the morning? [pause] Well, how firm are you?

The husband shifts in his seat, about to answer but his young wife cuts him off. The steady stream of her pressured speech has been non-stop for most of the last hour. After several years, their marriage is still unconsummated, apparently a situation that is seen quite commonly at the sexual dysfunction clinic. A comment from the wife sets off another line of questioning.

Oh, well… does your penis have a bend? Some penises do you know?

At once trying to normalize all experiences and put people at ease but yet creating pathology where there sometimes was none. The truth was, the problem was not his penis.

As a clinician our mandatory sexual medicine clinic is drearily painful for me. While I appreciate the importance of the clinic and the issues at hand, I am no psychologist and would make a poor counselor. We spend hours probing the ins and outs of the couples’ sexual lives (no pun intended). Bringing up sensitive issues from their past, guilt, abuse, fear. Low desire, no orgasm, and pain. Its all a bit depressing, there are few ‘happily ever after’ tales here.

They tell me there is hope though, with patients who are motivated and committed to treatment. I’ll let you know what I think in two months at the end of the rotation. All I know right now, is that sex is complex.

A Stolen Passport, a Crack House, and a Bunch of Good People

2010-01-24T16:55:00.000-08:00

***WARNING: This is a long read...but does have some funny points, best of all, its true!***

Dark and dingy, with the dust flying the police roughly drag eight of the nine men to standing position, throwing them against the wall in a line with arms above their heads. The ninth sits back in a chair, a large sore on his leg prevents him from standing. Most of them are chachexic, wasting away. About half seemed drugged up and drunk. The police empty a trash can across the floor, they are about a dozen of them, tearing things apart to search for any evidence. There's garbage everywhere, broken glass, dirty clothes strewn around. A few planks divide the small wooden shack on stilts into rooms. Its humid, adrenaline is pumping through every vessel of my body, and sweat drips off my chin as the dust settles around me. I no longer even notice the stench rising from the human waste and trash that pervades the muddy waters beneath the house.

"Who is it that did it? Point him out? Do you recognize him?"

There's a young guy that looks familiar and I weakly suggest it might have been him, but I can't be sure.

They grab him violently and start beating him with a baton, yelling insults,"fumones inutiles." Useless druggie. He curls up in pain. I put my hands on my head, in shock at what I am witnessing. Then my sister, who some erroneously think of as quiet and shy, reaches and firmly grabs the arm of the offending policeman. "Oye! SIN ABUSO!" Hey, no abuse! In no uncertain terms. She says it calmly and forcefully. The policeman stops and leads her to the back room where he explains that if we don't beat them they will never learn.

Rho in turn explains the a cycle of violence will solve nothing. My calm brave sister, who refuses to stand back and be a witness. And the beatings stop.

They are now searching the men from head to toe, most only wear tattered shorts. Two of the police turn to us, delicately holding up a pair of womens' underwear. "Is this yours?"

I can't help but laugh as I recognize my last remaining clean pair of knickers. They were in the guy's pocket. The look on my face must have revealed everything, as one of the on looking officers looked at me and made a scrubbing clothes motion with his hands. Saying with his expression, "yeah, you probably want to give that a really good wash!" Hilarious. It was in general a bit of a clown show, anyone would think it was a group of boys playing cops and robbers.

Now why you ask, were we in the middle of a crack house raid? A weird dream perhaps?

Well, it all started when after returning from a couple of days about 100km north of Iquitos in the jungle, we came back into town to find our hotel room not quite ready. No worries, we though we'd just pop out for lunch and come back later. Leaving a small backpack of clothes behind the desk, I took Bertha (The Camera) with the clothes that remained in a backpack with me. Our passport also happened to be in said backpack.

WHAT?!?

I know, I know. We broke rule number one of international engagement. The rule that says your passport should be strapped to your body, or safe in your hotel. We're not idiots either, we've both lived and worked on several continents. What can I say, nobody's perfect.

So we saunter off in the mid-day heat to find some lunch. Rho tells me to pick the place. So I pick. We go in, sit down. Stand up, leave. It was too gringo for Rho. We stroll down to the Malecon, a boardwalk of sorts that looks out over the Amazon River. Its about 20 meters above the now receded waters, at certain points it has stairs that descend into Belen, a shanty town of floating houses, others stand on stilts. Its where the very poor live, who have no land to own, no money to rent. When the river is high, you must paddle around to get to different houses, but now during dry season, the houses rest on swampy mud-flats. Latrines draining straight below the houses make for an odourous, messy backyard that results in increasing sicknesses during this time of year.

Its a beautiful day, we buy chicha morada popsicles and sit looking out at the river. My bag is in front of me, one arm through the shoulder strap, the other trying to ensure my rapidly melting ice-cream reaches my mouth.

Then, in a second. Two boys pause in front of us, grab, and run. And there goes Bertha. Shocked for a split second I pause, realizing what just happened I leap up and run after them. Valiantly hurling my popsicle which lands squarely on his ankle. Waste of a good popsicle.

The two descend down the stairs heading into Belen and I fly after them. Skipping several uneven steps at a time, all I can think about it violently tackling them. And together we disappear into the slum. Its the scene from Slumdog Millionaire. Mud is flying, someone sitting on their porch sees me chasing them and tries to cut them off, to no avail. We weave back and forth, around corners, under houses, across planks. Mud flying. Heart pounding. I get a hold of one of their shirts as I turn a corner, but he wrenches away and now they've disappeared for good. Enveloped by the slum.

I bend forward, hands on my knees, sweating and exhausted. Alone, in the middle of the slum. My right foot ankle deep in refuse. And the reality kicks in.

The passports are gone.

I don't mind so much donating my camera to the working poor (there’s insurance for that), but passports...now that's annoying. Rhoda and I eventually find each other and dejectedly try to find our way out. We stop to chat with people on the way out, who say the boys weren't from here, they are druggie types. The families we pass are appalled by the theft and offer condolences. They suggest we head to the police station. (Ironically two blocks from where we were sitting eating our ice lollies).

As we ascend back to the malecon to head to the police station, a shirtless kid, maybe eight years old, ran to catch-up with us, sporting baggy red basketball shorts. “Senorita, senorita!” He said he new the two guys, not by name, but he knew their house. His name was Michael, it turns out he was our Archangel. Instantly energized, we took off down the stairs again, following him. A bloke at the bottom of the stairs gently stops us, “wait a sec now, what are two girls going to do in there? Go get some police officers and take them with you.” He seemed genuinely concerned for our safety. So we trooped off with The Angel to light some fire under the police.

Rho mumbled about how the police are useless and when they are called in Luringancho, where she lives in Lima, they come after several hours and do absolutely nothing. Amazingly on this sunny, humid Sunday afternoon, the station was swarming with cops and Rhoda had absolutely no problem at all mobilizing them quickly with her perfect Lima accented Spanish. We started out with two officers, somehow a few motorcycles were added and it was with about a dozen uniformed, fully armed officers that we now descended into Belen. Surreal. Children, women, and men ran to see what the excitement was about. Hundreds of them, following the action. One of the kids, his feet bare and dirty, clothes encrusted with dirt, had a mobile phone he was snapping pictures of us with. Oh how the tables turn.

They surrounded a house, the herd of police suddenly dispersed into the tall grass and garbage behind the houses, then they all stand around, slightly dejected. No trace of anything to be found. Then as if on some silent clue they flock to another shack, propped up on stilts above the boggy ground, surrounding it, three of them climb up and cling to the wall at the back. A heated discussion occurred between the officers and a slurred voice from inside the hut. He refused to open the trapdoor at the top of the ladder which lead inside. For some reason the police wanted us to be very close…like at the bottom of the ladder, as they were deciding to break-in and raid things…not my favourite, not gonna lie.

And that was how I was somewhat dramatically re-united with the last clean pair of underwear, my beloved Bertha, and yes, those highly valued Canadian passports.

Its different how things work in Peru, we descend from the house to cheers from the gathered crowds. No one wants a crack house in their neighborhood. Then ALL of us (i.e. all dozen cops, the nine ‘delinquentes’, Rho and I and a few straggling kids), troop back to the police station.

The police take our statements with most of the accused lounging in the hall, hearing every detail, my name, age, where we’re staying, my profession… it was weird. The young guy a thought I recognized is called Juan, he’s 22. He sat in the corner of the stagnantly humid room where Rhoda had to article every single thing in the bag that we now had in (almost) its entirety. It had been spread around in every nook, cranny and pocket of the drug house.

As I gave my statement, I clearly heard Rhoda’s voice in fluent Spanish wafting from the other room as she explained to the police thugs how the hegemonic conceptions of masculinity contribute to domestic violence. She later educated me on the incredibly high prevalence of domestic abuse in the homes of police officers. Her views on drug addiction and its impact on society were also made known to the [unsuspecting] officers who gazed at her in wonder. This tall, attractive gringa who had no fear and was definitely only a gringa on the outside. The officers decided that my Spanish was from Cuzco, whereas Rhoda’s was most definitely a Lima accent. One of the officers wanted Rhoda to have his phone number…you know, in case anything else happened and we needed assistance…or if she wanted to go on a date later that would also be fine.

Hilarious.

We stumbled away, hungry, tired, sweaty and completely entertained from the police station a full four hours after the incident. Relaxing in the hotel that evening we were disturbed by loud knocking on our door. My nerves were slightly on edge and I leapt up off the bed at the sound. (Part of my jumpiness possibly due to the fact that I was quite scantily clad, a result of all one’s clothes being rubbed around a crack house and preferring not to wear said clothing). The two of the Peruvian ‘FBI’ wanted to talk to us, they returned again later with concerns about dollars they had found on Juan (when he went to relieve himself…I’d rather not know where they had been). It was a long time before I was able to sleep that night, fan wirring, bugs chirping, motocarros zipping by.

Our crowning glory happened the next morning as I sipped a dreamy espresso (the first of my trip might I add!) and we breakfasted on papaya and yogurt. As we flipped through the local newspaper, who should appear on page 14? Yours truly. Next to a story about the heroism of a successful police raid after a Canadian-Peruvian tourist who had been taking pictures was attacked by eight men! Our laughter spilled out all over the breakfast table.

Although I must say, as we strolled around Iquitos that day we were deeply grateful that all white people look the same. Also…we may have [innocently] lied to the FBI about when exactly our flight was leaving.

After all was said and done we felt prfoundly grateful. Interestingly, more than anything else I came away with renewed faith that in general, people are good. The whole experience gave us a glimpse of a side of life in Belen that no other tour could have given us. And as for those eight ‘violent delinquents’? I don’t feel violated in any way. I feel that they have had a hard life, yes there are choices we can all make about what activities we choose to be involved in, and I make no excuses for them, but the truth is, they were born into deep poverty whereas I was born with a large silver spoon in my mouth. Life isn’t fair, but its funny.

The Dust Turns to Mud

2010-01-13T13:38:00.000-08:00

Its January, the middle of summer, and supposed to be steaming hot. But strange weather has been availing this year. Is it El Nino or just global climate change. The locals are unsure. Either way, the pervasive dust has turned to mud in the overnight rain.

I'm visiting my sister who works for Oxfam-Quebec in one of Lima's barrios as the Gender Adviser for Peru. She's been called many things: Mother Rhoda, Rhodita, La Doctora... I think I'll stick with Rhodita.

I stroll with her from the Women's Center back to her house. As we walk down the road, flip flops reassuringly slapping my heels, a woman comes towards us, her furrowed brow brightens at the sight of Rhodita. She looks close to fifty but in reality is no more than 35. Greeting each other with the mandatory besito, a kiss on the cheek. I am introduced as the visiting sister.

Como has estado? How have you been? Rhodita looks at her with genuine concern.

Bueno, las cosas siguen...como sabes. Well, things are going... you know.

They talk of the lawyer that visit The Center on Saturdays to help people, and Jose, the psychologist, who is available for counseling.

No se si va a ayudar. I don't know if it will help. She shakes her head, every inch of her body announcing defeat.

Rhodita smiles gently, and with complete reassuring confidence says: Cosas van a mejorar, estoy completamente segura. Things will get better, I'm sure of it.

Espero que si. I hope so.

We kiss goodbye and she hurries down the road and up the hill back to her kids. She has five of them, the youngest has cerebral palsy, and a violently abusive husband. I naively ask who's taking care of the kids...uh, its the 12 year-old of course.

"You seem pretty sure things will get better, that's cool." I pipe-up.

Well, if you don't have hope you might as well just curl up and die. I don't know if things will change or not, but she needs hope.

If nothing else, Rhodita says it like it is.

As we continue walking down the street, a young girl sees us and throwing her arms open wide, cries "Rhoda!" and runs for a big hug with a twirl. Her older sister Melanie come for her hug as well, they are on their way back from the market. They've just started their summer vacation and Rhoda ask what they are up to, then pauses.

Hey, how's your foot?

Getting better, but it still hurts a bit. Melanie replies.

Show me. Rhodita hits my arm to get my attention, Look at it. What do you think?

And before I know it, I'm doing a consult on the street.

Moving on, Rhodita says, its just they couldn't afford to go to a doctor, so I thought, since I had a doctor I'd let you see it. She grins at me. Melanie had got a bad cut on her foot from a smashed beer bottle, as her father threw it against the wall. Also violent. There are six kids, one developmentally delayed and the oldest, Jonathan, was badly burned last year in a fire at work. He's still healing, but all extra cash goes to creams for his skin grafts.

Rhodita works until 7pm most nights as well as the majority of Saturdays. Despite her usual levels of fatigue she manages to take me out salsa dancing after the open-air rock concert we went to and crinkles her brow at me when I yawn at 2am. But reluctantly agrees to take me home anyway.

She lives simply but fully and intentionally. To me she seems happier and healthier than I've ever seen her. Her way of life and the knowledge of the huge challenges she has faced overwhelm me and inspire me to reassess how I live my everyday.

I've stolen her away for a few days, we're in Iquitos, only accessible by river and air. Only a few buildings stand between us and the Amazon river. As I write this the motocarros buzz past outside, cicadas occasionally chirp and the fan moves the humid air across the room. I can't help but be both grateful and humbled.

P.S. The next morning I was DEEPLY humbled... by having slept with about 200 of my closest ant friends in my bed... they tickle.

The Folly of Human Desire

2010-01-12T06:57:00.000-08:00

Only early afternoon, yet I was instantly exhausted by the couple that sat in front of us. She cried quietly into a tissue. He put his arm around her, looking slightly bored and detached as he looked at us accusingly. They had gone through three miscarriages and were now pregnant again, being followed closely at the recurrent pregnancy loss clinic after being fully investigated. An ultrasound had just shown a normal fetal heart rate at 10 weeks, but also found a subchorionic hematoma, a blood clot next to the developing embryo. Although things were fine at this point, it gives her about a 25% chance of losing this pregnancy as well.

There was a strange dynamic in the room. Deep pain and defensiveness. This is a place they had been before, and with all the medical technology in the world we could not give them a child of their own. I had seen the same look in the eyes of couples who have spent thousand of dollars on fertility treatments and IVF (in-vitro fertilization) to face failed pregnancies, or none at all.

A woman I saw at one of the fertility clinics had separated from her husband last year and was now dating someone else. Someone who would have a child with her. “He’s good enough and my eggs aren’t getting any younger.”

It amazes me. The desire we have to bring a child into the world. Is it desperate signals from rotting ovaries that do it? Maybe its the evolutionary drive to have our genetic material continued in the world? Or perhaps an equally altruistic and selfish desire to have someone else to love, to care for, and to bring us laughter. Is there a divine calling of love that creates this desperate need within us?

I don’t know what it is, but the desire for a child drives people mad. It breaks their hearts, destroys their marriages and makes them feel like they have failed at this business of life.

That same morning, prior to going to the recurrent pregnancy loss clinic they schedule residents at the Comprehensive Abortion and Reproductive Education clinic. Where the other side of human desire comes in. Seemingly the polar opposite, yet on some levels the same. The desperate need not to be pregnant. Not to have a child. Not to let anyone know. A 15 year old in foster care. A mother of four. Some heartbroken and scared, others logically facing the facts of life.

The incongruity in my mind and heart at the end of the day is a feeling I am slowly getting used to. The stories I have the privilege to witness in this messiness of life are not always easy to digest. We so much want what we cannot have and desperately don’t want what we have. The folly of human desire.

Leaky Ladies

2009-12-13T22:20:00.000-08:00

I've just finished up two months of urogynecology. I feel completely stress free. Its amazing how different areas of medicine are. The daily emotional stress I'm used to dealing with went from a hundred to zero. One rotation the bad news you break to people alters their life forever, but the next well... they already know the bad news.

I'm sorry Mrs. Smith, we have some bad news... you're leaking urine when you cough.

Uh yes... I'm aware of that.

The good news is... we can fix it!

That's how it goes. End of story. No broken baby, no cancer, no infertility, just a little fixable leakage. Of course its more interesting than that, there are plenty of ladies with an inside-out vagina after a few vaginal deliveries, or a uterus that fell out and is terribly annoying as it bangs between their legs when they walk. But guess what? We can fix that too! We just pull it back in and tack it to your sacrum...pretty fantastic, don't you think?

Although I really do enjoy the surgical aspects of urogynecology I must admit, there were some perfect quotes from nameless attendings that I am unlikely to miss.

"Some people call us vaginal plastic surgeons, but I prefer to call it origami of the vagina." [I commented to my attending that this should be the title of their next book.]

and

"Now, I supposed gallbladder surgeons think that gall bladders are lovely as well, but although not everyone thinks so, I think vaginas are beautiful, and they should be respected."

Oh dear...

And now I move from the incontinent to the infertile.

Old Mamas and Sister Surrogates

2009-10-09T14:44:00.000-07:00

56 yo G13 P1 T0 A11 L0 at 26 weeks gestation with severe IUGR.

[Translation: 56 year old woman who has had 13 pregnancies, one pre-term birth, no term births, 11 miscarriages and has no living children now 26 weeks pregnant with a fetus showing severe growing problems.]

I stopped short, going back to re-check the birth date. Yup. 56 years old. With a story that would break even a stone heart. Loss after loss, desperate for a child. She had had multiple failed cycles of IVF overseas. In Canada there are 'gentleman's agreements' that for the most part limit this from happening. You don't implant embryos in a women past her 44th birthday, unless its a donor egg and then not past her 50th birthday. This doesn't apply in India, South Africa, the US...

I'm not a mother, but I'd like to be someday and regardless, I have no concept of what this women has gone through and the importance of her having a child, that biologically speaking, she will never have. I can't help but think there are other options, as judgmental as it sounds. I have several single 'aunts', the kind any self-respecting missionary kid has growing up. Aunts of no blood relation, yet closer and more connected than any of my parents siblings were to me growing up in Peru. No, they didn't have biological children, but they were mothers to many children who yearned for love and acceptance.

My lady's baby was born by classical C-section a day after I met her. We couldn't communicate, even through a translator we spoke different languages, inherently clashing world views. Her baby's death in the NICU two days later, saddened me deeply, but more than that seeing his mother devoid of hope stabbed at my conscience. Who gave her the false hope that this would work? Who was it that took her money so freely and put her and a child in such desperate straights?

A few days later I experience a very different birth. The birth mother was from south India, this was her fourth pregnancy. I met her along with nine of her closest family members as she was labouring in the delivery suite. Flipping through the chart I saw form signed stating that this would be an open adoption. Confused, I read further...this sweet young Indian woman was giving birth to a child for her sister-in-law. I asked who wanted to catch the baby and cut the cord when it came out, directing my question to the sister-in-law.

"I can do that?" Her eyes wide with joy, brimming with tears, slightly incredulous. And I must say, I got a bit gooey-eyed myself as I lifted that squirming, slimy, pink, hairy baby into her arms. There was no question that she was that child's mother.

The two experiences clashed together in my head, perhaps it was just their temporal association and the similar cultures the two families were from. Such great joy following deep deep sadness. A sadness I can't help but think medical technology made much worse.

God Talk

2009-09-30T20:38:00.000-07:00

God gave you that tumour, and I'm going to take it away. - A reconstructive orthopedic surgeon to his patient.

Thankyou Jesus. - A pregnant woman undergoing laser ablation of the vessels connecting her twins after hearing that things were going well.

Actually, you can call me Alan. - The obstetrician performing the laser ablation on the patient.

Jesus Christ, Sheona! - My attending to me as I topple off my standing stool in the middle of a challenging surgery and sprawl backwards onto the floor.

If God didn't want you to masturbate he would have put your genitals splat in the middle of your back! - Overheard conversation of two psychiatric patients having a cigarette outside.

And then there was the five year old, wailing in his mothers arms after his grandma passed away in the hospital bed - Why...would...God...let that happen...why mom? Why?

God seems to be all over the place.

Danny-Walker, Tetralogy and TRAP

2009-08-05T21:24:00.000-07:00

There's this clinic called FDS, the Fetal Diagnostic Service. Here's how it works: you're thrilled that you're pregnant, things have been going fine and then you get your routine detailed ultrasound at about 20 weeks in. The ultrasound tech is evasive, won't tell you what they're really seeing, perhaps a radiologist comes in during the scan and mumbles. You figure out somethings isn't quite right. They say you need at special scan at the Center for Excellence Across the River.

A phone call the next day, you have an appointment in Vancouver tomorrow... book the whole day off.

You show up and wait. Then a medical genetics counselor sits down with you and your partner where they extract every ounce of family history you have. Did you have any maternal aunts with crooked teeth? Any distant uncles who died suddenly? Perhaps a sibling who was a little slow on the uptake?

More waiting.

Then an hour long ultrasound. A dim, cool room. Gooey gel, prodding, poking, sliding.

And you wait some more. Then an appointment with the medical geneticist followed by the perinatologist. You sit before them nauseated with anxiety.

There's part of you baby's brain that isn't developing properly, we call it hypoplasia of the cerebellar vermis also known as a Danny-Walker malformation. Prognosis is variable......

I imagine the rest fades into nothingness. Or maybe we say:

Your baby's heart doesn't seem to be forming properly. You see, its missing half the pump, the hoses at the top are backwards and there no pipe going to the lungs.

You're telling me my baby had a broken heart?

Today we had a TRAP sequence... it looks like you had triplets initially but it turns out that one of them is a 'pump twin' with no heart which is parasitising the other two babies. We could insert a radio-frequency do-ma-hickie into the pump twin's umbilical cord under radiological guidance to stop it pumping. We can experiment on you here, or you can always go to Toronto.

My twins are really triplets and one is a parasite?

I have no concept of what they go through, hearing that their dear, beloved child is broken. We often don't know the extent of it before birth or how drastically or minimally it will effect the life of their baby. Maternal fetal medicine is a tough rotation for me. It breaks my heart and blows my mind. We buzz placentas of twin pregnancies if they are growing unequally, when otherwise there would be a stillbirth. We try plugging up holes if your water breaks too early, give you Viagra to help your tiny tiny baby not growing well, give transfusions INSIDE the uterus to babies with Rh disease. Amazing things that give these babies a shot at life when nature would otherwise take it from them. It baffles me, fascinates me and fills me with questions I will never know the answer to.

R3 and Hope

2009-07-25T17:47:00.000-07:00

I have survived my second year of residency! The toughest most exhausting most soul destroying year there is. Part of me feels numb in disbelief, the other part nervous about the new expectations of me, but mostly, I feel hopeful. There's less call, more sleep, more awareness of the substance of life. I write after a sleepless night at The Baby Mill, but despite eyeball-stinging tiredness, I had fun. I had a blast catching wrinkly pink babies, sloshing out twins at that STAT stat C-section, popping a bloodvessel and my wrist bones in the exertion it took to pull up that low low head from the pelvis. Joking with the nurses, rolling my eyes with the attendings, reassuring patients... it felt like something I could do in the future.

Over the past year I've wondered how I've changed, how the 'system' has shaped me, dehumanized me, desensitized me and overall discouraged me. At times I lost sight of people. I stopped treating them as I would my best friend, my mom or my quirky cousin and started seeing them as illnesses and things on my 'to do' list. Now something has somehow reverted back to the Sheona I used to be. With feelings, goals and passion. Its refreshing. Hopeful even.

I miss my epidermis

2009-07-15T17:54:00.001-07:00

Three friends. 330km. One lost tent. One set of car keys missing. Three flat tires. One freshly torn ACL graft. Several thousand mg of ibuprofen. Three square inches of epidermis gone. So far, so good.

When it comes to your epidermis, it really is true that you don't know what you've got 'til its gone.

I'm missing mine. Right over my ischial tuberosities (i.e. bum).

Last weekend I took part in the Seattle to Portland bike ride. It was pretty incredible, we biked just under 330km in two days. About 10,000 people participate and its fully supported so you have food stops along the way, and you meet the most amazing people of all shapes, sizes, ages and walks of life. The first day was beautiful sunshine all day. Day two however involved plenty of rain, wind and three flats in our group. At moments I knew without a shadow of a doubt that it was not physically or mentally possible for me to finish the race. I had no idea I could bike that far! Unfortunately, I assumed that pain was normal when biking these distances...of course this is true, but there's pain and then there's bleeding.

I found it philosophically fascinating, that I have been trained so well. Manicured and groomed not to listen to my body. To ignore feelings of exhaustion and push to 36 hours with no sleep. To pretend that feeling rotten is just part of the race (or the job). To completely disconnect from the signals my body gives me. Fascinating.

Don't get me wrong, the race was awesome, and I'd do it again... but next time I'd listen. Walking around like a wounded cowboy just isn't worth it.

You Took a Strip Off my Soul

2009-06-26T17:56:00.000-07:00

Dear Midwife,

Just a friendly note to let you know you skillfully stripped the skin off my soul last night leaving me raw and sore. In general I tend to gel with your colleagues. I deeply respect the compassionate continuity of care you are able to provide. In fact, I personally would chose to be followed by midwifery if immaculate conception befalls me in the near future.

You say you're an open-minded, women-empowering, body and soul restoring wellness worker but all you saw were my greens. I have never felt so judged and marginalized in my life than when you confronted me as you 'advocated for your client'.

Do you know my name? My history? Do you know my passion for marginalized women? Do you care that I'm a person? Your blinders against Western medicine destroyed me. Your hate for all I represent was the focus, not the women you were to advocate for. The harsh words of an angry Obstetrician criticizing my decision-making is droplets off my skin compared to the soft hostility of your words.

Sincerely,

Wounded OB Resident

"No crying!"

2009-05-29T19:27:00.000-07:00

He was the cutest three year old I had met since the days of Samuel Houston and his insistent 'excuse me... excuse me.' Toby hopped up and down on the twirling stool, crawled onto his mom's bed constantly squirming out of this father's arms. He wasn't three actually, closer to two and three quarters.

His mom on the other hand was wearing fantastic penguin pajama pants with tiny flower petals dotted on her toe nails. She was exactly 24 weeks and 1 day pregnant, not just pregnant, pregnant with twins... not just twins, twins with a cramping uterus and a short cervix. Twenty-four weeks is viability, the age at which if a baby is born it will be resuscitated. The implication of pre-term birth this early are huge, really really little babies just aren't supposed to see the world that early.

We chatted, I got the history, all the annoying questions. Then as she lifted up her t-shirt so I could examine her belly, the dad asked Toby:

What do we say to the babies?

No crying!

And what else do we say?

Dohn come out! Throwing his arms up in the air as only a two and three quarter year old can do.

It was refreshing. Did I mention he was nearly as cute as Samuel Houston? There is enough human tragedy to fill the ocean, but this kid, he was hope.

90th Birthday Parties

2009-05-17T13:18:00.001-07:00

My Auntie Edna turned 90 yesterday, we had a great party. I read her this letter, one that I had sent last year (when I clearly had more hope and more sleep!)

Dear Auntie Edna,

It was so lovely to see you over Thanksgiving and I’ve been meaning to write this since I got back. I just got in from a fantastic bike ride through the Endowment lands. I got home covered in mud, chilled, and completely soaked but blissfully happy. The fresh, bright spring mossiness has now turned to the sweet, musty yellows of fall and each time I go out there I’m amazed at the towering trunks and lush vegetation, comforting in its peacefulness . . . I’m incredibly blessed.

I was a bit worried about you when we chatted in Calgary and I know you’re excited about getting to heaven and all but I was wondering if you were depressed. You voiced the frustration of having to rely on others so much and feeling like a burden with your physical limitations. It made my eyes well-up with tears that you felt this way. I suppose I understand it though, your whole life you have given and given and given, you’ve been self-sufficient and supported dozens and dozens of people spiritually, emotionally, financially and in other innumerable ways. Your whole life has been a gift to all of us and I hope and pray that as you live out your twilight years we who have been blessed by you are able to give back just a little bit of the immeasurable gifts you have lavished upon us with your time and your love. My other thought was that you no longer feel that you can give and contribute in the ways you have done your whole life. Well, here’s the deal, we’re not done with you yet. I get all choked up when I think about all the love, encouragement and support you have given me personally and my whole family, well, you are part of my family. You write us weekly letters when we’re not in Calgary, whether we’re in Tanzania, Peru, or Australia, those letters gave me roots, they held my home for me. You know me better than any biological or missionary aunts I’ve ever had. In this messy world we live in where who we are depends on what we accomplish you love me regardless of anything I do or don’t do. You’ve taught me that my worth doesn’t depend on what I do but on who I am. You loved me when I was a rambunctious, bratty little kid bouncing off the walls when you visited us in Peru, you loved me enough to go into a store and buy my me an Oilers shirt to bring me when you came to Ecuador, you loved me in all my bitterness about Canadian winters, and you need to know that your love still makes a difference to me now, today, on the soggy west coast. Your life is a testament to hope.

You probably want to know how I’m doing out here. Honestly, life is delicious (not gonna lie). God has given me a peace like I’ve never experienced before, about who I am, where I am, and what I’m doing. I have moments of incredible joy, my life is so full and I am blessed and privileged in a way that I am infinitely grateful for. God is so good. Not that things aren’t challenging now and then, but I am held tightly in a blanket of grace. I want to live fully, to do justice and show mercy. When I think of those in my life who have demonstrated this I think of you, you are living a rich legacy for all of us.

Love,

I Feel

2009-04-13T21:42:00.000-07:00

A single tear rolled down my cheek. I blinked, wiping it quickly away with my hand flippantly, hoping nobody noticed.

The deepest empathy pouring out of my being in response to the heartache before me.

It felt good to feel again.

My Wee Gran

2009-04-03T16:20:00.000-07:00

I'm all outta grandparents. My parents are orphans, and I'm a granorphan.

Although she was 90 with worsening dementia I still find myself not believing. The reality of it all is far away over the ocean, across the Firth of Fourth.

Gran was a constant, a deep part of my confused identity, and although the gran I knew changed drastically over the years, her loss is a loss of my foundation, my roots and I find myself shaken and unsteady. Her love for me was unconditional, as grandparents' love tends to be. It did not matter, what I did, where I traveled and what or if I studied, she loved me for no reason other than because I was me.

I don't remember my dad's father, who died when I was very young, running around terrrorizing my closest friends and family in Peru. But Gran was always there, in Balingry with Silva, her little terrier. Memories of the comforting smell of coal fires, endless chocolate biscuits and mince and 'taties for supper spring to mind. I remember curling in front of her fire, the scratchy rug on my cheek and smoky smell tickling my nose. When we lived in Scotland, Sunday afternoons were spent driving to Fife from Edinburgh across the Fourth Road bridge, a sacred time of walks with Silva and eating more Kit-Kats and Caramel bars than mom approved of and Gran insisted on.

After we moved to Ecuador and then Canada, we went back at least every two years to visit, and then it became us going individually as we grew older. I remember a trip with Rhoda after I'd spent a summer in Peru and I took two massive books of photos to tell her all about it. She was then visibly aging and her memory declining. I wondered how much of it she would take in. But she went through the hundreds of photos, asking questions and repeating again and again. "We just don't know how the other half of them lives, do we?"

No matter where we lived, in the vast extent of my families globe-trotting, Gran was immovable, unchanging and obviously the central part of my Scottish identity. She seemed to shrink each time we saw her, and always hugged us fiercely, smiling widely when we came. Her eyes watering when we left. Its heartbreaking to leave bits of your heart in so many places, and Gran was where I left the Scottish chunk of my heart. She held it safely. Now my heart is missing that same chunk with her gone.

My last visit with her was in March of last year. She had been in a nursing home in Cardenden for several years and was different than I had ever seen her before. When the care-giver introduced me, her grand-daughter from Scotland, she beamed from ear to ear, re-arranging all her wrinkles. She touched my face, and said my Gaelic name like only a wee granny from Fife can. Then in clear dulcet tones, she started to sing, I couldn't follow the meaning of the words, and I have no idea if she actually knew who I was, but she sang to me and told me she loved me and I will take it as a gift.

So as my parents bid farewell to Gran and she returned to ashes on Friday morning in Scotland, late at night in Vancouver I cut babies out of taut bellies. Slimy, flailing and crying indignantly at the insults life brings, new grandparents were made that will love these grandbabies for no other reason than that. That they are their grandchild.

Goodbye Gran, I love you.

Ticks and the Meaning of Life

2009-03-22T19:12:00.000-07:00

Pedro and Emeterio lead us, winding up and down the narrow path, clearing brush with machetes as we go. Dirt slides under my feet as we wind our way up to the falls through 'virgin' forests (as our hosts describe them). Twice I stop to pick ticks off my arm, tiny, red and leggy. Before embarking on the hike they doused us with cattle-strength tick spray, declining to disclose the ingredients of the white kerosene-smelling liquid. Its humorous to me that the ticks mock this surely cancer-causing chemical I've bathed in. My friend Luis in Vancouver has set my friends and I up with a trip to the ejido or cooperative farm, that his family is part of on the west coast of Mexico.

I had a strange flash back to a summer I spent in northern Peru after my second year of undergrad. I trekked through mud and bugs out to villages and along rivers to my hearts content collecting stool samples for parasite research [insert inapropiate comment here]. One six day trip where I got to tag along to Aguaruna villages has always stuck in my imagination, likely embellished with multiple tellings. It involved being auctioned off for marriage for two monkeys and a wild boar, eating roasted Rana frogs with plumb maggots from the Aguaje tree among other incidents. The first day of our trip the new outboard motor on the boat failed and we drifted slowly towards the shore. Several of the men hopped onto the muddy bank with their machetes to cut us some sugar care to chew on as the engine was tinkered with. In my naivety in all matters pertaining to tributaries to the Amazon I followed them onto shore thinking this was the perfect pit stop for my pea-sized bladder. Tromping through the mud into the jungle I found a spot and bared my hind end to the wild. Immediately a strange sensation, almost numbness, spread over every exposed inch of my tender skin. Turning to look, my bum was completely black with tiny biting black flies. I jumped up with a shriek and started slapping... to the exquisite delight of my traveling companions who instantly appeared out of the bush, machetes ready to rescue me from certain death.

It was a humbling summer... challenging, fun, eyeopening, lonely, profound... but definitely humbling.

Before I arranged the Peru trip that summer I had an emotional conversation with my parents. I hated university, didn't see the point of being there and had approached them with an (obscenely expensive) opportunity of a field school in Africa. I recall my dad's thoughtful words, giving perspective, delving to the root of my feelings. I had lost sight of the reason I was studying, exhausted and defeated. I find myself in a similar place now, not knowing why I drag myself out of bed each morning, work 100 hour weeks and hating how I have come to see people. As diseases and things on my to-do list instead of people. Scared, sick, loved people. It took a lot of mud and bugs to give me a glimpse of an alternate reality that summer in Peru, and maybe it just took some ticks in Mexico this time.

At days end we removed several more ticks from each others' bodies, squirming at the uncomfortable intimacy of having tiny squirming legs attached to our person... some very personal parts of our person no less. Sometimes it just takes a few ticks to regain faith in life. To be reminded of past passions and future hopes. To realize that I may be on a low part of my journey right now, but I still have a capacity for hope and opportunities to share that hope in ways that recently have seemed clouded over and far away. Ticks.

Grasping at Cockroaches*

2009-03-02T20:18:00.000-08:00

As the irritatingly perky barista raised an inquisitive eyebrow in my general slovenly direction, I realized I had in fact reached a brand new low.

Yes, I would like three shots of espresso in my extra-large coffee... and don't stinkin' think you can tell me to have a bloody fabulous day as you place it cheerily on the counter chic barista boy!

Other low points last week? I was told my humour makes it appear that I am in fact incompetent. I poked an (uninvited) hole in an (unsuspecting) uterus shortly after squirting my (unsuspecting) attending in the face with saline... to the OR nurses' delight. I actually did grocery shopping at the Shoppers IN the hospital (and felt an instant of normalcy as I strolled down the aisles mid-day). I ate poutine for breakfast, chocolate milk for lunch and an avocado for supper. Someone stole the carrier off my bike while at work after a long post-call day, causing tears to well up in my eyes and a lump of overwhelming emotion clogged my throat.

But truth is, I had felt that lump the day before. As I sat with Nate, a man in his early 70s, as his wife was vomiting into the toilet, a day after the surgery to debulk her advanced ovarian cancer. He wore a John Deere cap and an Abraham Lincoln-style beard. His gentle smile won me over as he told me about driving into town yesterday (from Fort St. Nowhere of course).

Isn't it amazing that at 9 at night those stores are still open? You'd never see that where we're from, everything rolls up at 7! I know Flo loves sausage rolls so I went out and bought two, one for me and one for her last night. We've been together 38 years you know, been through a lot, now its my turn to take care of her and boy does she ever have a will of steel.

The irony of retractable vomiting and the thoughtfulness of a sausage roll gift hit me. Flo came back from the washroom, stooped and thin, her weathered wrinkles gave the sunken post-chemo cheeks and bald head a look of wisdom beyond words. She was full of piss and vinegar alright. So we sat and chatted about nausea, sausage rolls and pick-up trucks.

It put all of my misery into a divine perspective.

So what if Dr. Orange feels I should be more professional and less personal? That's actually not who I aspire to be. I'd rather get to know Flo and Nate, joke about shooting gophers and figure out how we're going to treat her high blood pressure with home made pies and venison.

*Reference to Papillon (1973) ... yes, I'm planning an escape.

Pus and Tubes at the Death Star

2009-02-02T22:01:00.000-08:00

The tower looms up into the grey Vancouver winter sky. Fifteen floors of impersonal, cement general hospital. Endearingly known as the Death Star.

We see lots of ectopic pregnancies, miscarriages, and the most common thing I've seen? TOAs. Tubo-ovarian abscess. A big ball of pus wrapping your fallopian tubes in inflammatory angryness and your ovary in cozy adhesions. Causing you infertility and ectopic pregnancies in the future. Why all the pus? There's not enough condoms in the world. Why can't people just use a bleeding condom? Not gonna lie. I get the impression that Chlamydia is overated.

The drizzle falls. The pager beeps. I count up the days I have to go before I get to sleep in for a day... 1,2..... 18, 19.....26..... hmmmm... 26 days in a row. Mild nausea sweeps over me.

Three weekends in a row. On call.

Truth is, pus in the pelvis is fine... but I miss babies and the Happiness Ward.

First Rupture

2008-12-17T18:48:00.000-08:00

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

2008-12-09T16:43:00.000-08:00

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

2008-11-12T12:15:00.000-08:00

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

2008-10-20T21:54:00.000-07:00

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

2008-10-01T21:19:00.000-07:00

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

2008-08-30T21:13:00.000-07:00

"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

2008-08-02T15:11:00.000-07:00

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

2008-07-10T19:10:00.000-07:00

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

2008-06-25T21:35:00.000-07:00

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

2008-06-09T19:24:00.000-07:00

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

2008-06-03T17:37:00.001-07:00

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

2008-05-26T16:56:00.000-07:00

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

2008-05-07T19:00:00.000-07:00

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

2008-05-01T20:04:00.000-07:00

"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

2008-04-21T22:41:00.001-07:00

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

2008-03-29T17:05:00.000-07:00

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

2008-03-18T17:43:00.000-07:00

"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

2008-02-28T23:13:00.000-08:00

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!

2008-02-21T19:25:00.000-08:00

Helpful Hint #216

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

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

2008-02-16T20:07:00.000-08:00

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

2008-02-03T21:42:00.000-08:00

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

2008-01-23T22:47:00.000-08:00

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

2008-01-09T21:18:00.000-08:00

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.

Breaking News: Mary Not Mother of Modern Feminism

2007-12-25T18:46:00.000-08:00

I bought my roommate a fair trade chocolate advent calender. Although there were no complaints about the quality of the milk chocolate, the Christmas story told in daily snippets was an object of some contention. My roomie is profoundly spiritual (when it comes to kayaks) and a devout atheist. So the story went something like this:

December 4th - "Angel Gabriel told Mary she had been chosen to have God's son."

Roomie - What?!? Where's the free will in all of this? She doesn't even get to choose to have the kid or not?

December 5th - "An angel came to Joseph in a dream and told him to name the baby Jesus."

Roomie - Oh my goodness, this is ridiculous! Not only is there no choice about having the baby, but they can't even pick the name?

And so the story continued, but it does make you think. As a woman in a decidedly patriarchal society, maybe even misogynistic, I wonder how much choice she really had . . . how much choice did any woman have about reproductive issues at the start of the common era two thousand years ago. Heck, if a life-size glowing angel appeared in my room, I'd either say "Yeah, sure, just like you said!" . . . or, admit myself directly to the closest psychiatric ward.

My dad says the universe was thinner back then. That people were less stuck to science and more open and aware of the spiritual world interacting with the material one. The topic of women in the bible I am convinced must be taken with a healthy understanding of history.

Abject Incarnation

2007-12-24T13:20:00.000-08:00

Christmas eve, the sun burning down, heat rising in waves from tin roofs, and I stand sticky in the dress I had no doubt been forced to wear. We had started that morning with bags of flour and rice spread across the floor of our small neighbourhood church in Arequipa, evaporated milk stacked in rows, making Christmas hampers. There was then a pick-up truck ride involving lots of dust, very exciting for a kid, and we eventually came to a crowded community some would have described as a shanty town. My memories of the sun and dust are vivid but other details are fuzzy. We stopped at a home to deliver a hamper, were greeted warmly, but the family didn't take it. Instead, they came with us and we drove up the mountain, apparently they knew a family who needed that flour and rice more than they did. I can't have been more than six or seven years old, but my memories of Christmas were of decorating the cactus 'Christmas tree' in our yard, baby Jesus, giving to those who didn't have as much as we did, sun, and definitely dust. Later, after moving to Scotland I remember much more in the way of exciting gifts and chocolate, athough my parents swear we did get presents in Peru as well.

I was putting out nativity scenes for my mom today, something I love doing. I've been collecting them as long as I can remember. I was never too sure about my parents' olive wood scene from Israel though, the pale baby Jesus lies serenely in his manger with arms outstretched in a position no baby ever takes. Mary kneels, her face blank of emotion, and the sheperd boy at the back with the lamb on his shoulder is forever falling over due to a broken foot. I prefer the rough clay set where one of the wise men carries a bunch of bananas as a gift and a donkey with buck teeth looks on, or the jungle Jesus who lacks a diaper and clearly has two descended testicles, or the wooden scene from Thailand with elephants and chickens welcoming God. More powerful to me than the crucifixion or resurection is the incarnation. A squirming, wet, mucous and blood-covered screaming smelly newborn surrounded by a goat or two and a clueless father. Did Joseph cut the cord? Did the placenta come out intact? Did Mary have a third degree tear? What were Jesus' Apgars? God came down the birth canal of an unmarried teenager? Who thought this stuff up anyway? There is a certain scandal to it all, very abject, very humble and not an image that the Christmas season gives us today.

I am forever grateful for the gift my parents have given me. They introduced me to the God of the poor, born surrounded by abject poverty and scandal. Where faith means hope and justice for the poor and marginalized here on earth.

Christmas is Coming

2007-12-20T21:07:00.000-08:00

Tck tck tck tck tck.

Tck tck tck tck tck.

Like a computer game the red laser beam at the end of the scope shoots holes in the rough yellow rock lodged firmly in tunnel of the ureter projected on the screen above my head. My shoulders are weighed down by the lead apron we wear under the surgical gown (to protect my little ovaries from the x-rays) . My glasses dig into my nose from the pressure of the goggles to protect my eyes from the laser. It seems a little ludicrous that the laser beam will bounce off the kidney stone lodged in the ureter get all the way down the tube to the bladder and somehow out of the penis and bounce into my eyeball . . . oh well, protocol I suppose. After shooting up your rock you put in a little basket and pull out the pieces. Urologists really have fantastic tools and seemingly get to play video games all day.

Yesterday they took out someone's bladder because of cancer and made her a new one out of a piece of her colon. It took six and a half hours, but it was pretty incredible! There's a downside to any specialty though, even if they do have cool toys and fascinating operations. There's kidney transplants that don't work after family members have donated their own kidneys and there's always cancers that recur and eventually are untreatable.

Near the end of my day today I was called with a consult from the palliative ward. A 50 year old lady with a recent spread of her previously treated cancer now had a kidney that was swelling up and its function going downhill, just over the past week. This can often happen when cancers grow and block off one of your ureters. In my mind it was a no brainer, we just put a little tube in the ureter to release the pressure and save the kidney. Its a simple procedure and would relieve a lot of pain and nausea. I sat on her bed and explained it several times, listened to her questions, thinking myself quite convincing.

Eventually she asked a question that stopped me cold.

How would you want to die?

Skydiving perhaps? Maybe in the Congo.

Although I disagreed with her, even thought her foolish to want to die in such discomfort, I had to accept that this was her body and her life, not mine. I can explain things and give recommendations, but the choice is hers of how to go. Oh so somber a note as she lays in hospital with Christmas approaching. Merry Christmas to all, and to all a good night.

Snow Falling on Cedars

2007-12-02T11:22:00.000-08:00

I awoke to snow drifting down in big juicy flakes onto the blanket of white covering the world. Unable to resist a run I went out clad in touque and gloves. My shoes sticking and squeaking with each stride. Silently and peacefully floating down around me. The water at Jericho beach lapping against the white carpet of the beach, melting the shore edge and turning it dark. Dark as the nearly black ocean spreading out towards the hidden north shore. Hidden by low deep gray misty clouds. Bull rushes with dainty snow caps, the snow turning the pond into an slushy gray pool. Dogs tumble in the snow, kids rolling snowballs, laying on the lawn, arms and legs flapping to make snow angels with mouths wide open catching the snow. As I pound my way home, snow flakes melt against the hot skin of my face, making salty rivulets down to my lips. A moment of perfection.

And this afternoon I will go to my shift at the emergency department just as I did yesterday, where I will see how others experience the snow. A split chin after slipping on the ice, an elderly woman with a broken elbow and then the things that aren't just accidents. The homeless hypothermic, the red swollen hands from exposure, the black toes needing amputation.

I am the privileged.

Just like on TV

2007-11-26T21:46:00.000-08:00

I was pontificating on the differential diagnosis of a 'worst headache ever' with my preceptor . . . sub-arachnoid hemorrhage, encephalitis, stroke, cluster headache, mass effect . . . when one of the other emergency docs pops his head in the door.

Hey, there's a witnessed arrest coming in in v-tach, this would be as good one for you.

Oh, great! The words pop out of my mouth perkily without processing them.

Gown, gloves, and I stroll into the trauma room following paramedics, nurses, a respiratory therapist and two emergency docs. Standing at the back, observing, seeing what I can learn from this demonstration of the efficiencies of our wonderful medical system. Until the doc gestures at me to get to the head of the bed and thrusts the laryngoscope into my hand. Say what?!?

Have you intubated before?

Yup. Which is the truth, in fact, prior to this moment, my intubation success rate is 100%. That is, in the OR, with no stress and lots of time.

Our 'v-tach lady' had collapsed directly onto her face. A purple goose-egg was starting to swell up on her brow, her nose and chin were scraped and her front teeth loose, jutting out at strange angles and bleeding. Also of note, she had no neck and a receding chin. This combination is any doctors nightmare. It means that the magical smooth intubations you see on ER are in no way possible. And yes, its me currently holding the scope, not an ICU doc, not an anesthetist who has done thousands of these, and certainly not Noah Wyle, just little old me.

Okay, its a one shot deal. Go for it. 'Enough with the drama,' I silently say to my attending.

Metal blade slipping across the tongue, I haul on the handle desperately trying to see anything remotely resembling those golden vocal cords. All I see is blood and tongue. The sickening crunch of metal on teeth as I inadvertently preform a dental extraction and the nurse removes the loose tooth so it doesn't get in the way. When you learn this on the model in med school the head makes a little beeping sound when you lean on the teeth too hard . . . no such warning beep here.

Suction please. I can't see anything. Sluuuuuuuurrrrrrrp.

The emerg doc takes over, tries twice. Eventually getting in a bougie to thread the tube into place. He said it was the worst intubation he'd ever seen. Which didn't make me feel so bad.

I'm under the impression that the emergency department is great fun. Probably because I'm not the one who's really responsible for the patients in the end. But like any rotation there's the good that bad and the ugly.

The good. I got to sew a nose back together that had been sliced cleanly by the knife of 'This One Guy' at 2am when the patient had just been minding his own business out on the street.

The bad. I've had to do a significant amount of DREs (digital rectal exams . . . where the digital part has nothing to do with a Nintendo Wii . . . Wee.)

The ugly. My first ever 'trench foot' experience. Named after what happened to soldier's feet in the world wars from walking around in wet trenches for months on end. To describe it would be too traumatic for all those involved. Smell. Rot. Geeahrgh.

One thing I have learned: if you have friends called 'This One Guy' or 'That Bitch', don't give them your PIN number/welfare check/go drinking with them because they will without a doubt take off with your money/slice your nose open/sleep with your best friend/steal your drugs. In fact, maybe consider not seeing them at all, ever, and getting some new friends.

So yeah, its just like on TV. We even make out in the supply closets now and then.

Crack-a-Lackin'

2007-11-16T21:30:00.000-08:00

She sat across the table from us crossing and uncrossing her legs. Pushing herself up in the chair, shifting back and forth. Fingernails scratching endlessly, her knee, back arching to scratch her flank, then her head tilts to the side to itch behind her ear. She looks at me intently, then switches to the psychiatrist next to me, back and forth, and back. She wears a pink tank top and a shirt worn as a skirt that reaches nowhere near her mid-thigh. A smile on her face never pausing in her speech for a reaction.

"I just need some passes I feel so couped up in here there's no air I need some fresh air I have to go to my NA meeting tomorrow its not that I don't like it here I just get so bored just give me a chance to prove to you guys that I can do this I swear I didn't touch his pipe yesterday he just blew the smoke in my face that's why the test was positive I just need some passes I'm so done with him he stole my check he said he was going to make money with it but he just smoked it all away I told him he can't visit me anymore because he tried to sell me drugs after that and why would I stay with him a boyfriend should give me drugs if he's dealing I just need a pass just to go for a walk and get some fresh air."

She is young. On the streets since she was a teen and has never been in a relationship where she wasn't abused and taken advantage of. Its not a unique story. She's friendly with a bright smile and her slightly spread eyes give a hint of fetal alcohol syndrome. She turns a trick now and then when she runs out of money which she needs for her fairly substantial crack/cocaine addiction. Her mood is upbeat as she shifts and squirms in her seat. A disposition that turn directly to tears and irritability when we tell her she can only go on pass with staff. Her outfit has changed four times in the last 15 minutes before the interview. The girl is practically hopping in her chair and being eaten alive by her cravings. There is no doubt in our minds that as soon as she is discharged or goes on pass she'll use again.

So how does one react? Do I feel pity for her? Is she a hopeless case? Does she bring this cycle of sexual abuse and drugs on herself? Drugs that cause terrifying hallucinations of bodies being hacked to pieces that bring her into hospital.

I can't. I feel none of those things. I see her as a young woman who never had a chance. Who society has failed starting several generations ago. It makes something burn inside of me, something bittersweet. Her actions don't frustrate me. Her return to crack and her abuser don't surprise me anymore. I see smoldering hope in her eyes, and I don't THINK its just the bloodshotness.

I'm learning a lot about inner-city life. I know how much crack is a lot of crack, I know which the less seedy of seedy downtown hotels are and I know how to ask how quickly their check has gone to what drugs. But my problem is that I still trust people. And yes, its a problem but I see myself changing, for better or worse I'm not sure. My naive questions about abuse are now worded very differently, the queries about sex trade now flow naturally off my tongue. People hurt each other and they lie, steal, and cheat. My conundrum that I repeatedly come back to is how to keep my skin thick and my heart soft. For life to make any sense I have to believe that people are good, we're all just out there doing our best, a bunch of people trying to be. Each one of us with flaws and baggage.

Tasered

2007-11-13T22:14:00.000-08:00

A few weeks ago a man arrived at the Vancouver airport from Poland. He was acting strange, pacing back and forth and speaking in a language his fellow passengers didn't understand (presumably Polish). His name was Robert Dziekanski, it was his first international flight and as the story goes he was visiting his mother. A new country, a strange language, sleep deprivation, exhaustion. I can all too easily imagine the rising anxiety he must have felt, much like I felt on the Slovakian boarder with Austria a few years ago, but I digress, I just got harassed, not tasered. To get to the point, the police were called, approached him, tasered him and he collapsed. No CPR was started for 5-8 minutes. Last I checked, police officers are trained to do it. The paramedics arrived, but by that time his heart wasn't even twitching anymore.

It made me sad.

It made me think.

Cops have a tough job.

Also, tasers suck.

Three patients of mine experienced police force recently. One is stocky and muscular. I completely understood why he needed five officers and a paddy wagon to be brought in. He sported a dislocated finger and a gruesome black eye, the white of his eye bright red with blood. No need to taser this guy of course.

The second, well, I can see how she might be feisty but the truth is she's a tiny five foot Asian girl who weighs 100lbs soaking wet, okay, maybe 105. The police officer felt 'threatened' as she proceeded down the road towards him (with no weapon) so he 'bumped' her with the police car before they got out and tasered her. She definitely needed the taser she got. Oh, can't get my tongue unstuck from my cheek.

The third, also aggressive, out of control in his apartment. I had never seen the actual results of a taser before. A bruise the size of a pomelo, Citrus maxima (yes, we always use food to describe sizes) on his torso with two central dots where the actual 'taser' parts of the taser stick in the skin.

Now don't get me wrong. I'm glad they're using a taser gun and not the bullet variety, the whole point of it is to reduce mortality. People get out of control, they go 'crazy', for medical and non-medical reasons and really, I probably actually trust cops . . . most of the time. I sure wouldn't want their job.

But I don't think Robert Dziekanski was crazy. I think he was anxious and scared. And no one took the time to assess the situation and try to understand him. I'm starting to think that everyone expects the worst from people . . . especially when they are agitated and in an international airport. We all make mistakes. Maybe it hit home because their mistake cost a human life, and that's not so far from my personal fears.

Queens, God, and Hell's Angels

2007-10-30T16:26:00.000-07:00

If my calling had been psychiatry I would be in poor shape. Not that I don't enjoy the interactions with patients, its purely because I don't understand it. I just don't get it. When I see patients on a daily basis, what's the actual goal of my conversations with them? You can't just ask concrete things like, how's your pain, are you peeing, and how's breast feeding going. Instead you explore their delusions of grandeur or paranoia, you dive into the depths of their feelings of worthlessness depression and terrifying anxiety to see how the neurotransmitters in their brain are being affected by the cocktail of blockers or stimulators that you have them taking. You go up gradually on the anti-psychotics, play around with their sleep medication until they come back in touch with reality as we know it. Of course, those with more training in psychotherapy give cognitive behaviour homework to those with depressive and anxiety disorders, and together we work through coping strategies. But if you're frankly psychotic, if you think you're the queen of England, there is no logical reasoning that can make you believe otherwise. So we tinker with the neurons in their brain.

There are times when I'm intrigued by perceptions of reality and get caught up in the stories. I want to probe into their theories of spirituality and understand their relationships with God. But then I realize they are God and we're not actually talking about the same thing. As a medical student I remember walking through the unit and there was a patient lying on the ping pong table proclaiming that they were the Messiah. Another patient came up to her and said, "are you really God?" To which God responded indignantly, "yes, of course I am!" The reply came with a snort, "well do I ever have a bone to pick with you!"

Last week it was 'Welfare Wednesday' which meant being on call Sunday was incredibly busy. As it was explained to me, you get your check Wednesday, go buy your drug of choice, alcohol, crystal meth, crack, whatever, have your binge which can last two or three days and by the weekend you're in withdrawal and come to hospital with you heart about to stop or thinking Hell's Angels are hunting you down. Now some crazy people can be hilarious, bursting into song and quite comfortable in their role as the queen and its fun to joke about, but when Hell's Angels want you dead the fear is palpable. You see terror in their eyes and you can nearly smell their angst. Then its not funny at all, its terrifying, and all you want to do is convince then that they're safe . . . which you can't do, so you play with their neurons again.

So I am left fascinated by the mind and unable to understand its complexities. Entertained at times and heartbroken the next minute. It seems a lot of time is spent convincing people to take medications that they desperately need with the rest spent convincing people NOT to take drugs that alter their mental state. My mind is hopelessly concrete, and although I am intrigued by the minds of others, my skills lay in more surgical things . . . and catching babies on the happiness ward of course.

Psychosis NOS*

2007-10-24T17:20:00.000-07:00

Well, I've had a hard life. I'm not gonna lie to you. Why would I lie? Would you lie? Sorry, I don't mean to accuse you or anything, its just that you don't know who you can trust. Everyone has their own motives you know. But yes, my life is hard. Its hard being this sought after. They watch me all the time you know. I see them drive by me in cars when I ride my bike to work, or sometimes they just follow me, not overtaking just so they can watch me. Do I think someone's going to harm me? Oh no! Of course not, well, maybe kidnap me for a ransom, but only because I'm so well connected. My dad was a cocaine trafficker in his younger years--this is off the record, right? Anyway, so he's pretty wealthy and then there's the 'celebrity by association' that I get from my job. What job? I'm surprised you don't know! I guess you don't read the news much. Angelina, I'm her agent. Its busy, well, and complicated. Its a long story, but the problem is she's actually got quite the crush on me, hard to handle, you know, professionalism is vital these days with media coverage being what it is. But Brad's a bit jealous, as he gets, of course I'm not interested in the slightest, all she's got is skin, bones, tatoos, and lips. They send me these messages that get me all rilled up though. No, not voicemail, they usually talk through the TV and tell me to do things. I don't like it. What do they ask me to do? Oh, things like making sure no bad press gets out about them. Sometimes I just get so MAD! Today I had to take all 'The Enquirer' magazines off the shelves in Safeway and burn them. Security and the fire department are such idiots, they just don't understand the brilliance behind my actions. Yeah, I think that's who drove me here. Why am I even talking to you?

Anyway, so I might move to Peru, people know me there as well, but at least I'd get away from Angelina and her crazy boyfriend. Geez. What would I do in Peru? You must only watch sitcoms. I'm next in line to the throne. You'd have to pay some good money to get this kind of interview with me there. No royal family in Peru? Did you even finish high school? Hello . . . the Inca royal family! Basically I'm a direct descendant of Inti Raimi. Yeah, so my job possibilities there are basically endless. I could work on my classical guitar career, yeah, I'm pretty good, I've played with some of the greats. Led Zepellin and I actually did a duet together on his last album.

Do I hear things that other people don't? How should I know, I don't know what other people hear, its not like I'm inside their head or anything! Would I ever hurt myself? Are you nuts?!? I have endless possibility, money, AND I'm famous, my life is great! Why else would all these people be monitoring my movements if I wasn't something special? I'm actually most likely going to be the next prime minister of Canada, yeah, Stevie Harper is on the way out, did you hear that throne speech? He's nuts. But God has really given me a lot of gifts, I think I'm up for the task, I'd feed those poor people and set up all sorts of social programs to end inequality in the world.

Pills? You want me to take pills? You think I'll fall for that one? I only eat organic things, and those are NOT organic, I don't want to put chemicals into my body! Besides how do I know I can trust you? You keep on asking these weird questions, maybe you should see a psychiatrist. I get one phone call, right? I'm calling Angelina, and boy, is she ever gonna be pissed at you!

* not otherwise specified

Morilla, Meatloaf, and 10,000 cows

2007-10-20T10:47:00.000-07:00

We crawl through the fence and into the barnyard. Chickens, sheep, pygmy goats, regular goats, and a variety of cows, oh yeah, and a couple dogs. My aunt has names for all of them, well, maybe not the chickens. I follow her out to the pasture where the Jersey cows and calves are congregated, my new sneakers with the pink flowers on them encounter the slipperiness of a cow-paddy despite my best efforts. We throw bails over the fence for the cows. Scratchy, itchy hay on my arms, the warmth of the cows reassuring, manure on my jeans, the bright blue sky, farm house in the distance, the pasture scattered with farm machinery my grandparents used in the first part of the last century. Its all so familiar to me. I remember dusty summers exploring the woods, mud fights in the dug-out, riding horses (and getting bucked off), chasing cows, hot sleepless nights with mosquitoes biting and coyotes howling. Summers at the farm.

I visit a friend who has known me since I first came to Canada. I swear she's the reason I got through university . . . private tutoring and she didn't even start charging! Now she's married with a bun in the oven (notice the official obstetrician terminology), they live on a farmstead, have started a market garden and are building a new house. In my wildest dreams I never imagined her raising chickens and goats but now it seems like the most natural thing in the world. It somehow felt right to be eating things that were grown only a few hundred meters away. Maybe I'm idealizing it but the connection to seasons and the land is a different concept than in the city where our peas come from China year-round and apples are shipped from Washington instead of the Okanagan.

From the idyllic farmstead where I see all that is good about life in rural Alberta I went to the feedlot that my cousin manages. 10,000 head of cattle. To be honest I was expecting to be horrified with vagrant abuse of animals. To be even honester I was horrified at how naturally I accepted it as imperative to our lifestyle by the end of the day. To provide the all-powerful consumer with the beef we want at the right price this is how the system must work. 9lbs of grain for 1lb of meat. The healthiest, fattest cows I've ever seen. Vaccinations and growth hormone when they get shipped in, then they eat all day everyday, continuously monitored to make sure they stay healthy. Meat is big business in Alberta. I'm ashamed that I can't quite bring myself to tell my extended family that I'm mostly a vegetarian, it seems like the most intimate of betrayals that I am rejecting their very livelihood. Of course, I still love my cousin. "Different strokes for different folks," I tell him when he asks what I think of it all.

I loved every minute spent not thinking about anything remotely related to work. Of course, it can't be avoided when your cousin rips off his shirt and asks for his rash to be diagnosed or your aunt wants to know your opinion on cancer causation. I tried to spend lots of time kicking through crisp dry leaves and watching sunrises and sunsets. Life is good.

A large pumpkin, a mammoth zucchini, gourds, and garlic accompanied me on the Greyhound back to Calgary.

As far as my post-holiday resolutions:

Live more. Love more. Volunteer. Eat beets. Play guitar. Laugh more.

P.S. Morilla is a Jersey cow and Meatloaf is a pygmy goat.

Alberta Bound

2007-10-06T11:52:00.000-07:00

Friday brought with it an epic journey. First squeezing through the narrow pass of Phimosis, only to be met on the other side by the sticky pit of chronic Balanitis with crusting around the edges. Then, after wading through the mushy swamp of Prostatitis I ended my foul run of luck along the meandering stream of Epidydimitis with tender hard boiled eggs (without the shell).

Sticky foreskins and sensitive testicles aside, in all seriousness I have found a new appreciation for men's health over the past few days. Turns out sexual issues are important for the health of men as well as women . . . who knew?

Fortunately, after seeing four patients complaining of problems with 'the boys' my day brought a bit of variety. There was a lovely three year-old whose mom brought him in with a cold. He played doctor with my stethoscope and obediently opened his mouth wide for me to take a look. To me he was a little miracle, so smart and inquisitive, crawling up and down from the examining table with endless questions. Both his mom and dad are HIV +. He is negative and as healthy as any kid his age (snotty nose included!) Seeing him filled me with endless hope and optimism, that this can happen, and not just in Canada.

The afternoon was a bit more disturbing. A young guy of the exact same age as me and currently at university. He had a sore throat and had noticed a lump on his neck. I examined him and reassured him that he had a cold and most of the time you do get some swollen lymph nodes. He didn't buy it. "But why have I never had it before with a cold? This isn't normal." When the questions kept coming I realized there was something else going on. So I asked if he was worried about anything specific. The can of worms opened. Throat cancer and HIV. Lots of high risk sexual activity. However, he was skeptical about HIV. Wasn't it possible that its all just a money making scheme for doctors and drug companies. People are killing themselves with the drugs they take, you can treat it with diet.

I could nearly hear the creaking of my jaw dropping as he spoke. Speechless. Where do I even start? We had a long discussion, and I hope I opened some doors for dialogue. He went to get the blood work done and we'll see what happens. When I talked to my preceptor about him he said without hesitation, "he needs to wake up, or he's going to die."

In the span of a few hours I went from an explanation of a foreskin re-growing contraption, to a deep feeling of hope in the eyes of a child, to shock at a population that has somehow fallen through the cracks in understanding the gravity of what HIV means. The absurd, the wonderful, and the disturbing . . . its nuts! My work day came to a close on a high note with my evaluation. Stronger than your peers at this level. (What?!? Don't they know I went to U of C and am clearly deficient in pharmacology and anatomy?) Fantastic with patients, great people skills, open-minded and sensitive to patient issues. (Okay, I guess they do know I went to U of C).

And then . . . freedom. Frantic packing. Airport. Plane. Cowboy on plane. Calgary. Hugs, family. Bright sun, blue sky, golden leaves and of course, turkey.

Gay Men and African Women

2007-09-28T07:54:00.000-07:00

"Come on, don't be scared, just say it! FAGGOTS. That's the highest risk group in Vancouver." My preceptor spat out the words as he egged me on with a grin. He is a tall, ridiculously good looking, tanned and muscular gay man with salt and pepper stubble on his ever smiling face.

"I won't say it, so don't even try." Was my determined response.

For someone who sees herself as fairly open-minded and worldly my assumptions and stereotypes have been given a good beating this week, which is fantastic! I'm working at a clinic that functions as a family practice but focuses on the HIV+ population and specifically gay men. There have been both funny anecdotes and serious ethical questions that I've stumbled across which at week's end I find hard to process coherently.

There was the diagnosis I nearly missed because I didn't ask about nipple bitting . . . of course, silly me. Next I had a young businessman who skipped all pleasantries as he rushed into the room. "I have a rash." In a second, shirt and tie were off and he dropped his pants to show me the distribution. On the bright side, my choice of obstetrics has been confirmed. Although I love the HIV medicine, seriously folks, scrotal rashes are gross. I was also recruited to do a pap smear on a transgender young man who was going through gender reassignment but still had his uterus. So many fascinating and complex medical issues. Heck, not just medical issues.

A well-educated man in his 70s divulged to me just as he went out the door that he wouldn't even shake hands with 'them', he hadn't realized that the majority of the patients here were gay. He had even ignored the hand the doctor I was working with offered him. "You never know how you might catch it." Before retirement he had worked in a microbiology research lab. I was shocked by his views and told him that he should know better . . . with my usual undertone of humour of course.

The fashionista-shop-a-holic-I'm-in-love-with-Justin-Timberlake nurse shared his frustration with me after meeting with someone who had just found out they were HIV+. The patient is in his early thirties, as is the nurse. "There's just no excuse, I don't understand it. In this day and age we know about the disease, we know how prevalent it is and we know how to prevent it. I don't want to judge, but I just don't get how people go ahead and do what they do." My reaction was a bit of surprise I suppose. I thought that this nurse, having worked in the area for several years, with first hand experience would have some insight into why people are still getting infected. Even though HIV is no longer a death sentence and is treatable, it still turns lives upside down.

Perhaps it was similar to the shock I felt when on returning to Tanzania I ran into the husband of the head nurse I had worked with in Uha. We were waiting for transport out to the village. He was returning from her funeral, having died of the unspeakable disease and leaving two young sons. She knew all there was to know about the disease. We led HIV/AIDS seminars together for women, she counseled people to get tested and tell their partners, she delivered the babies of women we knew were infected and saw their fear and pain. But still, with all her education and experience she could not completely control her own health. Was her husband sleeping around? Had she been cheating on him? It doesn't matter, does it? Disease doesn't take a moral stand.

That's the conclusion I've come to. Several people asked me this week that it must be so different working with HIV populations here compared to Africa. More resources? Yes. But the loneliness is the same. Sickness and suffering unite us in our humanity. To look in the eyes of a middle-aged white professional man or to hold the calloused hand of a young mother from Uha I feel the same heaviness is my chest. That this world is not as it should be, and in the depth of our suffering there is inexplicable hope when we realize we suffer together.

Life is Beautiful

2007-09-25T15:45:00.000-07:00

Life was not beautiful at 2pm when I was still at the hospital on Thursday afternoon after being up most of the night. Its the tightness you get in your temples, the blurry vision and incomplete sentences that are frustrating to no end. The ultimate problem is that you stop caring. I swear I dosed off while peeing then jerked awake and later found myself 'resting my eyes' when walking down long corridors (just for efficiency's sake of course). Not that the night was uneventful, we extracted a bottle of Dove shampoo from an unnamed body orifice (take a wild guess which one). It brought a whole new approach to the Dove campaign for real beauty. As the story goes he had been "watching a documentary on the male G-spot", which is surprising, because normally the story is "I was doing my laundry naked and I just fell on the flashlight" or "I slipped in the shower and . . ." Nice to have an honest answer I guess. But ANYWAY, I digress . . .

Eventually I got home, collapsed for an hour nap, dragged my pathetic self out of bed for a shower and headed to the airport to pick up a friend visiting from Calgary. And so began my lovely long weekend. There were three friends from various locations crashing at our house Thursday night. Friday was a deliciously relaxing day involving warm gooey cinnamon buns for breakfast, an exquisite foot spa (apparently that means pedicure with benefits), a run through the endowment lands and along the beach in the rain culminating with yoga by the ocean. This was directly followed by hot tea and the whole day was peppered with endless discussions about love, poverty, economics, and toe nail polish.

By 8pm Friday I was on the ferry with another set of friends heading to Galiano island. Saturday morning brought with it a brilliant blue sky and calm waters as we crammed our camping gear into the kayaks and battened down the hatches. Of course Bertha (my camera) was strapped to the deck of my kayak in her fancy Pelican box. We paddled along the coast, past intricate sandstone carvings molded by the ocean, turkey vultures circling overhead, cormorants skimmed the water as we came upon their nesting site and dozens of seals sunned themselves on rocks. A pair of otters crawled out of the water and playfully rubbed water from their eyes as they scurried around the rocks. The whole time our chatter was nearly with pressured speech about all the challenges and experiences that residency has brought interspersed with silence in awe of the beauty around us. We crossed the straight to Wallace island, camping on the northern tip. Uncontrollable laughter accompanied our racoon-safe food hang before our pitas, hummus and wine appetizer. The sun sank slowly behind Saltspring island to the West sending shimmering gold across the water to our feet. A day of perfection, surreal in its beauty and a lifetime away from anything mildly related to medicine.

Sunday morning the sun greeted us again, unheard of on a random weekend in September on the West coast! The wind had picked up but we had a 'following sea' which pushed as back along the coast. Out of sheer necessity I actually started paddling with good technique, figuring out how to isolate those back muscles (fortunately my roomie is a professional!) Soggy, chilled, and blissfully exhausted we glided back into the Montague marina.

Life is beautiful. I am profoundly privileged and blessed to be who I am where I am right now. This situation is helped by the fact that I'm now working in a clinic that doesn't start until 9am! Can you believe it?!? 9 to 5, its novel, and no call! In the mornings I curl up in a chair sipping tea and listen to morning meditations courtesy of the world-wide-web and the Jesuits. The outlook is good!

Nostalgia

2007-09-18T17:19:00.000-07:00

The sky was bright but the rain fell steadily, pattering softly on the roof and I sat inside insulated from the cold dampness. Slippers on, cozy in my hoodie. Something about today made me want to be back in Tanzania. Maybe it was reading about flooding in Africa on the BBC news, or the frustration of running around doing nothing at work today, who knows. Maybe its the rain.

The memories so vivid. Breeze blowing through tall grass on the plains, clouds rolling across the hills. Bright green maize sprouting in rows of dark brown earth. Women in the fields, weeding, children on their backs. Visitors, always visitors. Children holding my hand, doing homework on the cool cement floor of my living room/kitchen, kicking the soccer ball out in front of my house. Surrounded by people. Walking down dusty paths to visit people, flip flops reassuringly slapping my heels with each step. Shared chai, scalding my mouth, ginger warming my throat. When it rained I couldn't hear my roommate Atu over the thundering on the metal roof. Water seeped under the door and earwigs fell from the roof. No insulation from life. Every moment was about being, not doing. I learned how to fully appreciate the present, not regretting the past or worrying about the future. "Time is not passing, it is coming."

The rain petered out as the sun set and transformed the low-lying clouds over Vancouver into delicious golden peaches and oranges. We slurped noodles on the front porch watching bikers whiz by and dogs pull their humans out for evening strolls. The long long distance from Tanzania isn't just geographical but living in the present seemed like it was infinitely possible in the moment as the moon rose and the light faded. So tomorrow I'll got back to the same hospital with the same people, but I'll try to be instead of do.

Voldemort and Sierra Leone

2007-09-12T16:34:00.000-07:00

Blurp-blurp. Blurp-blurp. The submarine sonar sound of my pager swims in my ears through the thick darkness. I page the number.

"Trauma team activation. Multiple stabbings."

Then I'm in the trauma room, everything is happening through a fog. Nurses, paremedics and the emergency doctor are there but no one is doing anything. Blood everywhere. Then somehow its me, gasping for breath, blood coming from the side of my chest, standing there bent over.

The scar on my forehead burns as I'm ordering two large bore IVs, bolus 2 litres, CBC, type and screen for the trauma patient. The image in my head (as pain sears through the scar on my forehead) is of a fetal heart rate tracing, plunging lower and lower, the sound of the doppler pounding out the heart rate getting slower and slower. Wawumph, wawumph . . . wawumph. Nobody is doing anything about it. I hear myself yelling at the shock of no one rushing the woman to the operating room as the baby's heart rate drops. And then I'm running as if through wet cement, the air thicker than molasses, trying to get to the labour and delivery ward in time to save the baby. The elevators are blocked by scrawny African teenage boys with AK-47s, their eyes dead, their voices threaten me as I'm yelling, desperate to get upstairs. I can't control my body's movements. Then my surrounding are no longer the hospital halls but a war zone in Sierra Leone. A young boy with his machine gun hanging down his back pushes a wheelbarrow through tall grass in front of him piled with dead bodies. Flies. Heat. Fear.

Blurp-blurp. Blurp-blurp.

I wake with a start, my heart racing, full of fear, clammy with sweat. The dim shapes of the call room come into focus.

"Mrs. K hasn't peed for 6 hours."

Clearly I'm going nuts. Surgery must be stressing me out. That and I'm reading too much Harry Potter. I'm also reading "A long way gone: memoirs of a boy soldier". Vivid and moving. Maybe too vivid for me these days.

P.S. I don't actually have a scar on my forehead the connects me directly to labour and delivery and the mind of Voldemort . . . I don't think.

Cutting

2007-09-10T19:32:00.000-07:00

Its official. I'm addicted. I love cutting. I can't even explain the exhilaration of it, probably some psychiatric problem I'm sure.

Mr. A is a divorced videographer in his 50s. We got a call from the ICU, it was one of the more, um, exuberant residents. This is how it went when we returned the page:

"F***, what's his name? What's the fat guys name? Anyway, we have a guy with alcoholic pancreatitis and he's going to f***ing die if you don't cut his belly open, we can't even ventilate him anymore."

Years and years of education to come up with such eloquent and concise vocabulary, that's quality.

The 'fat guy' had abdominal compartment syndrome. Pancreatitis is really quite nasty, your pancreas digests itself and then works on digesting the rest of your insides. The pressure in Mr. A's belly was so high it was pushing up against his chest and they were having difficulty getting air into his lungs. Unfortunately, his deaf mother in a nursing home was his next of kin (i.e. decision maker) so she signed things over to his ex-wife . . . who decided he didn't really need the said 'life-saving' surgery. So, we did what most patriarchal medical doctors do when the decision-maker doesn't agree with their treatment . . . two ICU physicians signed a form to make the decision for him, that is, the decision we wanted made.

Our part was the decompressive laparotomy. Quite barbaric really. Although the really barbaric part was when the chief resident handed me the scalpel. The belly before us distended and rock hard from the pressure.

Cut with the belly of the knife. 90 degrees to the skin. One smooth, continuous motion. And there I went. From just below his sternum, around the belly button, and down to his pubic bone. Then we cauterized through the thick layer of fat, through the muscle, fascia and then pink intestines just oozed out, worming their way out of the pressurized cavity. An image of a snake pit from an Indiana Jones movie crossed my mind. Dark brown fluid poured from the opening. Dirty yellow omental fat covered with what looked like white lichen, where its being digested by pancreatic enzymes. Quite the rush.

We didn't close him up, instead we put layer after layer of sticky saran wrap over the gapping belly, cut a whole in the middle and connect it to a vacuum. Back to the ICU he went, most likely to die.

I love cutting. I can't deny that I find surgery stimulating and fascinating, but its just not the same as obstetrics. The full words to describe my thoughts fail me, but the fact is, I'm a better person when I'm doing obstetrics and women's health. My heart felt cold as we wheeled Mr A back to the ICU. In my mind he was the 'fat guy'. I had no connection to him, and yes, compassion, but no empathy.

Three weeks ago there was a woman here on holiday from Spain. She was 17 week pregnant and having a miscarriage. I spend most of my day with her and her husband. I suppose it helped that I spoke Spanish but my soul resonated with their situation. First talking to her and explaining what to expect. Then assuring she had a private room in the emergency department (no small feat). Then fighting again as she was transferred up to the surgery ward to a four-person room as she laboured. Finally staying after I could have gone home to reassure both her and the nursing staff who had never had anything like this happen on their floor before. At days end I caught that tiny being cupped in my hand, wrapped him in a towel and placed him by the window for the priest to come and bless him. Neither of the parents wanted to see. After that, I examined him and slid his miniature body into the plastic pathology container to be sent off. I left them that night feeling not only like a real doctor but a deeply human one.

The reality is that you can't identify with everyone. My hope is that everyone can empathize with someone, being aware of feelings towards patients is probably the first step. Maybe cutting isn't everything, it makes my heart beat fast, but it doesn't make it sing.

Paradise Plagiarism

2007-09-03T21:25:00.000-07:00

This is copied (with permission) from someone very dear to me. Her description makes my eyes well up with emotion and then smile at the next paragraph. It is both beautiful and tragic, reminding me of the world outside my everyday bubble. Heartbreaking, frustrating, and hopeful all at once. She has a gift, both in how she shares this story, and in the work that she does so passionately.

FRIDAY

You work with it most days. You’re trained to not let it affect your innards. You see it all the time all around you, but some days it just kicks you in the gut. You can feel it in your stomach and the discomfort is intense and doesn’t go away.

It was a Friday. You know, the usual, choose which house in the slum is the poorest to improve to create a better quality of life for a family this means going around to visit the “poor” families to see who has the greatest need, determine what is greatest need and who seriously contemplate who it was that decided that you had the capabilities to make that determination.

This is the part that kicked me in the gut. We visited three houses. All members of the Centro Mujer, women and their families. All living in deplorable conditions, a true violation of human rights. Accompanied by a 50 year old worker at the centre, who is known for her strong opinions and harsh words, we walk a few blocks up, through the now closed market with all the smells of the afternoon after a market. We come to the house of a grandmother who takes care of her three grandchildren, her whole extended family live in this house. It has brick walls on two sides, the front is of plywood. Outside it has a tree planted by a previous group of gringos, the tree is called Angel Guardian. The front room has a tin roof, we go back to see the bedroom, straw matting and a tarp for a roof, we peer into the room, trying to focus in the dimness even though it is mid day, we see the drizzle accumulating in puddles on the tarp and the drips slowly making their way to the bed and all the possessions below. We say we are just visiting to invite her to help with the event tomorrow, she says she will come and she will make some nice hot ponche for the tourists, so they don’t get too cold. She’s always very hospitable, she apologizes that she has nothing to feed us, as she didn’t know we were coming. She apologizes for the state of poverty she lives in.

We walk a few more blocks down some muddy alleys past an old rusted out car. There is a piece of plywood blocking the distance between the old car and a big rock, must be the door. We knock, a girl answers, she must be about 8, she is looking after her cousins and her mother isn’t home, we look past her to see another rusted out car and two little girls, the oldest no more than two years old, sticking their heads out of the windowless windows of the car, where they had just woke from their naps. Yes they were all sleeping in the old cars, she says, because that’s the only place the rain doesn’t come in at night, well except through the windows, but the roof keeps them a bit dry she says. This is how they live. The faces of those two little beautiful creations in that car will always be burned in my memory. The inequality and injustice of great poverty hit me so strongly in that moment that I truly felt winded and on the verge of tears and had to turn around and walk away. I am supposed to be a professional, I have seen great poverty all over the world, but sometimes, for some inexplicable reason it hits you with enough strength to knock you out. It gives you great pain, but it also reminds you why you do what you do. Because it is a failure of humanity, our personal failure, that those beautiful children have to grow up in extreme poverty with no option for escape, so few opportunities available to them. It is a travesty that we are all responsible to make right. That is why I do what I do, and every once in while, you just need a kick in the gut.

The third house still awaited us, but I had already made up my mind which family we would be building a house for tomorrow. That is, until I reached the third house. We walked up to the cemetery, we wanted to take a moto taxi but none of them go that far, they don’t like to go through the cemetery. So we walk through the cemetery, getting decidedly soggy and the bottoms of my pants and shoes covered in mud and goodness knows what else from the continuous foggy, dreary, drizzle that is Lima in winter. We arrive at Paraiso, or Paradise, on the other side of the cemetery, I have visited it many times and it always gives me a different concept of my definition of paradise. It is one of the poorer areas of the slum, an invasion, a squatter settlement, meaning the families that live here could be kicked off their land at any time. No running water or sewer, minimal electricity, most people here cook with kerosene as opposed to propane that is more economical but needs to be bought by the tank which requires more money at one time than most people living here in paradise can afford. We start climbing the cerros, and the mud squelches under my shoes, I slip and slide in some small river of unknown liquid that is trickling down the hill, almost wipe out but I cling to a rock jutting out of the side of the hill. We reach the house, a woman I have known for two years, her 8 year old daughter comes to greet me, the friendliest kid I know, always wanting a hug and wondering how I am. She often accompanies me on home visits that I do in this neighbourhood. I go into their house; its walls are built of straw matting and the roof as well. The three little pigs wouldn’t stand a chance in here. Normally if you have straw matting on your roof, because it is the cheapest construction material, you would also have some sort of plastic or tarp to keep the rain out. This family doesn’t, she tells me her three small children are always sick with respiratory problems from the constant damp and dust. They have all been in and out of hospital since they were born. We chat for a while; she works sewing beads onto t-shirts- you know like the ones you buy at Old Navy or the Gap? She gets paid 20 cents a shirt and each shirt takes her about 2 hours, it is painstaking work, tiny beads in exact formation, you often get discounted, she says she hasn’t been paid for her work for the last month and a half. I leave her to her work and discuss the three houses with my colleague. We decide on the last house we saw. I go back to the house and tell this woman that tomorrow we will build walls and a roof for her house, so that her children don’t have to be sick all the time. The look in her eyes I will never forget, she had no words to say to me but the tears started to fall down her face, I have never felt so blessed to be able to accompany her in that moment.

So continuing on with the Friday night, after determining who is the poorest of the poor your job is to: get building supplies, find someone to build it - that is, find someone who knows something about construction who wants to work with a few hours notice on the biggest holiday in Peru, 28 de Julio, Independence Day, an impossible task- tell the family to clear their stuff out, get building supplies through the cemetery and up the hill to the straw matting that was the existing house, figure out how to get four pre-used pre-built plywood walls off of the third floor of the Centro Mujer, which is currently undergoing construction so the brick walls are still wet with mortar- try not to knock them down—get these plywood walls down to the street, through the cemetery and up the hill- with only the help of five older women who aren’t really the wall moving types. All because a group of gringos is coming, with about half a day notice and want to build a house. While you are doing all of the above, also, teach one of the final sessions, on how to be a leader in the community to stop the endemic violence, to a group of volunteer domestic violence counselors, as there is no access to sufficient professional services in the slum that I call home, San Juan de Lurigancho.

BUT, that’s not all, one of the women who you are training has a epileptic seizure in the middle of the workshop, this then precipitates hysterical crying from one of the other women whose mother is dying in hospital and her husband has just left her and her two children after beating her so badly she was unconscious and is therefore triggered because of being seriously traumatized and under a lot of stress.

AND, or perhaps because of, all the excitement, you start to see stars, which might be exciting if you had just imbibed some sort of hallucinogenic plant found only in the deepest, darkest Peruvian Amazon jungle, however, having experienced this before, you know that you have not had access to such a plant and therefore it is in fact the beginning of a migraine…. soon the vomiting and possibly suicide inducing headache will begin…. but for now, you can’t see. As you are the only one in the centre and the group came all this way on the cold, drizzly day you must finish the session. So you give them a group activity to do while you slip away for a minute to run down the block to your house and pop some gravol and pain pills so at least you won’t vomit on the fabulous women while you finish the session, hoping that you remember the just of what you were planning on saying as you can’t read any of your notes, due to the flashing lights in your eyes.

So while you are feeling around your room to find your drugs, you hear what sounds distinctly like gunshots….but being in a poor slum, you once again thank God that the many gangs in the neighborhood can’t afford guns and usually just throw rocks and beat rival gangs with sticks. However, on your return to the Centro Mujer, you notice everyone picking themselves up off the floor and brushing themselves off. You ask, what’s going on, thinking perhaps it was some sort of icebreaker or other fun activity that they decided to try since you were not there temporarily to lead the group. ---Turns out that it was in fact gun shots that you heard and somehow one of the gangs was shooting at a rival gang member, right outside the centre, on the street corner you just walk past, where the women were helping to lower plywood walls moments earlier. Hmm, makes you think, this getting rid of the violence thing is tricky, these motivated women you’re training don’t really know what they signed themselves up for. Creating change in a community that has deeply ingrained inequality, poverty and violence, the possibilities are endless.

Just your run of the mill, average, boring Friday.

Smoking is the devil

2007-08-28T16:00:00.000-07:00

"Hoedit, hoedit!" An escalating raspy voice calls down the hall to hold the elevator and his electric wheelchair whizzes into view as the doors close. I lunged for the open door button since my attending, chief resident, and two drunk guys in the elevator with me all seemed blissfully oblivious to what was going on.

I had seen him before in the halls. His long, thin frame propped awkwardly on his wheelchair, his body stiff. Most of both his feet are missing, bandaged and oozing but somehow he manages to hold his IV pole between them, in front of his chair as he motors around. The stubs of his index finger and thumb on his right control the joystick on his chair. I don't think he has any teeth and appears to be hooked up to a milky-yellow IV bag for all his nutrients. His pale face with sunken cheeks and stubble is friendly, the toothless grin never leaving, an unlit cigarette between his lips, he's on his way outside for a smoke. Smoking 'till his last days.

Yesterday was my first day of general surgery, and as Murphy's law goes, I was on call. Unlike obstetrics, there is no senior resident or attending staff 'in house' so you're it overnight unless something big happens...then you're it until help comes. The reason I bring up my friend with missing fingers and feet is that the general surgery resident on call 'cross-covers' for all the vascular surgery patients overnight. The vascular resident gave me a call before she went home (after her 36 hours stint or so) to let me know about some patients I might 'hear about' overnight. Two of them had various levels of legs amputated, both DNR (do not resuscitate). "We really thought they'd die over the weekend, so any day now really, just make sure they're comfortable." Vascular surgery seems terribly depressing. Reconnecting and propping open arteries in an attempt to get perfusion to limbs. Arteries choc-full of nasty fatty plaques from long lives of smoking, high cholesterol, diabetes, and obesity. When people think of why they shouldn't smoke they probably think of lung cancer, but really, the heart attacks and rotting amputated limbs ultimately affect more people and needless to say, the impact on quality of life is fairly monstrous.

So I scrambled to figure out the patients on my own team, before reviewing the other general surgery team's patients AND all these vascular patients who had had surgeries I understood in only a simple textbook manner.

My senior resident left at 8pm after we had swamped our way through about six consults and booked an appendectomy for surgery later that night. I had a clear 'to-do' list in my mind of paperwork, dictations, labs and a CT scan to follow-up on to make sure we couldn't 'turf' one of our patients in the emergency department to GI and avoid admitting her. It was quite clear that I should call him only if I was really really uncomfortable with what was going on, in which case I should definitely call him...a fine balance.

A call from the ward at 2am.
"Are you familiar with Mr. Jones?"
"Nope. But you can tell me about him."
"Well, he doesn't have a pulse (I swear there was a pause here) in his left foot."
"Oh...what surgery did he have? Has he ever had a pulse in that foot?"
"Bilateral fem-pop last week." Pause. I hear the flip, flip, flip through the chart. "Actually, I guess we haven't ever picked up his dorsalis pedis pulse."
"Good...uh...I mean, not good, but no change then. Are his vitals stable otherwise?"
"Yes, sorry to bother you."
"No really, its okay, thanks for letting me know."

I clunk the phone down with relief. After clicking the light off, I lay down again on the ancient, hard, creaky hospital bed with thinly disguised rubber pillow that are standard in the call rooms. I'm exhausted but sleep and adrenaline don't mix well. Constantly dreading a call about my little lady with a bowel obstruction whose pain I just got under control an hour ago. The knowledge that I also hold the trauma pager is like a ball of lead in my stomach. I do get some sleep, but the pages continue, slowly I get comfortable and my heart stops pounding each time I hear the beeping.

Morning does eventually come. No one died, well, on my watch at least. The frenzied surgery rounds begin. Warp speed in and out of patients' rooms so the surgery residents can get to the ORs on time. When we finish the chief turns to me and says in a cheery voice, "I know you're post-call, but there are some great cases in the OR today. They'd be perfect for you to see as an OB/GYN resident. You're free to stay all day if you'd like!" Honestly, I wasn't really sure if he was serious or not... since I had only know him for a day I chose the 'serious' option instead of breaking into uncontrollable laughter like I felt like doing. I ended up staying for two surgeries that admittedly were very relevant and they actually let me do a fair amount which was a good trade-off for bleary-eyedness. Too bad for the ani of those involved of course.

To be known

2007-08-23T21:08:00.000-07:00

My sister came to visit last week, I hadn't seen her since April. Post-call we went for what are advertised as 'the best' cinnamon buns in Vancouver and she listened to the exhausted kid sister who wishes she wasn't a doctor and doesn't really know how she'll survive residency or ever be in a healthy relationship. Then we hit IKEA so she could re-design my room. I had an unexplainable attraction to every single bed I saw, it was like a strong magnetic pull. She patiently pulled me out of each one I crawled into until we eventually got to the picture frame section where my energy was suddenly revived. I didn't have to be funny . . . or even awake apparently, she would still hang out with me in all my grumpy, sleepy, post-callness.

I managed to meet up with her for lunch on Davie street, just next to the hospital one day. She laughed at my scrubs and openly mocked me for wearing them in public. Of course, I hadn't had time to change clothes AND have lunch with her, how picky can you get?!? But she knows me. Underneath the Dr. name tag, stethoscope and greens I'm just a sister, as vulnerable, human, and mock-able as ever. And it felt good just to be me with no labels and no explanations.

On Galiano island, together we joked about the watery hippie chai they sold at the craft market, lacking in both substance and spice. My sister being the ultimate chai expert having drunk it on dodgy Indian trains in ceramic mugs. We read Harry Potter to each other on the beach with several smiles in our direction from passers-by. Then we did a rather soggy hike along a coast-line ridge, misty and beautiful. We were told it was a 'dry' rain . . . I still haven't got the west coast lingo down apparently since I have no idea how that describes pouring rain.

We talked about the past and the future, our hopes and fears, I laughed until my eyes watered. I was reminded of the power of being known and loved by someone. In the midst of the excitement and exhilaration of moving to an amazing new place, starting an overwhelming, scary, (and fantastic) new job you can sometimes push the loneliness away but it always pops up. My life seems like a never-ending cycle; wake-up, get on bike, work, come home, eat, run or bike, collapse into bed, then start over. I miss being known. I miss filling my time with people instead of activities. Which is why it was so good to remember that I am known. There may not be a tangible presence that I can touch, but I am known.

Urgent section... no senior

2007-08-13T14:40:00.000-07:00

Rushing down the hall. Fumbling the ties of my mask as I walk together with the obstetrician.

Water running, pink foam covering hands. Scrub, scrub, scrub. Repeatedly. Nails, palms, individual fingers, one at a time. Wrists, then down the arm. Rinse, spraying water down my greens. Water running off my elbows. I back into the room through swinging doors, arms held out, at 90 degrees like a robot, hands pointing to the ceiling.

Sterile hand towel rough on my hands. I scoop my arms into the blue gown. Hands deep into latex gloves held out for me, snapping gratifyingly around my arms. Tight springiness of my gloves reassuring, sterile gown stiff as I move. The curves of the body on the table become only an anatomic circle of skin in a blue sterile operating field. Bright lights spotlight the belly swollen with pregnancy.

Cautery in place. Suction ready. Heart pounding. Hand steady. Knife. Exhilarated. Bleary eyes fully cleared with the adrenaline of the cut.

Flash of custard yellow shiny fat globules as the skin parts, then bright red specs, spread and flood the incision. Deeper now, a sheen of fat particles on the surface of pooling red blood. Tiny fountain from an artery. Snapping of clamps. Cautery buzzing. Pungent smell of burning blood, tissue, smoke. Suction slurping. Snipping scissors slice through fascia. Knife again. Green fluid spurts. Cord floats out. Then pressure. I'm standing on a stool pressing all my weight down onto her belly while matted wet black hair emerges from below. Scrunkled, wrinkled face finally forced out. Body gray, covered with thick whitish-yellow paste. A girl. Pause. Breathing stops. Silence. Snap. Snap. Scissors snip. Slimy warm limbs held tightly in my hands, I turn and place her in the sterile white flannel the nurse is holding. No cry. Suction slurps. Heads crowd around the warmer. Hands flying. Then a gurgling cry, squirming baby. The room breaths again.

Blood spurts, flooding the uterus as the placenta slips out. Warm, pulsating. Clamps, sutures. Suction squealing as dark livery clots dangle off its tip. Ties. Cautery. Gauze. Gaping uterus closed, fascia comes together. Back up to the custard fat, no longer shiny. Krink krink krink as I staple the final edges together.

Only now does my heart slow, tearing off my gown, gloves sticky with dried blood snapped into the garbage. Blood and fluid all over my ankles and feet. Scattered bloody footprints bright on the floor.

Wading in the exhilaration of it all. Senses overloaded. Wow, that was cool.

The problem with pain

2007-08-08T13:55:00.000-07:00

She came in weeks ago, blissfully oblivious to how her world was literally about to turn upside-down. We'll call her Suzie. She was at her routine 20 week ultrasound and they found that she was 4cm dilated. That's bad news. A diagnosis of cervical insufficiency, meaning your cervix just doesn't stay closed if any pressure is put on it. Previously, its been called cervical incompetency, somehow implying a deficiency on the mother's part, that she was incompetent in carrying a baby. An active high school teacher, Suzie was now given the choice of a 'rescue' stitch in her cervix and complete bed rest until delivery (with a fairly low success rate), or to just let labour happen and put in a prophylactic stitch early in her next pregnancy. Suzie and her hubby chose the procedure and bed rest. They desperately wanted this pregnancy, having already experienced two miscarriages. It would be at least 4 weeks until baby would even be a candidate for resuscitation at 24 weeks. As days went by, and turned into weeks, Suzie bled a bit, sometimes she cramped. Then we wouldn't even let her up to the bathroom and we but her in 'Trendelenburg' position, so she lay every day, all day, with her head far below her feet. Scared even to have a bowel movement.

At 23 weeks, babies born are not resuscitated, the cut-off for viability is 24 weeks, even then, only 50% actually survive and 85-90% will be blind, deaf, or have mental or physical disabilities. But parents can request resus at 24 weeks. After 25 weeks, resuscitation happens most of the time, regardless of parental choice. A strange set of rules, built like a fence around the ethical principles of trying to do more good than harm.

We were updated each day, until she hit 23 weeks and 5 days. Suzie's water broke, she went into labour and we had to take her to the operating room to remove the stitches so they wouldn't completely tear through her cervix and permanently damage it for any future attempts at pregnancy.

Some images will forever be burned into my mind, and this is one of them. A small, tight, shiny membrane slowly proceeding from the vagina, feet first. Tiny feet in a glass globe coming out towards us, each only 2 or 3 cm long with five delicate, miniature toes on each foot. Imprinting their footprints forever onto my heart as they came.

We swam in the sorrow and intensity of the moment. The air felt like viscous liquid around me. Their grief making waves that hit each person in the room. Completely enveloping me in the heart-wrenching, soul-destroying pain of the present moment. A father's tears dripping freely onto the face of his tiny tiny son, swaddled in towels, eyelids still fused. Time stood still. Masked faces in sterile gowns blurred in the periphery of the operating room and the only thing real was a husband and wife, a sister gazing and embracing this tiny being, silently yelling out in agony, guilt, and anger. Raw. Abject. The physical pain and emotional intensity of this delivery not followed by pure joy and sheer bewilderment at the miracle of a new living, breathing, crying being that most deliveries have.

I've watched dozens of partners, mothers, and friends watch their loved one go through the exquisitely miserable pain of labour. Some are so uncomfortable they have to leave often, to get ice chips, a blanket, anything, to feel like they are doing something. I remember one husband unable to coach or encourage, but could only hold his wife's head close to his, looking straight into her eyes, never moving for over an hour, being fully present in her reality with unspoken intensity. Its near impossible to watch someone go through such agonizing suffering and not be able to alleviate it or share their burden. Being a religious person, pain and suffering are central to my understanding of our place in the world and really, a huge part of what life is all about. Sharing in the messiness and aching of humanity, crying out in unison at all the injustice that life may bring.

This past week, a dear dear friend of mine had to have labour induced after her baby was found to no longer have a heartbeat. It wasn't unexpected, and we had discussed all sort of options and decisions they may have had to make in the future. But the all-consuming brokenness and grief that comes with the loss of a child, with all the hopes for their future is devastating. It gave my experiences at work a whole new meaning. Dimensions that I never imagined were clear to me, as I saw my friend's story in each of my patients. Her fears and her dreams, and now her brokenness. There are no neat answers to explain the pain. No glib words of comfort or encouragement. This all-consuming pain must be experienced completely and without filters.

Pain is a personal thing. You can witness it, you may even share in it and feel like you're drowning in it, but it must always be owned. You can't take it away from someone else to free them from it. Somehow, unexplainably, I find hope in the midst of these messy emotions. A hope found in the knowledge that this pain is at the center of what it means to be truly human.

Lost in Dictation

2007-08-03T17:12:00.000-07:00

I didn't have to do much dictating in medical school, but now that I'm a lowly resident there isn't a day that goes by without having to participate in this dreadful ritual. How it works? You call a number, and talk to the phone about a patient. You have to do it for all consults, deliveries, and yes, the dreaded discharge summaries which get sent to the family docs so they have a clue about what's happening to their patients. It was only in my third week that I discovered the pause and rewind buttons, those poor, poor, people who have to transcribe these things! "Ummm . . . uhh . . . note to transcriber, delete that last sentence . . . uh . . . I . . . uh meant to say . . . " Then last week, I had my first official doze-off during a discharge summary which I was trying to do before going home post-call . . . I'm such a dimwit!

As my friends and family can attest, I have a mumbling problem. In regular conversation, this isn't an issue, people just look at me funny and I pause and repeat. One friend, in the middle of an animated story I was telling her, tilted her head to the side, squinted her eyes and said, "funny, sound is coming out, but your lips just aren't moving." Unfortunately, as I found out when I actually read one of the consults I dictated, it may become a more of an issue. One of my patients ended up having a 67cm abscess in her pelvis. Now, even if you're not an expert in abscesses or the pelvis, wouldn't you maybe question something the size of an exercise ball being drained through someone's vagina?!? It was actually 6-7cm of course, but reading it on the computer I laughed out loud, imagining this slim woman waddling around. I was at the nursing station and everyone promptly assumed I was on Facebook. Hehehe, nope, doesn't take much to amuse me.

It made me think of one of my classmate's attempts at getting some tips on how to dictate and googled "medical transcription tips". The results were hilarious, although I can only remember a few of them:

1) When dictating, please place the receiver as far into your armpit as possible and whisper softly.
2) If you need to cough or sneeze at any time, please remove from armpit, and do so directly into the phone receiver.
3) Please make sure to spell out uncommon names like "Brown" or "Smith" but don't waste time spelling simple names like Ghchoayeyzfhgfr.

Then some of the mistakes that have been made:

1) Because the couple is having trouble conceiving, I have referred them to a futility expert.
2) On rectal exam, the thyroid was found to be enlarged.
3) During her first visit to the emergency department, she was examined, x-rated, and discharged home.

So my new goal is to speak clearly, mostly to avoid medico-legal problems in the future, and ultimately, I sure hope those nice people at transcription have a whole lot of patience and a sense of humour (I always thank them copiously after each dictation).

3 kisses and a love note

2007-08-01T19:17:00.000-07:00

Today was an exceptionally good day.

It started out with a patient leaving us a large box of chocolate truffles. Absolutely heavenly, or devilish, I can't quite decide, either way, they were so good it was practically scandalous. Creamy richness melting on my tongue.

Then my lovely little Thai patient gave me a big sloppy kiss on the neck when she was hugging me on the way out the door (after she had a picture taken with baby and me). She may have been going for my cheek, but she just wasn't tall enough, her chin was about up to my elbow.

Later in the day my other favourite patient, a young girl here doing a masters from Ecuador, wrote me a sweet note on a postcard from Quito. Her story had inspired me and the nurses had found me more than once just sitting chatting with her and her mom in their room. I'm keeping the note to read on the bad days:

Agosto 1, 2007
Dra Shohona,
Espero que siempre conserves tu sonrisa y buen caracter, y que alegres a tus pacientes. Exitos y bendiciones. Gracias por todo.
Rita, Karla, y Nicole

That was two more kisses which put my tally up to three, although I'm not sure if Ecuadorian 'besitos' really count. Its more like shaking hands, everyone kisses everyone in Ecuador! Oh well, I'll count them anyway.

I realize that I'm deeply blessed and privileged to share just a little of the beauty of life with each of these people, each with their own stories of love and pain.

Today there was also a memorial held for the woman who died last week. Unfortunately I couldn't make it, but the still fresh memories of death and sorrow made a striking juxtaposition on the joy and gratefulness I was filled with today. Life is such a contradiction, so hard yet happy, so miserable yet lovely. But today, today was a good day.