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.

When the heart wants to stop

Recently I had a case that stirred emotion: joy, frustration, concern, pride.

It’s not every day that my heart feels such a range of flutters while at work; generally, while I love what I do, I don’t always want to jump up and down on the couch screaming “Woohoo!”.  With this case, I had a woohoo moment.

 

A reasonably healthy older patient presented to our emergency department after fainting.  Actually, he didn’t just faint.  Most people faint after feeling unwell, or having the classic sensation of light headedness, a black haze clouding their vision, ringing in the ears, maybe nausea…what we call a prodrome.  Rarely, a person will lose consciousness suddenly, without warning, and go down hard.  When a physician hears that kind of story, we call it syncope with no prodrome – and it always raises the red flag.  With these cases, we must always consider a cardiac cause, i.e. an abnormal rhythm, that makes the individual pass out without warning, like a shark in the water pulling them down.

 

This patient had a syncope with no prodrome.  When he was initially assessed by my resident, he felt reasonably well with no headache, neck pain, chest pain, palpitations or other symptoms.  He did admit to feeling generally weak for the last few days or so.  The exam was completely normal, and the first electrocardiogram (cardiac rhythm evaluation) was normal.  Completely normal.

 

We sent the patient for imaging studies to make sure he had nothing serious as a sequelae of his fall.  Trauma is a pretty straightforward field to an experienced emergency physician: it involves evaluation and stabilization of a patient’s airway, breathing and circulation, monitoring of vital signs, and head to toe evaluation for injuries.  Diagnosis is clear as well: CT, xray and bedside ultrasound, along with routine labs.  There are protocols and algorithms that guide us.  For example, this patient needed a cervical collar because as an older person he fell outside the range of our evidence based decision rules (which allow us to say that a patient does not need xrays of their neck to rule out fracture).  We asked for a CT scan of his head and neck.  When I saw the images of a brain full of blood and a fractured skull, I knew this patient needed urgent transfer to a trauma center, and urgent platelet transfusions to combat the anti-platelet medication he was on.

 

I called the trauma team leader urgently and discussed the case, but stressed the point that aside from the traumatic injuries, this patient still needed a workup for the cause of syncope.  I told the surgeon that I was concerned that the etiology was cardiac in nature, and that the patient would be at risk of further deterioration if it was not addressed.  His answer?  “I am more worried about the blood in his brain”.  Needless to say, I documented that interaction very clearly.

 

Shortly thereafter, the ambulance crew arrived to take our patient to the trauma center.  Suddenly, as I stood a few steps away from the room, and just prior to loading him on the ambulance stretcher, a code blue was called for our patient.  My resident and I ran to the room, and found the patient not breathing and staring into space.  He rapidly recovered but we rushed him to the resuscitation room with the immediate decision to intubate him for airway protection during transport.  While in the resus room and preparing for the procedure, I glanced up at the rhythm on the monitor and my heart skipped beats just as the patient’s heart was skipping beats.  Many beats.  Dropped beats.  Non conducted beats.  Meaning, this was, finally, a cardiac syncope.  The patient fainted not once, but twice – and the second time just happened to be here, in my ED, with his chest hooked up to a monitor that captured the rhythm as it happened.  And there it was: the heart was beating in a totally dissociated rhythm, meaning that the 4 chambers of the heart were not coordinating, not sending appropriate signals to each other.  A rhythm like this means that blood isn’t adequately pumped to vital organs, including the brain, so a person will faint.

 

Or the heart will stop.

 

His heart essentially did stop.  For a few seconds.  At least the major chambers of the heart stopped.  The atria, the smaller chambers at the top of the heart, were sending signals that the ventricles lower down were not receiving.  So the ventricles were not beating, for a good 15 to 30 seconds.  Lucky for him and for us, he came back without intervention and we were able to get on top of it by applying pacer pads to his chest in case it happened again.

 

I called the surgeon back.  Hello, his heart is the problem; the bleeding brain is the consequence.  GET CARDIO INVOLVED ASAP.  He agreed.

 

I shipped the patient off with a nurse, a respiratory therapist and my resident with a pocket full of lifesaving medication and a monitor that could start pacing the patient if needed – keep the patient’s heart beating in an organized fashion.

 

When my resident got back from the transfer, and I heard that he made it there without incident, only then could my own heart go back to beating smoothly.  Not that my heart rate ever increased – it doesn’t, when I deal with stressful cases at work.  But the feeling of my heart in my throat fluttering like a bird caught in a nest finally resolved.  My heart was free, and rivers of pride and relief flooded me like a hurricane.

 

This case was so great not only because we saved a life – because we did – but also because it tied together everything I learned in medical school, residency and attending staff life.  It reminded me, again, of the sheer scope of knowledge I have been blessed to possess after so many years of striving to learn it.  I feel so in awe of the physicians who came before me, who learned all of this through trial and error and hard hard work. They created protocols, wrote textbooks, trained learners and now I hold all that history, and power, of medicine, in myself.  And I am passing it on to residents, students, and the entire team I work with, every day.  This is the joy of what we do – constant learning, constant growth, sometimes fulfillment.

 

And saving lives, even when the heart wants to stop.

Devotion

Today I am starting a new endeavour.  I signed up for monthly creative writing care packages from a group in Toronto called Firefly Creative Writing.  These envelopes are meant to inspire and open the doors to writing, in people like myself who don’t often find the time to sit down and devote ourselves to the task.

The stimulus word this month is Devotion, and we are urged to stir the creative juices around this theme all through this month.  Here is my first go:

 


 

To whom, to what, am I devoted?  The answer seems clear as day: my children, my husband, my parents, my sisters, my patients and medicine.  Am I devoted to myself?  This is one concept that is difficult as a full time working physician and mother.  I spent so many years working towards various goals: finish my studies, become a doctor, get married, have kids, make enough money to support a family.  When does devotion get returned to me?

I see love and caring in the eyes of my children, and yes, they are devoted to me – but they are also separate beings growing and changing and becoming spectacular souls.  My husband is devoted to me, but must spread that devotion to our children and to his own world of triathlon training and maintenance of our home.  My parents devote a portion of themselves to me, but also to my sisters, to each other, to their own patients and medical practice.

I suppose, then, devotion is by necessity something that is divided.  The dictionary definition, “love, loyalty or enthusiasm for a person, activity or cause” certainly sums it up correctly: one can be devoted to numerous things all at once.

It is time, then, to become devoted to myself.  Time for self-reflection, self-care, and improving my own core being.  I spend so much time trying to help others, that I get lost in the process.

As a physician mother, my life looks something like this: wake at 6 a.m. after a night broken up by kids having nightmares, needing to pee, or just needing a snuggle.  Do morning routine, get kids to school with help of husband, by 7:45 a.m.  Head to work for 8:00 am and work non-stop, usually mostly on my feet, with no breaks for snack, lunch or clearing my head, until about 6 pm.  Leave work and get home around 6:30 or 7 pm, join family in time for bath, stories and bedtime.  Snuggle kids and love them till they pass out around 9 pm.  Spend time with husband if he’s not already asleep, then sit down for late dinner (sometimes with, sometimes without husband) and watch tv or read news on my phone until I pass out somewhere around midnight.  Get woken usually once or twice a night by my warm cozy kids needing me, and start over again at 6 a.m.  Alternatively, if I work nights, I get up at 6 a.m., do morning routine, take kids to school, do all sorts of stuff all day long (academic commitments, housework, paperwork) and try to nap a couple of hours, pick up kids from school at 4, hang out with family, dinner, bath, bedtime and leave for work at 10:30 pm.

In all of this there is no time or space for me.  Today, as I write this, I have a total of 5 hours of sleep under my belt after a late shift last night, and I go to work at 10:30 pm tonight so won’t sleep again until around noon tomorrow.  I carved out a couple of hours this afternoon to take care of family finances, and to devote time to writing.  At the expense of sleep.

No one teaches us in school that life is hard.

It’s hard for everyone; there are very few for whom life is easy.  We are all on different paths that take us to places and situations we never dreamed, be those positive or negative.  Those paths are not usually straightforward, and the work it takes to arrive at our goals is not simple or light.

But in all this, in the maze we create for ourselves, there needs to be some devotion to our own souls.

Today, I asked my chief and ED scheduler to consider allowing me to work as a nocturnist; i.e., only night shifts.  Am I crazy?  Perhaps.  But working two or three nights a week will allow me to keep consistency in my schedule, stick to a sleep routine, and be there for my family in a much more present way.  Of course it will mean that I am absent from my marital bed for half my life (shocking to think of it that way) but that is what happens right now anyways – along with days, evenings and weekend shifts thrown into the mix.  I think it’s the best thing for me and for my family, and I don’t plan on doing it forever.  I see working nights for a few years, then re-evaluating.

 

I finally feel like I’m taking a step towards improving myself, and to me, this is the meaning of devotion.

Growing Up

Today I did the normal attending staff physician thing of going to grand rounds.  Grand rounds are mornings of learning, with a few hours of interesting talks by residents, staff and visiting lecturers.  This morning, an old friend was our guest lecturer.

 

Fourteen years ago we began medical school together in the hallowed halls of an old building on the side of a mountain, and every day we climbed hills both physical and figurative as medicine poured itself into our minds and hearts.  For 18 months of clerkship, when medical students first interact with patients, we grew into being doctors.  On so many occasions, he saved me – and perhaps I saved him too.  I remember those days as if they happened yesterday; they were days full of excitement, emotion, and exhaustion.  Probably some of the most illuminating days of my life, I grew from a little wee baby medical student into a competent trainee physician.  But it was not an easy road, and it really helped to have a friend to lean on.  This friend stayed my constant, as somehow we ended up in almost every rotation together.  When medical school was finished, we went our separate ways into residency and our futures.

 

As he said today, “look at us now”.  Both of us ended up as Emergency Physicians, he in the US and me here in Canada.  All grown up, we have both been attending staff for years now.  We teach and train our own crop of medical students.  Listening to him give a dynamic and passionate talk, his words resonated with me.  The years melted away and I remembered why our friendship took root in the first place: our hearts are in the same place with regards to patients.  We both value our patients’ stories, the person behind the sickness.  We respond to our patients with patience, compassion, and an open mind.

 

Listening to my old friend helped me remember, today, the emotion and joy of what we do each shift, each patient encounter.  Seeing him, hearing his voice, brought me back to that day in Geriatrics, in 2006, when a little old lady refused to get in her bed because she thought there were cockroaches.  No one could convince her otherwise, as she was delirious.  But this young man, this third year medical student with not much experience but lots of compassion, hopped in her smelly sick bed and lay down to prove the absence of said cockroaches.  Wouldn’t you know it, she smiled and got back in bed as soon as he got back up.

 

So thank you, my friend, for being the confidante I needed when life kept throwing pain and fear and stress at us.  Thank you for giving the smiles and hugs I needed back then, when often life was so lonely even in hallways full of people.  And thank you, for bringing back memories and emotions that can hopefully knit their ways back into my daily practice, and help me find joy in the every day at work again.

 

Night shift love song 2

To my husband

 

When I leave you

You are alone

My car pulls out

The house is dark

 

Inside you sleep

But you are awake

You keep watch

You keep them safe

 

You are by yourself

The bed an empty space

No one to hold you

No one to keep you warm

 

I am awake

Wandering corridors at work

I care for others all night

But I am not with you

 

You are my strength

You guard our treasures

You are their rock

You are our foundation

 

But you sleep alone

I walk alone

Our paths cross so briefly

We live far apart

 

Yet our hearts are one

We work as one

Symbiotic organisms

Each half of the other

 

And our home is warm

A place of love

A house of peace

A source of joy

 

When I come home to your arms

My world is calm

You fill me up

Our hearts are one.

Night shift love song 1

To my children

At home

The lights are out

You sleep soundly

Your little hearts peaceful

Your bright beautiful brains calm

 

No doubt weaving dreams of adventure like quilts in the night

Soaring on air through wide spaces and light

Your breath like warm breeze quiet and sweet

Your hands open, your fingers reach, touch things I can’t see

Your hair tumbling on pillows softly caress

Your voices at times rustle like a flowing dress

 

Yet you sleep on, safe, warm, cuddled snug in your beds

 

Where I left you, when I left, closed the door to our home

Stepped into the night and out of your space

Now I walk through bright hallways, not free as you are

Awake, in the nightmares that my patients live out

 

I am here, taking care of strangers

I sit on their beds as I sat on yours

I hold their hands, as I held yours

I listen to their stories, as I heard yours

 

I am here

In the light, in the chaos

Wishing I were with you

In the dark, in the peace

Warm and snuggled in your beds

With healthy hearts beating close to mine

And happy souls holding mine.

A physician mother’s take on the news

When I went to bed last night and when I woke up this morning, I heard the reassuring sound of my children breathing in their dreams.

I went in their rooms, kissed their heads, smelled their scents, and walked away comforted.

I am blessed to be free and able to do these things.

I am lucky to live in a country where my life is not threatened, where my children are safe, where we are at peace.

I am fortunate to have never been uprooted, never had to leave all I know and love to find a safe place for my family.

 

Today, I am troubled, shocked, dismayed, and viscerally enraged when I think of families being separated at the border of another ostensibly safe and free country; the United States of America.  All I can see in my mind are the arms of mothers reaching for children who have been ripped, crying, from their bosoms.  All I can hear are the screams for parents taken to detention without having been given time to say goodbye or comfort their little ones.

 

While my children slept peacefully with mother and father only a few steps away, thousands of children just like them have been drowning in a sea of uncertainty and fear.

 

My heart breaks to imagine the tiny child lying in a strange room, in a strange cot, surrounded by strangers and a strange language.  I wonder how my three year old boy would cope, without the parents he so depends on and loves.  I can hardly do it, visualize that pain, without feeling my soul slashed within me.  To consider my eight year old daughter, alone, at risk, in danger, spins my mind in ways I would rather not go.

 

And what about the parents?

 

If I were suddenly faced with my children being dragged off, crying for me, with no way of knowing what happened to them or if I would ever see them again, I’m not sure how I would survive.  We are talking about the children, and their trauma, but let’s also consider that their parents (who are only trying to find better lives for their families) are going through a different but equal trauma.  Who will soothe their pain?

 

Today, I find myself a part of a movement of people of equal minds, equal wills, who are trying to make a change for good.

 

Let us hope, pray and wish that these families will be reunited and that the pain they have suffered will eventually be calmed.

 

And let us also hope, pray and wish that enough of humanity will continue to take a stand against evil, so that we are not thrown backwards in a wormhole of time to another place, another face, another monster long dead.  Let us not repeat history; let us forge anew a world where children are safe with their parents and no one fears that their safe haven will be instead hell on earth.

My mentor

Dear Dr. X.,

I am writing even though you will never see this letter.

I am writing because in the trauma room of the hospital you trained me at, you taught me to be an Emergency Physician.  You took me, you molded me, you showed me how to teach and how to be taught.

You helped me reach a strength inside of me that I knew was there but couldn’t always grasp.

You took my weak, and made it strong.

Watching you work so hard to save the lives of some of life’s worst people, showed me how to turn off the judgement, and turn on the medicine.

Working side by side with you on a 14 year old gang member, shot in the torso, you guiding my hands to compress his heart inside the open chest, that made me grow.  Finally giving up and letting go, you telling me to let go – that taught me that often, all we can do is let go.

So Dr. X., thank you for guiding me to strength.

Thank you for not being easy on me.

Thank you for all the support, a hand in the small of my back in the worst of traumas.

I still feel that hand every day.

The River

These days, my work feels like a place I go to for money.

Sometimes, all I want is to get home and rest, read a book.

But then, with a rush, the shift starts and soon enough a patient’s story will draw me in.

Suddenly work turns into a journey, a choose your own adventure tale where every choice I make as a physician spins me down a new river.

Without warning, one story ends and I am thrown off the falls into a brand new place, a new space, a new raft with a new patient.

Abruptly, work becomes whitewater, with everything rushing by; pieces of stories like driftwood hitting me if I’m not careful.

Then, as fast as it began, the book finishes and I give the now empty pages over to the next doctor, the next ship’s captain.

I clean my stethoscope, put my pens and my oars away, and strip off my dirty scrubs.

Naked, I pull on my new uniform and head home to the next raging river, where I’ll most certainly be carried away anew.

The Wheel

I remember the time when work was full of wonder.

Every day was amazing.

I woke up each morning with a spring in my step, so excited for what the day would bring.

Where did all the joy go?

Why is it hard to access the happy in my days?  It can’t be for lack of it; I know I smile and laugh at work.  Could it be because work is too hard?  Unlikely – I don’t find it hard at all.

The joy is lost, because these days work feels like someone else is running the show.  It’s all about seeing as many patients as I can, using as few system resources as I can, making sure to press all the buttons and do everything right.

This is not why I became an emergency physician.

I became a doctor in order to help people who are hurting.  These days I feel like often my patients are secondary – they are just cogs in a wheel.

How can I find that joy again?

Only from my patients.

Sometimes, on a night shift when the rest of the world is sleeping, I sit on the side of my patient’s bed and really listen to their story.  When I do this, I can feel that wheel inching to a stop.  It’s like a ship, straining at anchor, and I just have to strain back.  I sit, I listen, and I allow myself to feel some joy.  The joy of being a good person, a good doctor.

But then – the wheel turns again and the joy fades away.

When I loved Surgery

Before I became an Emergency Physician, there was a part of me that fell madly in love with Trauma Surgery.  I did many electives in that field, and even applied to Surgery (along with Emerg and Pediatrics) during my residency applications.  Sometimes, I still miss the art of it. 

October, 2005

Surgery is like art: fluid, the dexterous surgeon’s hands paint the knot they tie onto a canvass of the human form, supine beneath.  Musical, the anethetist’s machines tap the patient’s heartbeat like distant drumming on a beach in the afternoon; any change and the heart catches in me until the rhythm is back in step with my breath.

In the ICU I lean at the foot of the bed watching rapt as sunlight streams onto the blank page ahead of me; the patient’s abdomen open and ready for the surgeon’s thread to piece it back together like a long-scattered puzzle.  They gown up with ease, a dance of sterility as they cover every inch of skin and prepare to approach the man lying before us.  One on either side they prepare their instruments as I assist from my position at the patient’s feet.  Needles poised they begin to sew, and like an old dress being refitted the skin begins to take back it’s once anatomic position.  Soft concerto plays in the sunlit room with soft conversation over the quiet form of the man we are trying to heal.  My mind takes it in and my heart feels something like a butterfly stirring from it’s cocoon, pulsing, pushing to fly free.  In another day I find myself back by this man’s bedside, and it is I who holds the needle while my resident holds his, and together we stitch the remainder of my patient’s fragile skin.  A first glimmer of a new world, I have now sewn my first sutures that will hold a man’s body together.  Awestruck I feel the sun on me and hear my own words in conversation with concerto and sterile procedure and surgeon’s tools in my hands – I hold the needle, I thread the suture.

In the trauma room they wheel him in quiet; he says not a word as we inspect the stab wound to his side.  I take the history, I get his consent for surgery, he is my patient.  In the OR he goes under the knife with ease, anesthesia a gift, and when we are done he comes to agitated, fighting the tube.  Nurses try to hold him down, orderlies call for restraints, and I push through to the head of his bed.  Calmly I take his hand, use my other hand to grasp his chin and firmly turn his head towards me.  I tell him to look at me, look in my eyes, calm down, you were stabbed and now you’ve had surgery, you’re in the operating room, remember me?  Relaxing he lies back quiet and the nurses can’t believe it; but they must know all it takes is compassion!  Later I go to his room to check on him, and he asks me “where have you been?  I’ve been waiting for you!”.  Two days ago, healed, we parted ways and he went home to recuperate.

Another night, another young man stabbed.  In good shape with no need to operate, instead we must suture his long slash wound to the flank.  With instruction from my resident, I set up, prep, drape the patient and begin to sew.  Outside the trauma bay his friends gape through the windows, to them it’s like ER, it’s like Grey’s Anatomy, they watch me suture their friend.  But I don’t see them; I am lost in the art of the needle, the skin, the blood and the knots.  I am watching the future scar under my hands take shape, the close approximation of the tissue, the tiny holes my needle makes as it glides in and out smoothly.  My hands dance with eachother like swans intertwining their long necks; out of their waltz comes beauty and elegance, little square knots millimeters apart. 

Surgery is like art; unknowing I have become part of the canvass yet also one of the painters.  I am a fresh white page waiting to be written, as is the patient I tend, as are the stories yet untold.  There are now some doodles on my self-portrait, and so much more yet to be drawn.  Surgery is magic, surgery is beauty, surgery steals your soul in months of sleepless call that is so wonderful somehow that you almost forget you ever needed to rest.  And when you do rest – sleep is heaven and my bed is a cloud.  But surgery – it beckons again before sunrise and with no reluctance whatsoever I walk to the hospital with a skip in my step and a pale moon above.