Cold Feet

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

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

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

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

Three Codes

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

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

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

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

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

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

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

Language School

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

Blank stare.

No hablo ICU. Ai don es-spik ICU.

Espanol. Si.

Kiswahili. Ndiyo.

ICU. Uh... no.

Bad Day

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

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

This is the worst day ever.

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

Memo to me: GET OVER YOURSELF.

The Poverty Industry

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

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

Okay. No. No. Are the answers.

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

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

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

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

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

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

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

Overwhelmed by Hope

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

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

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

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

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

My Yellow Man

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

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

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

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

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

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

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

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


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