My First Blog Post

Here I am.

I’ve been wanting to do this for quite some time.

For those of you who have known me for many years, you may remember when I used to send out email journal entries.  I like to think I was blogging before blogging was a thing, but I didn’t have a platform except for email.

Now, thanks to a few eloquent colleagues and an IT savvy husband, I’ve moved onto the WordPress platform and will begin blogging in earnest (I hope!).

Being an Emergency Physician, mother of two, wife and human can get quite busy.  It’s hard to find time to sit down and write, let the creative juices flow, put words to paper (or screen as the case is these days).

I’ve come to the realization over the last few years as an attending staff, that I need a place to open up and decompress.  I’m tired of coming home and keeping it all bottled up inside.  It’s too much to bear, as so many physicians could attest.  What we do daily is hard stuff – never mind the joys and perils of motherhood on top of that.  Being a doctor can be a lonely profession, when it comes to discussing the emotions that run rampant every day.  I’m lucky in that over the last year or two I’ve become part of a supportive online community of people like me, and have found a space there to at times discuss my day.

But now, I am ready for the next step.  Ready to let the world in.  I have a lot to say, lots of stories to tell.  My patients’ worlds affect me, as much as I affect their lives when they present to my Emergency Department.  I carry them inside my heart, and there is much value in the things they teach me.  I would like to share it with you.

Come along, and I hope the ride will be interesting.

Balance

Saved two lives today. At least, and maybe more.

Then, I walked out of the Emerg and back into my life, where I am no longer lifesaving hero doc but Mommy and wife. The hands that held the tube that opened the airway to bring a person back to life today, now hold tiny hands of sweet smelling children who snuggle me as they fall asleep. The brain that pulsated with knowledge and medical puzzle solving energy shifts into multitasking parent mode. The confident, firm, strong female physician softens, becomes just a bit less of that, on the homefront.

When I leave the ED, I walk to my locker and change out of my black scrubs and into soft clean clothes – a metamorphosis, I shed the skin I wear that gets me through my days. When I used to work on an ambulance in Israel, I was quite aware of the wall I built around myself to shelter from the storm of emotion all around. Here, in my daily work environment in Canada, I no longer have to have a firm brick wall to block out fear. Instead, I have this snakeskin that I shed as I shed my scrubs.

At work, I can be fierce. I can be what I need to be, to get things done for my patients. I can feel the armour of scales around me as I confront the sorrow, the anger, the vulnerability of patients before me; and I can peel those scales back a few at a time if I choose. Maybe I will sit on a patient’s bed like I did the other day, and take a few extra minutes to feel real feelings with them. Maybe I won’t – maybe I will be stoic and the tears will flow later. If at all.

When I leave the ED, I enter a world of joy and happiness where people are lovely, beautiful, fresh and innocent. I lie in the bed of my daughter and smell her clean skin, feel her perfect heartbeat, hear her deep calm and normal breathing. I hug my bouncing baby boy in my arms and hear him giggle with a clear voice, feel him pull my hair with strong hands. I admire my husband’s muscled arms and toned physique, feel his strength as he holds me. I move from a world of sickness, to a world of health. A place of so much darkness, to a place of joy and light.

 

How do I do it?

I wish I could tell you.

I wish I knew.

 

Sometimes, it’s hard to make that transition.

Stories of my patients get caught in my heart, and it’s hard to let them go.

Sometimes, my daughter wants to hear “work stories”, and in telling them I bring together my separate worlds. Is that a good thing? I don’t know. All I know, is that hearing her want to know about my other world, makes me feel something intangible. Pride? Love? Vulnerability? Fear? I want her to stay innocent, but I want her to know what Mommy does. It’s a fine line.

Motherhood. Physicianship. Balance. Sometimes it’s all I can do to stay whole.

Paradox

I work in a field where I am constantly faced with moral dilemmas. None is more difficult to reconcile than the one I encountered recently, and that I deal with on an almost daily basis.

Being a physician, I am trained to solve problems.

That is who I am, at my core – a really great puzzler, decoder, riddle solver. I pick up a chart in my Emergency Department, scan the initial triage notes and vital signs along with the chief complaint and past medical history of the patient. This gives me the first few pieces – the corners of the puzzle. I can set my game, plan my approach. Walking in the room, my first impression of the patient before me gives me more clues. I ask questions to further elucidate the nature of the person’s visit to the hospital, and choose different lines of questioning to take me to the heart of the matter. I’m like a detective, using information I gather to help me formulate the next set of queries.

Laying of hands comes next; I use my senses (sixth included) to, at this point, confirm or deny the conclusions I have started to develop. I look, listen, smell, feel and sense what the illness is. Then using the tools at my disposal – labs, imaging, electrocardiogram – I try to place the final puzzle pieces.

Finally, I can step back and hopefully see what the answer is.

Sometimes (and more and more often the more experienced I become), the answer is clear very quickly. Sometimes, it sits in the shadows of my mind, furtively hiding and moving, appearing and disappearing, not quite showing itself until the final pieces are placed.

The other day I had such a case.

I have struggled, since my time as an ambulance medic in Israel, to reconcile the two competing natures in me as a physician: one, the pursuer of answers – searching, excited, drawn in by the hunt, relishing the chase. The other, the human – apprehensive, empathetic, hurting inside for the patient before me because I know what is hurting them.

Working through a diagnosis gives me a rush, tickles my senses, it’s like an addiction – and it’s probably this that makes me a good emergency doc. I sniff out the sickness, and I tackle it head on. I don’t give up. I dig and dig until it opens itself to me like a treasure chest. And I am relieved, happy, excited to share the findings – but then, my humanity kicks in and I realize how horrible these very same treasures, answers, pieces I have found, really are. The gold nuggets of discovery are disease, sickness, trauma, pain.

Th other day, I had to tell my patient and her son that the relatively benign (to her) constellation of symptoms she described to me meant she had a tumour both in her chest and in her brain.

 

She will die.

 

And me, I am the one who dug for buried treasure.

I solved the puzzle.

I won the game.

I am the messenger.

I am the physician.

But I am also human, and being so, I am disgusted with myself.

Soul Searching

I am currently working on a presentation that I will be giving next week, called “Death in the ED”.

During my research for this talk, I was trying to find information, guidelines, on when Emergency Physicians can and should stop resuscitative measures on a patient.  The issue is very complex, and there does not seem to be a clear cut answer.  In my practice, I have relied on multiple clinical predictors and factors such as whether the patient’s heart is beating on my bedside ultrasound, or what the blood gas shows during CPR, or historical factors such as how long CPR was done for and whether the patient ever had a shockable rhythm (i.e. a rhythm that responds to electrical intervention).  My colleagues and I have made decisions to terminate CPR based on these findings, and I don’t regret doing so because in each case I very deeply considered all the information I had in my hands at that moment in time and made the decision based on the facts I had.

But today, I watched a Youtube video that will completely change my practice from here on in, and that made me question so many decisions I have made.  This video was by a colleague speaking at a conference a couple of years ago, in which he very convincingly detailed all the other things we should consider during a resuscitation, including new methods and tools we have at hand now that might make a difference.

At the end of his talk, he was in tears.  The audience was in tears.  I was in tears.

It’s hard sometimes, in the work that we do as emergency physicians, to separate ourselves from the algorithms and textbook learning we have memorized, and think outside the box.  It’s easy to follow what we’ve been taught, easy to say we tried everything we were supposed to try, and stop at that.  It’s easy to say, I don’t think this patient will survive.  But can we do that?  Should we do that?  At what point should we truly stop resuscitating our patients?

I don’t know.  I still don’t know.  But this 30 minute talk I watched today stirred something in me and will change my practice going forward.  This is why it is so important to keep learning as a doctor; never stop, never quit reading and watching videos, listening to podcasts.

We have never learned enough, we will never know it all.

And most of all, we will never ever be able to predict with certainty, who might live and who might die.  We can only try to steer things in one direction or another, using all tools and knowledge we have.

My long white coat

I wrote this piece ten years ago, but I can see the hospital room as if it were yesterday…

 

My patient is dying. I have a patient, and he is dying. There is a man I take care of every day, and soon he will be dead. No matter how I rephrase that, whether I use the terms “dying”, “passing away”, “end-of-life”, “palliative”, or “terminal”, it’s all the same thing. It might be easier if he had lived a full life, saw the faces of his children, or would go in a peaceful manner. Would it be easier? Would it be less harsh, less unfair, if he had months to say goodbye instead of days or weeks? Today, he almost had hours…

I have a patient, and he is dying. He came to us with pain, just some pain, a nagging, aching, annoying pain deep inside where you know pain can’t be good. We didn’t know what to make of it at first, when we saw his scans, but the disease inside him soon became clear. The reports, though only providing this thing with a name, told us all so much more as we read the literature on this rare monster – incurable, six months to a year at best, no real hope to provide to the family or the patient himself.

My patient is dying. Yesterday I took him on a trip downstairs for a procedure – I stayed with him and his family for over an hour, relaxing them, trying to keep him in a calm state and make sure his pain was controlled. We did well yesterday. There was hope at least for comfort, if nothing else. Then today – his wife catching me in the hall, saying “he’s in so much pain, he can’t take it anymore!” – finding him writhing in bed like I’ve never seen. Examining him, knowing that something really really wrong was going on inside, and knowing exactly what it was the second I touched him. Running to find my senior residents, not exaggerating as I stated the emergency before me. Then – I took them on another trip, the patient and his family, back downstairs to the same floor, the same wing. I took them for another procedure, and this time it was so different. So much pain, so much heartache, the tears in his wife’s eyes held back by her strength and solidity of being. He, so much wanting to let go for all the pain, me, hand on his arm, soft words to calm him, urging relaxation techniques that he had learnt previously. Using the healing arts in direct conjunction with the surgical procedure, all at once, feeling like the blood running into his arm from the transfusion paralleled the strength I tried to give him as we worked through that hour together. And when it was all done – he was so much better, he could breathe again, his pain was so much less.

But my patient is still dying.

No matter what comfort I can offer, no matter how much all the hospital teams try to keep him from experiencing the gnawing creature inside him, my patient is going to die soon. But each day he teaches me; his trust teaches me responsibility, his strength teaches me strength. His body teaches me to trust my intuition, my clinical skills, my judgment; his soul teaches me to stay longer when the day ends, go back to the room and check before I leave, respond when I’m asked to, no matter the time of day or night.

Because we’re doctors – and our patients die.

But before they do, an exchange happens: we give of ourselves, and we take for ourselves. My patient is dying, but he won’t go without leaving something of himself with me; our process together will change my practice forever.

Yet even saying that, trying to end with hope, keep my positive outlook, I know that when he goes it will be his wife’s eyes I see. Because more than all of what I just wrote, what this patient and his wife have taught me is the importance of love. The fleeting nature of life, that scary knowledge as a physician that it can all go in seconds – this, my patient is teaching me. Love, the glory of it and the utter vulnerability of it; a fear, a dread, knowing that love can mean loss, heartbreak, inability to be whole again – he shows me this. But it’s a beautiful thing to witness, in all of it’s fragility, evidencing such power.

Life, death, struggle, love, beauty, faith, trust, hope; this is the world I wander through in witness each day I don my long white resident’s coat and take the title “Doctor”.

Back to the Beginning

Let’s travel back in time, to my first few months of medical school.  Here’s a snapshot of the early days of a medical student’s training.

 

Sept.17, 2003 – 1:40 a.m.
Going to bed – but before I do, I figure I should write some “last words”.  No, I’m not about to die some grisly death (God forbid!), rather I feel like tomorrow morning (this morning!) is truly a new day.  At 9:30 a.m. I walk into my first Gross Anatomy lab of med school.  Today in our first anatomy lecture, our professors came in in their white lab coats and Dr. Miller put up an overhead that read(ish):

“Welcome to Anatomy – the real medical school”. 

Oh, the drama of it!  All the hype, the movies, ER, House of God – the stories of all the intrepid souls before! (Totally meant to be read with sarcasm)

Seriously though – I suppose meeting my first cadaver will be a life-changing moment.  Not that I haven’t seen death before – bodies torn apart, first on TV and then on Jaffa Street and Bus #20 in Jerusalem.  I saw a man in Haifa who’d landed 4 flights down from where he’d started.  Then came my patient lying dying in ambulance #60 under my hands – closing his eyes that just stayed open.

So meeting an embalmed corpse in 7.5 hours shouldn’t really be that bad.
But then why can’t I sleep?
Sept. 17, 2003, evening
I’ve decided to name my cadaver Salma – like Shalom, but as our individual is a woman a female name is necessary.  Shalom is peace, rest, completion – the woman our cadaver once held inside is gone, hopefully to a quiet and restful place – her soul is at peace.  And her body was left here for us – a shell, a whole home for a now departed existence.

Faced with dissecting a dead human being, we joked and laughed about stupidities.  A bunch of freaked out medical students, trying subconsciously to joke death away.  Perhaps if we giggle, death will pass us by because laughter belongs to the living.  In a room of 48 dead people and 200 live ones, we stood and tried to keep a handle on our own fears.

In the shower just now I thought about the food I had just eaten for dinner.  Then I flashed back to the fatty tissue I held between finger and scalpel today, and realized something.  That mushy yellow stuff represents a life – a life of eating.  Did our woman enjoy festive meals with family?  Picnics on the water with her lover and children?  Maybe she ate a chocolate-covered strawberry, or a cone of Ben and Jerry’s ice cream on a hot summer day.  And what did I do with all of her life, her nourishment, her stored energy and warmth?  I cut it off as fast as possible to expose the beautifully striated muscle beneath.

But is that so wrong in itself?  Perhaps in life no one knew her inner strength – yet today I discovered the fan-shaped and strikingly fine pectoralis minor.  A smaller muscle overshadowed by her larger counterpart, pectoralis major.  And working lower down towards the back, a buried treasure of serratus anterior.  8 lengths of fibrous, strong muscle waiting for discovery.

I know how fanciful this all sounds – but truthfully I had the most wonderful experience this morning.

I walked to class, nervous and a little nauseous, with 5 others from my class.  It was a beautiful sunny walk until we entered Strathcona (our building) – there the sunshine couldn’t follow.  Upstairs, everyone was getting out their equipment and donning their white lab coats.  I was somewhat disoriented, but excited.

Entering the Gross Anatomy lab for the first time, all I saw was a sea of white.  White coats – and then green shrouds covering almost 50 cadavers atop dissecting tables.  A huge room, a bucket and a sponge beneath each table, long sinks, closed circuit TV to follow the lab talks, and the smell of embalming fluid.

The sound of nerves permeated the room.  Honestly, if nerves could be heard, they were screaming this morning.  But we all hid it well, no one fainted that I know of.

I don’t feel that we gave our woman enough dignity or respect today.  I want to ask her permission or thank her, express my gratitude for the gift of her body to study.  I feel that Salma has given me an immeasurable present by allowing me to use her to learn medicine.  I want to learn all I can from her body – take from this year everything I will need for later on.  By giving me herself to discover, she has not only helped me realize my dreams, she has also saved every life I will one day save.  Her hands will give mine strength and my eyes will see anatomy with the clarity of hers.

Life has definitely shifted.  Something new is beginning.

When I walked across the grassy Reservoir today, the sun was brighter and the grass was softer.  Life was suddenly bigger – a door opened today.

Today I really, finally, feel like a medical student.  Today, finally, I am grateful.

A Reflection

Ten years ago today I ran to the trauma bay at the Hospital, after being paged “Trauma Team to the Trauma Room”. I was a third year medical student in my first month of clerkship, which happened to be Trauma Surgery. The junior resident and I were the first people in the room that morning, and I can still feel the vibrations of the multitude of ambulance stretchers rolling in the door. I can still hear the chaos forming around me, and I can still sense the bubble of calm I felt descend upon me as I realized this was no regular trauma – this was a Code Orange: a multicasualty disaster. This, was a college shooting.

Not long before, a gunman had opened fire in the cafeteria, where I sat and ate daily for a year, in the place where I went to school just ten years prior. Now, his victims were finally being brought to us at the hospital.

They rolled in one after another, into a space where usually we see at most 3 patients at a time, for a total of 13. Somehow, by transferring patients out of the the main ER and up to floors or out to other hospitals, we made room for all the kids (that’s what they were) and their various degrees of gunshot wounds. I remember diving right into the work – even preparing to intubate a young man who had a gunshot wound to the head (I believe it turned out to just have grazed his scalp). I remember the attending emergency and surgical staff advising me, directing me, and in fact letting me work quite independently. I remember the ER residents standing in the open doorway surveying the scene, deciding where/how to dive in and help – they had just come back from their academic half day and looked quite like lost puppies.

Most of all, I remember that through the noise, and the tumult around me, inside I felt calm, peaceful, directed. I knew what to do, knew how to do it, knew how to multitask in a safe way in this kind of situation.

How did I know this as a third year medical student? I teach third year students in the ED, who are in their first month of clinical work, and most of them know nothing. They don’t know anything at all. They know book learning, but put them in a resus room with sick patients and they are clueless.

I was a different breed – I had spent a year and a half plus some more summers as an ambulance medic in Israel during the second intifada. I had worn bulletproof vests to the scenes of bus bombings, putting my gloves on and my gear together in the back of a screaming ambulance. I had been in the midst of disasters of human making, and I had taken care of patients just like these kids – victims of despicable acts. So my brain, heart and hands knew what to do.

I suppose, however, that even though in the moment I find it easy to handle medical care in a disaster situation, the after effects are lifelong.

Today might be the ten year anniversary of the College shootings, but yesterday brought back other just as grim memories.

Out of nowhere, a man contacted me on Facebook and threw me back 13 years, to 2003.  I was finishing my shift on ambulance 64 in Jerusalem when it happened. In fact, I was in the bathroom with my pants around my ankles, when a siren went off in the station. Jumping up I ran outside to see all the medics and volunteers rushing to the ambulances, so I did the same. Off we drove at high speed, my driver one of the first ones on the scene of a horrifying bus bombing – of the bus I would have been on if I hadn’t stopped to use the toilet.

My driver grabbed the stretcher and told me to stay with the truck, charged me with protecting it with my life from others who might try to take it or load it with patients. He dove into the scene, and while I waited and watched the horror in front of me, another medic ran up with a man on a stretcher. Lifeless. I could do nothing as he pushed the stretcher into the ambulance, but as I bent down to care for the patient it was clear he had not survived. It’s the first time I learned the word “X” in Hebrew – meaning, triage code black, already dead, do not transfer.  My driver came running with another patient on his stretcher, and pulled the first patient’s stretcher back out to wait on the side.

I learned, in that moment, the true meaning behind multicasualty disaster triage.

Leave the dead, we cannot help them. Save the living. Quickly.

In the back of our ambulance with me lay a fellow ambulance volunteer – a young man, younger than I was, still in his ambulance uniform. Covered in tiny shards of glass and shrapnel. Crying in pain, afraid. I tried to wipe the mess off of him instinctively, and remember clearly looking down at the palm of my right hand to see a giant tear in my glove and blood on my hand. I spent the next many long (but really short) minutes of our lives examining him, but mostly holding his hand as we sped through the streets. Then I remember giving him to the doctors in the trauma room at the hospital, and going back outside to scrub down the blood and glass filled ambulance.

Yesterday, that patient found me on Facebook. 13 years older and an ocean apart, he looked me up. He’s now married with 2 children, and works as an ambulance driver himself. Looking at his pictures online, I felt myself melt into a mess of tears and joy. We saved a life that day, and here are the fruits of that – a marriage, 2 children, and a man who is saving others’ lives daily. So by saving him, we did in fact save entire worlds – his, his wife’s, his children’s, and that of every patient he helps over the course of his life.

 

Medicine is a crazy world, and what a blessing that it is part of mine.

I am grateful every day for all these experiences I continue to go through. Sometimes it’s easy to lose sight of what it is to be a physician, but then little things happen like a former patient finding you on social media, and it lights the way back to the reason I became a doctor in the first place.

I wanted to make a difference.

I wanted to help people.

I wanted to bring peace and solace in a time of darkness.

It turns out, in fact, that times of darkness in my own life have brought peace and meaning to my future.

Goodnight

At the end of a long evening shift, I climbed a few flights of stairs, to see dead people.

At my hospital, during the evening/night, the admitting physicians call the Emergency MD who is on, to go make declarations of death if needed (so the primary MD can stay at home).

That evening, two patients passed away on one of the wards.  At 1 a.m. I finally made it up to their rooms, and entered each quietly and with respect.

I have to admit, I am always a bit trepidatious when entering a room with a dead body. It’s a weird feeling, to be in a space with the shell of a person, knowing their soul has probably moved on. For each patient when we declare death, the physician must listen for breath and heart sounds, check for pupillary reflexes and get a general impression of the patient’s body.

One patient I examined was an elderly man, and I made sure to close his eyes after I finished. The other patient was a bit more difficult for me. It was a young man whom I had actually admitted to hospital three weeks ago, a gentleman with developmental delay due to cerebral palsy. When I entered his room, his body was covered completely with the white body bag and a blue sheet. It looked like a person hiding under a blanket, and you can imagine how creepy that is when you are alone in the room at 1 a.m. with a corpse. I examined him and exited the room as quickly as possible.

Declaring a patient dead is something we as physicians are taught how to do. I still remember some of my first experiences, as a medical student on the ward. I think I will always feel that discomfort, of being in a room with Death.

Death is an unknown, unknowable entity that our patients escape to when they have had enough of living and need to have their suffering relieved.

It is a place, or it is a being, or it is a state of being.

Whatever it is, Death is a physical presence in the room with me when I examine a patient who has passed. I feel Death looking over my shoulder as I listen to a soundless chest, open shut eyes; it is as if I am interfering with the process.

I tell Death, I am not here to cheat you. I am here to acknowledge you and give you custody of these souls. Then I cover them up, close their eyes, say goodbye and walk back out into Life.

This discussion with Death will always remain a part of a physician’s life, part of my own life, and I accept the role because in such a way I accord a final respect to my patients.

____________________________________________________________________________________________

11:20 a.m.

 

Sitting in a coffee shop

Rain, wet snow outside

Earlier this morning I sent you on your way

With a touch on your cold skin

Closing of your eyes

Covering your face.

 

I walked down the hall to you

Quiet steps

Knowing what was to come

A little scared

Ready to do my duty

Give you closure.

 

You lay there under a sheet

In a white plastic bag

Skin mottled

Mouth open

At peace

After so long.

 

I remember you

Coming in to my department

In pain

Unable to care for yourself

A prisoner to a body

A gift not fully given.

 

Born without oxygen

Your brain changed

No longer promising

Your life became so hard

But now you are quiet

You wander far away.

 

I look up at the clock

A crucifix above

Must have calmed you

I listen to an empty chest

Wish you a safe journey

Cover you again.

 

Down the hall

Another, I approach you

Older, so old

Ravaged by disease

Now you sleep

I close your open eyes.

 

I sit at the desk

Write the certificates

Attest to your deaths

Attest to your new journey

A final note in your chart

And I can’t help but imagine.

 

I write your name

I write your parents’ names

I write your wife’s name

I write your address

Where you lived your life

Where your story was told.

 

I finish your story

I sign the papers

Close the chart

Put away my pen

Take off my stethoscope

Wash my hands

Say goodnight.

Not a Superstar

Do you know those people?

The ones who consistently stand out. The ones who get accolades from all angles. The ones who can do no wrong. The ones who you can’t even fault, because they are superb human beings as well as professional superheroes.

Trust me, I know those people. It’s hard not to feel a twinge of jealousy, especially since becoming a physician demands more than a tad of that “type A”, competitive edge personality.

I, as opposed to those people, fly under the radar. I’m a great doc, don’t get me wrong.

But I’m no superstar.

I’m no research junkie, or trauma superman, or critical care genius who knows how to use ECMO. Those MDs, they are amazing. I learn from them. I follow their lead. I appreciate that they are a few levels above me in terms of medical or academic know-how.

But I also appreciate my own skills.

I am that doctor who gives a shit. I am that doctor who will sit by the bedside in a crazy full ED and take one extra minute to hear my patient’s demented ramblings about who they were 50 years ago, and hold their hand while I do so.

I am the doctor that my support staff love to work with, because I am laid back (on the outside) but get it all done without anger or attitude.

I am the doctor that knows the nurses names, is friendly with the unit agents, smiles at the orderlies (who bring me soups and lunches and anything they think I need, because they like me).

But I am not the doctor who gets my face in the media photos, not the doctor who gives one liners to the press. I am not the doctor that my Chief sees as being an asset to the advancement of the department. I am not the doctor who gets high powered job offers. I am not the doctor who leads fellowships.

My husband said it best tonight, when I was tearful on the couch and trying to understand my role in my profession. He said, just as I am not the girl you date, I am the girl you marry, so am I not the doc who grabs the spotlight – rather I am the doc who is dependable and takes care of my patients well.

I am the doc you want when you come to the ED.

I have to learn to accept it.

I am not a superstar.

And maybe it’s better that way.

 

A look back

Over the years I have written many journal entries about patients I have seen, or situations I have encountered in my travels through first ambulance work, then medical school, residency and now life as an attending staff.  Periodically I will post one on this blog.  Here is the first, from a few years back when working at a pediatric center.

Trigger warning: severe illness in a child, a teenager with violent thoughts.

 

“A hard day”

It’s late, and finally the house is quiet. My sweet girl is asleep for the last hour and a half, my hubby too. I finished watching the no-brain-involved reality TV silliness of The Bachelor, and now it’s time to dive into the day.

It was a hard day. Perhaps the hardest I’ve had yet as staff. Maybe I write that every time I sit down to the keyboard, but I can’t recall. It feels like the hardest day.  Today I saw a few semi-sick kids, many not-sick kids, but two cases really stood out.

I walked into a room to find a beautiful little girl, 6 years old, lying on the examining table. Immediately I knew something was up, because 6 year olds don’t lie still for very long, especially not on hospital beds. She sat up only when I asked her to, so I could examine her left ear that was draining pus and blood for the last week. Her mother mentioned in passing that her daughter had been looking a bit pale. On exam, besides the ear I noted multiple lymph nodes on both sides of her neck – not unusual in a child with a rip roaring otitis (ear infection). However, given the pallor and the obvious fatigue, I ordered a CBC (complete blood count) to ensure that there wasn’t more going on. My mind was steering towards a complication of otitis, such as a mastoiditis or intracranial infection (although both seemed unlikely). I managed to arrange for the ENT specialists to have a look at her and send her back down to the emerg for the CBC.

A few hours later I got the blood test back, and I had to sit down in horror because my legs felt weak. On the paper in front of me was a life sentence for the beautiful black haired angel with the sweet innocent smile: leukemia. Not a definite diagnosis without a bone marrow biopsy, but this blood test was highly suspicious for malignancy. This left me no choice but to call the hematologist to assess her, and before he could come down I wanted to tell the mother why he would be visiting the bedside. I called the mom and girl into a quiet room in our observation area, and sat down with them to explain.

In medicine, we are always taught to be direct.

Don’t beat around the bush.

Tell it like it is.

So I did.

I told the mother that the reason her daughter was so pale and so exhausted, and probably why her infection was not improving on antibiotics, was because it was very possible that she has leukemia. Immediately, it was as if I had taken a knife and stabbed it through her heart. The mother burst into tears, a look of shock and betrayal on her face. She reached out to her daughter, lying on the bed next to her, with a gesture that as a mother I understood to mean – how could this happen to my healthy, lovely child? I understood her fears without having to ask; when she asked me if her daughter was going to die I knew her terror. I tried to reassure by informing her of how eminently treatable most leukemias are in young children, and by telling her that the diagnosis was still unconfirmed.

But the minute a physician raises the spectre of cancer, all rational thought goes out the window and the emotional train wreck begins.

Thinking back on things, I do wish that I had thought to ask her to have her husband come before we had the discussion, but then again if I had said that she would have already known that something serious was wrong. And I also wonder, should I have spoken to mom separately from her daughter, who had to witness this breakdown in her mother? I examined the girl’s abdomen for an enlarged liver and spleen as her mother was wiping her tears, and I took the time to explain to the child that her mother was crying because she was worried about her being sick in the hospital. I told her that we were probably going to have to give her medicine to help make her better, and the innocent asked “what is medicine?”. My heart broke as I explained that medicine is a special thing doctors use to fix kids who are sick.

How do you explain illness, severe illness, to a child? How do you explain to her that she will have years ahead of her of IVs, toxins running through her system that will actually heal her? How do you tell a little girl with long, curly braids that she will lose all that glorious hair?

As an Emergency Physician, I don’t generally have to go into all this detail. Thank God for hematologists and oncologists, who help relieve that burden. Thank God. But even trying to just explain what “medicine” is, to a six year old whose mother is crying her heart out in anguish, that is maybe the hardest thing I have ever done in my life. Ever.

When I got home I hugged my daughter so much. I told her how glad I am that she is mine, and that she is healthy. When I got frustrated because she wouldn’t go to bed, I kicked myself for yelling. All I could think of was how that mother must feel tonight. Is she sitting by her baby’s bed, touching her hair, crying into the pillow? As a mom, I can only imagine that she is.

 

The second case that threw me today was a boy I saw immediately after breaking the cancer diagnosis. He was sent in by his school for aggression issues. At 14 he was entitled to talk to me alone, without a parent present, so when he asked his dad to wait outside the room I felt it was appropriate. However, as with any patient at the Emerg for psychiatric issues, I made sure I had the exit close by.

I asked him, “why are you here today?” and boy was I unprepared for the answer. He proceeded to tell me how the school had sent him to the ED for violent thoughts. Over the last two weeks, this boy had been ruminating on killing every person in his school, teachers and students both. He told me how he wanted to take guns and shoot them all, and he even made the hand motions at me “pow pow, pow pow”. When I asked him why, he said that he didn’t know. There were no specific triggers. He said that he doesn’t like people, that he feels he has to pretend to be friends with others, when really he doesn’t feel anything at all towards them. I asked him if he had access to firearms at home, and he said no. But he said he has knives, and then said that he wouldn’t use those. I knew I had to do some sort of physical exam on this young man, but my guard was up as I listened to his heart and lungs. As I was close to him and starting my neurological exam, he began to look at me in a creepy way that really rattled my cage. I got the heebie-jeebies, which I very very rarely get in the ED. But when I do get that feeling, I know it’s time to leave the room, and fast. So I did.

Psychiatry and social work assessed him, and felt similarly to me but with the added thought that he was possibly experiencing the prodrome of a psychiatric illness such as psychosis or schizophrenia. However I was shocked when they decided that he was dischargeable, with a close follow-up. They had discussed this with the young man and his father, and while the father seemed to be minimizing the situation, the patient said that he would feel safer if he stayed in hospital because he didn’t know what he might do otherwise.

I called psychiatry back and said that I was very uncomfortable with the idea of discharging this patient, and that I thought we should hold him overnight for observation on the psychiatric ward. I pushed, and managed to convince the psychiatrist. Later when she came down to write the orders, she thanked me because she agreed it was the right call to keep him. I told her, we hospitalize people for way less than threatening to commit mass murder and shoot up their entire school. Thankfully, the patient was admitted to the psychiatric ward.

I can only hope that by this intervention perhaps I have helped prevent the next school shooting. If not, at least I know I did the best I could and acted in the most responsible manner. This kid scared me; I have the impression he is likely sociopathic and I am not entirely sure what can be done to remedy this. I can’t help it, I felt like I was in the presence of a monster-to-be. The way he eyed me when I came close to examine him, it felt so deeply, viscerally scary. So scary. Looking into his eyes felt like looking into the eyes of a lion who is stalking you. Predatorial.

 

So that was my day. Along with those were a suicidal 11 year old and a 10 year old with a pathologic fracture through what could very well be a sarcoma of his upper arm.

Not a fun day. Such a hard day.

And yet – this is why I do what I do.

I diagnosed leukemia in a girl who presented for an ear infection, and hopefully by picking it up early she may do better in the long run.

I possibly stopped a teenager from killing people.

At least I can sleep tonight knowing that the pain I feel inside is okay, because good came of it.

But it doesn’t make it hurt any less.

Goodnight. Kiss your kids.

Night Shift

A few nights ago I worked one of my many night shifts.  As a mom with two young kids, I find it is a lot easier on family life and on the kids, if I work while they are asleep.  This means I do my regular day, take a nap at some point if possible and then again once the kids are asleep.  I head out to work for 11 pm as one of two docs responsible for our giant ED until 8 am.  It used to be one doc on at night, but seeing 30 new patients while reassessing at times up to 60 others, was clearly unsafe for all involved.  After we filled our roster with a few new MDs, this allowed us to put a second doc on at night.

Working the night shift, there is a motto that many of us learn in medical school: “keep them alive until 8:05”.  This phrase always rang true for everything from the pediatrics ward, to the internal medicine ward, the ICU, and the Emergency Department.  Having less people to take care of patients in the wee hours can often feel scary, but now that I work so many nights I am very comfortable with all of it.

In fact, I rather enjoy it.  I love the peace and quiet of the place.  Walking the halls of a hospital at night has brought me solace since my clerkship years in medical school; there is something about the silence, the emptiness, that soothes a doctor’s soul.

In the ED itself, there are way less bodies, because the consulting services round during the daytime hours with gaggles of students and residents.  These groups are like ducklings, following their leader around the hospital, bringing chaos and noise wherever they roam.

So at night, when they are not present, neither is the chaos.

The last night shift I worked, was quite calm.  I don’t use the word “quiet” in the ED, because this inevitably jinxes everything and suddenly the resus room is full and everyone is trying to die.  (Given that I am writing this while sitting on a chair in the mall watching my kids play, rather than in the ED, means that I can actually use that word for once).  There was a steady influx of new patients most of the night, but the cases were straightforward and no one was really sick.  The patients that were handed over to me from the evening were relatively stable, so I didn’t have to worry too much about them either.  I actually found myself bored!  A big change from the week before, when my resus room was full and I intubated three patients, did CPR on two, and saved two of the three.

While a quiet shift may seem like a blessing to some of you, others will recognize my need to constantly be busy on shift.  When I go to work, I like to work hard.  Otherwise why be there at all?  I could stay home and watch TV if I wanted to relax.  If I’m at work, give me a full rack of charts, a packed waiting room, lots of sick people to help, and then I’ll be happy.  It’s not that I crave illness in others – it’s that if they are going to be sick, I’d rather they be sick during my shift and not during the next.

As an ED physician, I have also realized something I never knew about myself:  I likely have some form of attention deficit hyperactivity syndrome (ADHD).  I think perhaps all ED MDs must have a component of this, to be able to handle the constant interruptions, diversity of patient presentations, responsibility for dozens of patients all at once.  My brain is constantly going, on fire, all shift long,  Multitasking more than you might think possible, is the way to get through the day/evening/night.  Pay too much attention on one thing, focus too hard on it, and you develop tunnel vision.  The rest of the ED risks being blocked out.  This can happen, especially in a long resuscitation – and it’s vital that I keep reminding myself to shift back and forth in my thoughts between the resus going on in front of me and the rest of my patients in the department who may also need me at the same time.

Speaking of needing me – when the shift was over, the patients all still alive and some of them better off than they had been previously, as I was getting changed in the locker room, I got a call from my son’s daycare.  Turns out, my sickest patient of the day wasn’t in the ED – he was in my car.  After I picked up my febrile 2 year old and was driving him to the pediatrician’s office, he proceeded to vomit silently in the back seat.  I looked back at one point and his face was purple; he was choking on vomit and could not breathe.  His eyes were huge and he had his hands in the air.  I pulled over hastily, jumped out, ran to his side of the car and stuck my fingers in his mouth to pull out the chunks.  Thankfully his airway cleared and though he continued to vomit, he could breathe again.  I wrapped him in a blanket and got him to the doctor, having had the only adrenaline rush of the night.

My shift was over, but the next shift, that of motherhood, had begun.

Only bedtime would finally let me rest.