My Black Scrubs

The first line of the chart read, “ID: 42y F. Markedly obese”.

Not simply “42y F” as I would have written, but “markedly obese”.

As if her obesity was the most important part of her. Her defining feature. The reason she came to the Emergency Department.

Written by a young male colleague, this way of identifying the patient I was about to meet unsettled me. Mrs. D. had presented to the ED the night before, due to pain in the back of her left knee and lower leg. She was asked to return this morning to have a venous duplex exam, which is an ultrasound of the veins of the leg, to ensure she didn’t have a blood clot.

Walking into the room, I met Mrs. D. as she stepped off the digital scale. It read 412.7 lbs. She looked at me, and I could see the shame in her eyes. Before she could speak, I said,

“Why were you weighing yourself?”

“It’s been years since I did. No scale will hold me.”

“It doesn’t really matter, you know. Your weight doesn’t define you.”

Giving me a sad but sweet smile, Mrs. D. sat down on the lazyboy in the corner. I knew we could relate, because I myself weigh at least 100 lbs more than I should, and it shows. I smiled back at her, taking in the fatigue on her face but also the light and the beauty.

In that same moment, I glanced at her legs, showing from the knees down as she pulled up the flowy spring dress she wore. On quick inspection, I couldn’t tell if one was more swollen than the other. After asking permission, I leaned down and palpated each leg, pressing deep to see if I could elicit pitting edema (when the tissues stay pressed in, forming a divot, for a few seconds). The legs looked equal-sized and non-pitting (which argued against a blood clot), without any redness or heat to suggest infection. Her left knee, however, was quite tender in the medial (inner) aspect, and upon further discussion I came to the conclusion that her pain was most likely related to a knee sprain as opposed to any other pathology.

It wasn’t a stretch to see that the colleague who was so quick to brush off Mrs. D. as obese, likely hadn’t taken the time to adequately examine her very large legs. He probably felt revulsed by them, and would not have worked very hard at identifying landmarks or particular points of tenderness. I, on the other hand, having no fear or concern about her size, quickly ascertained a more appropriate differential diagnosis.

When Mrs. D. returned from her ultrasound with a report showing no clot, I was not surprised. Sitting her down again, I explained what I thought, which was that her pain was joint related. While true that her weight could be a contributing factor, I was careful to explain that I thought she had actually injured the knee with a particular movement. She told me that her work involves heavy lifting, and that she is always on her feet both at work and at home where she functions as a caregiver to her elderly parents. Her kids are teenagers already, so don’t need as much help as toddlers would, but she still finds herself running after them at times.

As we neared the end of our conversation, I could see the tears brimming to the surface, though Mrs. D. tried to seem stoic and nonchalant. It was easy for me to understand her fatigue, her sheer exhaustion, and in that moment I grasped why she was really in the ED. Yes, her leg was hurting. But more than that – she was hurting. Sitting down across from her, I asked if she was ok. Tears began to spill down her cheeks as she realized that yes, this doctor actually cared. This doctor was going to delve deeper than flesh, look beyond the obesity that my junior colleague had marked as her defining characteristic.

She chose to trust me, and with the tears spilled her story. She needed a break. Her body ached. Her emotions were fraught. She was stressed at work, stressed at home, pushed to her breaking point. She couldn’t take it anymore. But she didn’t feel right taking time off work, because the team needed her. They were short-staffed. She thought they would be upset with her. She didn’t want to leave them in the lurch.

I left the room momentarily and returned with an Off Work note. I told her that my prescription for her was two weeks off, to rest and recuperate. I explained that her knee needed a break, and so did she. Looking at me with relief, I could see that this was what she needed – someone else to say, “You need to stop”. She thanked me for actually listening to her, and left the room with a small smile.

Mrs. D. made me reflect on what it means to be an obese person in this world. Being obese myself, I feel shame at the size of my body, the rolls of my stomach, my flabby upper arms, my enormous thighs. I feel disgusted with what I’ve let my body become. But then, I look at a woman like Mrs. D., twice my size, and I recognize how truly beautiful a large body can be. My girth holds me up; it bolsters me. It can be a strength, rather than a weakness. A large body is just that – a large body. It doesn’t define who a person is, how they see themselves, what they can do in the world. As a physician, I try to remember this every day and with every patient. Every body is different, as is every soul.

Defining a person by their obesity, their anorexia, their body hair, their scars – this is not how I want to practice medicine. It is not how I want to live my life. I understand what it’s like to inhabit a body that others judge, and knowing how that makes me feel, I would do an utter disservice to my patients were I to judge them based on their looks.

Thank you, beautiful Mrs. D., for stepping on that scale with courage, letting me see your fortitude, and by doing so, reminding me of my own.

All it takes is an instant, one moment, one nick in the tissue and it’s over. One rip, one rend, the fabric opening so finely then suddenly tearing – spilling a life, emptying a vessel. The aorta, largest vessel in the body and most explosive, a ticking time bomb without sound. A silent assassin, pulsating innocently until one day, one millisecond in time, it destroys. Life-giver, bringing blood and oxygen to each cell, and life-taker.

And that’s it. A life, so many years of growth, love, things beyond measure, gone in a flash of blood and tears and emptiness. Leaving a void, unimaginable to the ones left in the wake of the red tide inside you. You are gone, without even the time to say goodbye.

The aorta – nightmare of the emergency physician, demon of my dreams.

This week covid finally got me.

Thank God and science for vaccines and Paxlovid.

It’s the end of Tuesday tonight, and on Saturday I worked a night shift from midnight until 10 a.m. Sunday morning. During the shift, I began to feel a bit faint. I had vertigo, that sensation of motion that is so disconcerting, but I attributed it to having been on the boat all day with my family prior to coming to work. By 10, when I was preparing to leave the hospital, I felt presyncopal. I had to sit down, because I truly felt like I might pass out. I chalked it up to exhaustion and went home.

I don’t really remember much from there on – getting home, maybe grabbing something to eat in the kitchen, falling into bed and asleep within minutes. Usually after a night shift I come home, make breakfast, maybe shower, watch an hour of TV to decompress, read the news and eventually fall asleep later than I had planned. Not this time. I woke up multiple times during the day, and though my AC was blasting I felt hot hot hot. I had a rip roaring headache (but I always get this after a shift, and my period is due), but suddenly I also had significant nasal congestion. After waking up a billion times I decided I couldn’t really sleep, and when I got out of bed at 5 pm to go to the washroom I realized I had chills. I took my temp and without much surprise saw 38C come up on the thermometer. Huddling back under my covers I texted “FUCK, I have fever” to my colleague at work, to my husband and to my mom. I took the rapid covid test kit and swabbed myself. Within seconds the telltale two lines appeared.

I felt the world close in on me. I could see my life flash before my eyes – really. I watched scenes – of proned patients, ventilators, staff in full PPE – parade through my mind as I ticked off my risk factors: severe asthma, obesity, on a biologic medication that could suppress my immune response. Add to that my two previous pulmonary embolisms and the fact that covid causes clots. Taking a deep breath I swallowed two Tylenol and texted my colleague in charge of this at work, who promptly got on the phone with my colleagues in ID. Within 2 hours my mother had picked up my prescription for Paxlovid and left it outside my door along with fresh fruit, and I downed the first three pills minutes later.

After getting a handle on myself I tested my 7 year old son (actually, he tested himself – what a brave kid) and he rapidly came up positive. Luckily, my husband and daughter tested negative. I pulled my son into our bedroom and shut the door.

My boy and I have been isolating in my bedroom since then, using the upstairs washroom, and his bedroom when he wants to play. We walk through the downstairs in N95s to get to the backyard, where we can eat and relax in fresh air. The healthy pair have taken up residence in the living room, sleeping in blankets and sleeping bags on our couch. They watch TV and movies in the evenings and bring us sickies our meals. Not so bad – things could be much worse than this. We are blessed to have a home on multiple floors with a big back deck and yard. Isolating from family in a small apartment must be extremely difficult.

Paxlovid is a game changer, along with the four doses of vaccine I received over the last year and a half. Whereas early in the pandemic I might have ended up ventilated in the ICU, or worse, dead, I can happily say that I think I will be just fine. Aside from the disgusting metallic taste in my mouth (a constant since starting the medication), I am feeling a heck of a lot better. On day 1 and 2 I felt like I had been hit by a truck and could barely move around. My body ached, my energy was at zero, my head hurt like hell and I had soaking night sweats. By the end of day 2 I was already feeling better. Today, I felt myself except for the lack of energy. I did however feel spry enough to plant in our garden, but for the rest of the day I sat in a comfy chair on the deck and read “Station Eleven”. Creepy book – written in 2014, it’s an imagined existence after a pandemic wipes out global society. It’s a fantastic read, and though I had bought it just before covid, I couldn’t bring myself to read it until I finally caught the virus.

So here I am, on the other side of imagining my own demise, surviving and thriving enough to write this piece. It’s devastating however, to realize that all it took was one week – ONE WEEK – of enjoying normal life again, in order to finally catch the beast. I was off work on staycation, and we sent one child to day camp and the other to riding camp. We went to swim team practices, a packed swim meet, tennis lessons and horseback riding lessons. We went to indoor swim lessons, and didn’t wear masks on the pool deck. We participated in a back-to-life normal Canada Day celebration with inflatables, face painting, singing, cotton candy and pony rides. We lay on the grass in the field by the pool with a thousand other happy people, watching the fireworks in the sky above; we screamed with joy along with everyone else. We lifted our voices in peace and gratitude for surviving, for finding this moment in time when life once again felt like it used to.

And this is where it got us.

Thank God and science for vaccines and Paxlovid.

Otherwise, I don’t know where we would be.

But here we are, and we are fine. It was worth it. For our family to live a quasi-normal life, I would take multiple episodes of feeling like a train ran me over, as long as I come out of it feeling OK and healthy. I will take as many boosters as the healthcare system offers me, if it means we can live our lives and hug our friends with love and joy in our hearts.

Don’t get me wrong – we all still need to be cautious. Wear masks indoors. Stay home if you have any symptoms. But get vaccinated, boosted, and do it proudly. This will save you – this will save us all.

May 25, 2021
2:18 am

My dad’s slippers sit
On the wooden shoe shelf in the garage
Covered, squeezed in, under others
My mother’s slippers too

They remind me of loss
These soft slides used to sit in prime position in the front hall
Waiting for warm, old, familiar feet
To fill them and come in

The floors are lonely
Quiet, desolate, cool and forlorn
Missing the creak, the slap of your feet
Gathering dust in corners unswept

I want to see your feet fill these shoes
Walking on the scratched hardwood
Resting next to the couch as we sit side by side
Curled up cozy under you in my home

These slippers, they haunt me
Sing soft sounds of regret and yearning
Peering up at me with hope
Reminding me that soon, soon you will come

On a recent night shift, there must have been a full moon.  The ED was packed, to the hilt, and my colleague and I were frazzled by the sheer volume of sick patients.  Sitting at my desk to write notes, I was in full view of the two locked rooms we use for agitated psychiatric or intoxicated patients. Most nights, there is someone with fire in their eyes staring at me through the window; other nights, someone will stand there screaming obscenities.  On the wildest of nights, my heart will jump into my throat when suddenly a violent hand slams itself against the door, or a patient throws the entire bed at the wall.

The other night, even the police who brought my patient in were left stunned.

I could hear her screaming from long before she arrived in the room.  Her deep, loud, angry and psychotic voice boomed down the hallways, announcing a fearsome presence and a need for medication stat.  They brought her in shackles, hands and feet cuffed, a treatment reserved for the most dangerous of the bunch.  Two young male officers seemed way out of their skill set; they held her arms carefully and evidently trying not to hurt her but still not get hurt themselves.  I wondered if police academy prepared them for this? 

Flanked by our MIBs (“Men in Black” – our ED ex-military security team), I entered the room in gown, gloves, N95 mask and face shield.  The patient wore no mask, and screamed at the security team to take their masks off. Pandemic be damned – in her fiery mind certainly a mere virus was quite unimportant.  She demanded to see the President of the United States. Not having him on speed dial, I offered myself as someone she could talk to instead.  I can’t quite recall the names she called me. 

Ever the idealist, I tried to build rapport with this woman in psychosis; I complimented her long, thick, rope-like dreads.  “You have great hair!” – what a mistake.  In a heartbeat or less, she whipped her head around like a medusa; talons of hair went flying into the eyes and faces of the poor young officers. 

“That’s enough, four point restraints, Ativan 2, Haldol 5, Benadryl 50 stat.”

Within minutes she was laying on the bed, medications beginning to chase away the demons and force her into sleep.

Two shocked and frightened countenances greeted me as the officers joined me at my desk; they had never seen anything quite like the show tonight.  Thankfully their eyes and faces were no worse for being whipped with intensity, and they left, shaking their heads, to get some fresh air. 

They left, and left me with a pit of fear in my stomach.  Women and men just like my patient, suffer with mental illness in our society.  But those who are untreated, those who refuse to comply with treatment, pose a real risk.  A woman such as this, in the throes of distress, does not see the world as you or I do.  She sees random people as dangerous, villains, threats.  This is the kind of individual who could lash out at any moment, at any person in her line of vision.  She may not know what she is doing, but she would do it anyway – and an innocent person could get hurt or killed.  The way she looked at me and spat horrors in my face, sent me away with goosebumps.  The mind is a formidable foe when it’s connections are out of sync. 

I left that night feeling like I often do these days: helpless, hopeless, and devastated.  My heart felt like those dreads had whipped it apart, and tangles of dirty hair were strangling my optimism.  Emergency Medicine can do that to you, but it can also lift you higher than you ever thought possible.  I hope I find that elevation on the next shift.

There is something mystical that happens, sometimes, in the middle of a busy shift in a moment of connection. Placing my stethoscope on her chest with one hand while the other hand sits reassuringly on her shoulder, feeling the beat of her heart and the rush of her breath in my ears. She’s old, frail, hard of hearing and sweet. Wearing a chain of gold on her neck, gilded like a queen, she sparkles quietly in the white sheeted hospital bed. Somehow, through my PPE and my walls she pulls emotion from me – not knowing, she can’t sense the relief I feel. Relief, that I can still connect, still find meaning in the smallest of examination details in the emerg. Through it all, through the Covid pandemic and my own shortness of breath, I find peace. For a moment.

I start my shift in the locker room, as I always do, saying hello and goodbye to the nurses coming and going, fresh and stressed, eyes sparkling or hooded. Tonight one sits quietly on the bench holding the small of her back, tired, defeated, she gets up to leave me space as I beg her to stay. Next, I look up at a colleague with sad eyes, as we ask each other, “how are you?”. Masked, I can’t see the up or downturn of her mouth, but she says “so so” with a gesture of her hand and turns away. Stopping, I think how to ask, should I ask, and the locker room empty save for us I gather strength to say “what’s wrong?”. Suddenly the tears burst into her eyes and I can see the relief; she opens the gates and tells me. Somehow, through my difficulty breathing and with my hoarse poorly perceptible voice I give and take with her until she feels supported, heard and with a plan. Thanking me she leaves, to meet me shortly in our unit, both of us soon to be masked and shielded against what’s to come. Pulling my walls up tight again I take my deep calming strained breaths and remind myself, through a haze of my own tears, that this is what I come to work for. To help those in need, to heal, to offer any strength I can at any moment that I can.

Caring for the wellbeing of my colleagues is just as important, now, as the care of our patients. Without imparting strength to each other, and holding our friends up when they are weak, we can’t continue to face the tsunami of pain each shift. So, breathless, we give to each other when we can hardly give to ourselves, and find peace, even just for a moment.

The house is asleep, and I can’t turn off my brain. I just cried my way through an episode of Seal Team, especially the part where two Seals are opening up to a psychologist about feeling broken. One says he’s tired of pretending he’s ok, that he has PTSD and needs help. Later he breaks down and his wife folds him in her arms, and tells him she’s there to pick up the pieces.

I feel like that Seal. Maybe that’s why this show resonates with me. After all I’m not one for gratuitous violence and warfare; I’ve often asked myself if I only watch it because I have crushed on David Boreanaz since he headlined Buffy and then Angel. But no – now I see, the hell they go through reflects the hell we go through in medicine.

These days it’s really hard to self-reflect, and to allow others to read my words or feel my emotions. There’s just too much pain in our world now, and everyone is suffering. What makes my pain more important than my neighbour’s? Nothing. But I’m going to allow myself to write about it and let others read it because maybe it will give you, the reader, license to sit with your own grief by feeling mine.

Every day I go to work, it’s a minefield. I never know what or whom I will meet and maybe destroy, and be destroyed by. When I pick up a chart for an ankle sprain, that patient could be the woman whose husband pushed her down the stairs and that’s why she sprained her ankle. Or the chest pain in a 20 year old man could be lymphoma. Or the constipation in the 40 year old exceedingly kind looking man with the soft accented voice could be new rectal cancer.

After a minor car accident a few months ago, the X-ray of her ribs was normal and my patient was sent home by the physician she saw at a community hospital in Ontario. She was still in pain three months later, so she presented to the ambulatory side of our ED. I figured, when I saw her, maybe a small fracture was missed and it’s not healing well, or perhaps it’s all just muscular pain. My clinical assessment found tenderness along one rib in particular. Repeat xray showed something not quite right, so I ordered a CT. Before even reading the whole report, in my haste to keep going and see new patients, I called her into the reassessment room. She met me smiling and thanked me for the analgesia, that had dramatically improved her pain. Reading the concluding statement of the report as I stood across from her expectant face, I took a sharp breath and without the ability to self edit I said “oh no, I’m so sorry”. Then “let’s sit down”. Her face froze. I had fucked up. I had stabbed her in the heart with my stupid words. Thankfully her husband was there and guided her to a seat. A harbinger of doom, I read the words aloud that sealed the fate not only of herself, but of her lover and her family, forever changing their lives.

Metastases. Multiple. Unknown primary.

Her eyes, wet. Her husband’s eyes meeting mine, knowing. The world shifting.

It was however, as if she already knew. The gnawing bone pain waking her and keeping her from sleep could only be one thing. And she knew. She just knew. And she tried her best to be strong for her husband. Together, they accepted the words, the plan, the further CT scans that found a large lung cancer. Together, they stoically met the dangers with swords in hand.

And me – I am devastated. Crushed. Heartbroken. Not only by the diagnosis and knowing what comes next, but by my failure. My failure to keep my mouth shut, to hold, to wait. Maybe it’s burnout, exhaustion, sleep deprivation. Maybe it’s stupidity. Maybe it’s delirium. No matter what, it’s awful.

So I know how those soldiers felt, in their moments of emotional agony. I feel it too. Emergency Medicine, medicine in general, hurts my soul in ways I never knew it would. Sometimes I wish I didn’t know what I know. Walking into a room after reading a triage note, and already knowing what I’ll find. Knowing the diagnosis and the denouement of my patients stories way before they do. Prophecy of sorts, based on training and experience. And prophets have never had it easy. Foresight is a curse, a crutch, a needle always stabbing just that right spot where the pain is always fresh.

Medicine also lifts me. Sometimes. But lately? Nope. It has drowned me.

And I feel broken too. Hoping somehow to mend the pieces, sew them together like the wounds I’ve fixed at work, stitch them or crazy glue them until it’s possible to continue. The Seals on the show say “ignore and override” – this can be said for physicians and nurses as well. But it’s not the right thing to do.

I hope by reading my story and hearing my struggle it can help you with yours. Don’t let Medicine crush you. Fight back, with all your strength. Talk about it. Write about it. But let it out. In the space between people there is healing – there is space for all the hurt inside to come out. Though you may be scared to burden others, if they care for you, let them be your parachute.

March 5, 2021

3:07 a.m.

One year later and this pandemic rages on. These days I’m more and more taught, my muscles reflecting my mind as they ache and pain.  Work gets more frightening each day as those I work with get sick.  Now I get phone calls for contact tracing (“did you work closely with so-and-so last week? Did you take your mask off at all during your shift?”) and more of my “cold zone” patients end up hot. The stress rises and sometimes peaks; I erupt volcanically with tears, raising my voice to my family at any little offense when really the problems lie outside our home.

When I come home to a full bed as I did tonight, two kids, a puppy and hubby all snuggled and at peace, it reminds me why we chose this path of true isolation. I remember why my kids aren’t in school, why I pulled out of the hot zones back in May, why we remain so strictly alone. This is my family, these are my loves, pieces of my soul. Their health, my health, are paramount to all of our mental health. Keeping them all safe is my responsibility; worrying that I could bring this raging beast home to them is the most scary thing of all.  So I work in the cold zone, sacrificing some of my favourite parts of emergency medicine, to keep them safe. I sit with the kids all day, distance learning grade 5 and kindergarten, so that they will be educated and stimulated even if not in the physical classroom. I drive hours twice a week to bring my girl horseback riding, and another day each week to go ski, because they need the distractions and the outdoors. 

I’ve come to understand that this time is not for me. It’s not about me. It’s about ensuring my children make it through to the other side of covid intact, happy, strong and sweet. They are the most important pieces of my puzzle, and their health is all that matters.

Scenes from my neighborhood, walking my dog on a warm, wintry Friday evening before curfew during a pandemic:

A bus brushes by me

Police settle in to wait for their prey

A mother and child play I spy on the sidewalk

Twinkling lights on trees, homes, posts

Empty, dark parks void of play

Pedestrians give each other a wide berth as we pass

Children play hockey on their backyard rink lit by street lamps

Elderly couple says the sabbath blessing over wine on a back deck separated from the family inside by a sliding door

The Rabbi on our street smiles and says “Good Shabbos” walking by

Empty streets

My dog’s breath

Quiet steps in the night.

By now I’m sure most of us have had the Covid dreams, as I have. The ones where I am going about my usual activities and suddenly I realize I’m not wearing a mask. I freak out, like I used to do in dreams when I realized I was in class naked, or wearing only underwear at work. Now it’s mask and distancing anxiety manifesting at night in dreams.

But I also have Covid daydreams. I wonder how many of us do. Each time I enter the parking garage at work I can almost see the covid zombie jumping out at me from between two parked cars. I clean my hands, phone and ID tag as fast as possible, change my shoes and hop in the car quickly, always sensing some horror just outside my peripheral vision.

Then there is the one about one of my closest friends getting sick, and I can see myself kneeling by the bedside as they struggle to breathe, me in PPE and alone as no other visitors are allowed. It’s devastating and frightening, and I’ve been seeing this vision since about a month before the pandemic set in.

Dreams and daydreams used to be safe spaces to let imagination roam; this beastly virus has taken that soothing place from me and likely from many others. If only sleep would give peace, if only my waking meanderings of thought were pleasant.

Let’s hope once this thing ends that I return to flying over landscapes and adventuring through time when I close my eyes.