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.

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.

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.

Today was a generic Vertical day.

Vertical is what we call the walk-in side of the ED – get it, because patients generally remain vertical and don’t need a stretcher to lie down horizontally.

Meaning they are less sick.  Which isn’t always the case.

Today however, most of my patients were of the vertical nature.  Seeing less acutely ill patients can be frustrating for an Emergency Physician, since what we are there to do is save lives.  It’s sometimes easy to forget the human behind the medical case; here in Quebec, many people are not fortunate enough to have a family doctor so they present to the ED for things that would be much better served in clinic.  Patients don’t see the flow issues that we as health care workers see.  They don’t see the bigger picture of backlogs in the medical system caused by the daily flood of less acute medical presentations.

What they see, is their own suffering.

We as physicians are trained to explore the patient’s targeted history and physical for those nuggets of information that will lead to a diagnosis, or to something we can perhaps fix.

We aren’t as attuned to the story behind it all.

I met a lady today, a beautiful, elderly lady originally an immigrant to Canada.  She came to the ED because of a relatively minor complaint, but when taken into context with the rest of her life was actually a rather serious issue.  She had pain, and it was interfering with her daily activities and especially with her ability to care for her sick husband.  Unfortunately there was not much I could do for this in the ED, so I ended up referring her to see a specialist.

But what I did do for her, was sit with her in the exam room and listen a bit to her story.  Through her words I could imagine the sprightly, strong farmer she used to be, working the land, loving her husband, raising her children until deciding one day that life in Canada might be better for the family.  I could see the optimism and hope they set out with, as she retold the story.  I could also share in her regret, and her missing her homeland, as she told me how she now struggles on icy ground and even fell down a set of snowy stairs last year – all the while asking herself why on earth she uprooted her family and moved to this cold place.

All this, I heard as I ran my hands down her legs to check for edema, injury, neurovascular abnormalities.  I could almost read her life story in the scars on her skin and the song in her voice.  Finally we said goodbye, and I moved on with my day and she hers.

But she changed my day, she brightened it.

Later in the day I met another elderly lady, who drove me crazy.

I was trapped in an exam room with her for way too long, as she wouldn’t let me interrupt her pressured, rapid speech.  She told me her life story as well, in tangential snippets of information, all the while assuring me that each little thing she said was “so important, so important”.  I tried my hardest to listen, connect the dots, find out why she thought each thing she brought up was “so important” to the presentation at hand.  In truth, the diagnosis for her presenting complaint was simple and relatively trivial.  But her evaluation took longer than any other today, because of her personality.  I am generally an extremely patient physician; I listen, I care, I allow patients to open up.  But with this particular lady, I had to finally cut her off and leave the room with her still speaking – there was no other way.  I felt terrible, like a bad person, for dismissing this lonely elderly lady.  By the end of the day, when I encountered her again to discuss the results of her tests, she had clearly formed an attachment to me.  She held my hand, thanked me, told me she loved me, that she wanted to see me again and bring me a gift.  And of course, this made me feel even worse, for having such unkind thoughts towards her in my heart.  I smiled, shook her hand and wished her luck as she left with her husband.

I wish, somehow, that I knew a little bit about her background, her story.  What made her like this?  How is her home life?  Is she happy, or just overwhelmed with anxiety and psychiatric illness?

I may never know.

Vertical – a place many Emergency Physicians hate.

A place that at times makes me want to run screaming for the hills in aggravation.

But also, a place that can be like a national park where you could go for a walk and suddenly stumble upon a rare jewel.

Sometimes, vertical opens my mind, and my heart, to my patients.