Looking back – the NICU

Periodically I like to reflect on the journey I took to become the physician (and mother) I am today.  Here is an excerpt from my time as a third year medical student working in the neonatal intensive care unit.  I can still feel, smell and hear the sensations described in this piece, and it reminds me of the passion and wonder of my early training years.

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2006: The NICU

For weeks I’ve been dreading this part of my pediatrics rotation – the Neonatal Intensive Care Unit.  Two weeks of psychological trauma and sleep deprivation, according to those who went before me.  Therefore I was understandably quite nervous on the morning I walked into the bright, loud, extremely full NICU.  I chose to take the first call shift, on the first day, because I wanted to dive right in and get the gist of things quickly.  So on Monday, with butterflies flapping up a monsoon in my belly, I donned my scrubs and took the call pager for the next 32 hours.  No regrets.

The NICU is a whole new world full of new sounds, smells, sights, tastes and touch.  Some of the babies are so tiny it’s hard to imagine that they are really there at all – one 24 weeker weighed only 530 grams at birth (imagine that, it’s barely over one pound!).  We have a baby that was born at 23 weeks – that’s below the usual threshold for survival (24 weeks, when the lungs start producing surfactant, a soapy substance that keeps your alveoli – air sacs – open).  We also have big babies born to diabetic moms, a baby born addicted to methadone and in withdrawal, some babies who were just too small at birth and need nutrition, triplets, and more.  Just the sight of the 24 weeker whose feet are the size of my thumb (and I have small hands!) and in whose body courses blood the equivalent volume of maybe ¼ can of soda, is something that takes getting used to.

Babies smell differently, as we all know, but they smell even more foreign when they’ve just been born and are lying under my hands as I wipe them down and suction goop from their mouths.  I can’t describe the smell – but not unpleasant by any means.  Taste is a sense I didn’t expect to experience in this rotation, but my lips have an icky rubbing alcohol taste to them thanks to all the handwashing I do every day – I guess somehow after I wash some of the stuff gets on my face (after seeing the baby, of course).

And sound – the NICU assaults my ears like no other place in the hospital so far.  There was only one moment of relative quiet today, at around 7:45 a.m., when the monitors for once were silent and the babies weren’t crying, and the nurses weren’t all talking.  Otherwise – imagine one large room full of over 32 crying babies, add in about 30 monitors all clanging and beeping away with alarms that generally mean nothing, then on top of all that add in the regular noises of a hospital ward with families and nurses and doctors all conversing.  Then, periodically, throw in some strange clanging followed by a hollow intercom voice warning of a code red (fire) somewhere in the hospital, and phones ringing, beepers going off and overall one big hullabaloo.  Next – imagine you’re a little tiny premature baby in an incubator, trying desperately hard to feed and grow and overcome your obstacles, and every moment of your day is full of an assault of noise.  So when I come home to the peace of my apartment, I try hard not to complain to myself about the headache – because I remember that I’ve left my patients, my babies, back in a room that never quiets, a land that never sleeps.

Finally, touching these little infants, these barely former fetuses (my Dad’s great expression that he uses about me all the time but that seems to fit these babies to a “T”) stirs in me something very human, very primitive, very womanly and motherly – call it maternal instinct.  My attending said to me today as we were watching a delivery of a premie, that he could hear my biological clock ticking.  I denied it, but inside I knew how true that was.  The skin of a baby, of a premie, is so fragile and shiny and thin sometimes that you almost fear to touch it because it seems like it should just melt under your fingers.  I am continually amazed that the infant stethoscope I am using on these teeny chests doesn’t rip a gash in their frail skin.  But then, the older babies (still premature but not extreme) are so soft and downy, warm and cozy that sometimes I just want to scoop them up out of their incubators like the nurses do, and comfort them in my arms.  Today my attending called Marc and I to come observe him doing a circumcision in the normal nursery (where the regular not-at-risk babies go), and he asked me to keep the little boy (2 days old) calm and happy throughout the procedure.  A daunting task – some strange man is looming over you with some strange metal apparatus, about to cut part of your penis, and some strange woman is trying to keep you from crying – is that going to work??  A trick they use in neonates is to give them some sugar solution before procedures, which gets their endorphins going and helps them feel less pain (theoretically).  So I gave the baby sucrose, then when it didn’t quite do the trick, I stuck my gloved finger in his mouth and let him latch on and suck.  The baby showed absolutely zero distress throughout the circumcision (performed with a local anesthetic) and actually fell asleep sucking on my finger while the physician was in the midst of cutting.  What a bizarre feeling, to have a tiny little baby sucking on your finger with incredible force.  I have to admit, it stirred up some strange unknown feelings inside, deeply physical sensations that only a baby sucking must be able to do to a woman.  But not unwelcome.

 

The NICU is a beautiful place – seriously.  I am loving my time there, completely unexpectedly.  The vulnerability of these little ones is astounding, and the teamwork involved in ensuring their survival rivals the multidisciplinary approach of the Saint Mary’s geriatrics ward.  The medicine of the place is complex physiology at it’s best and worst for a med student like me who needs to search her brain for the deep seated subconscious memories of first year.  Then there is the acuity of it all – and I love acuity.  I thrive on action, getting my hands into the thick of things, resuscitation.  That is why I love emergency medicine – and in the NICU I get a small flavour of this.  This evening before I left at 7:30 pm, I was rounding on some of my patients when my attending and I saw one of the nurses bagging a baby who had pulled out his own endotracheal tube (what we use for intubation, to help the baby keep his airway open).  We immediately stepped in, and it was so natural to me as I took over bagging the baby (giving breaths with a bag and mask).  He was so calm, my staff, and so was I because for me this is what medicine is all about.  As the baby started breathing on his own and just required oxygen by nose, inside I felt magic.  Watching his parents walking to the bus stop ahead of me upon leaving the hospital, hand in hand with sunshine in her hair and a smile on her face, I felt what it is I am here in medicine for.  We saved this baby’s life in a few short moments of breathing for him and cleaning his airway of vomit – and in those few seconds we gave hope back to a frightened couple who thought their baby was on the brink.  That is medicine at it’s best, saving a life, inspiring hope. As the Talmud says “one who saves a life is as if he/she saved a world entire”; by allowing a baby to live, you give it a chance to grow and one day have children of it’s own perhaps, and a whole new world around that little soul.

 

Yes, the NICU is a place of fear, but through it runs a river of magic.

Succor

It’s been a busy week of evening shifts, working from 4 pm to 1 am and home by 2, asleep by 3, up at 6.  Doing this four times so far in the last six days has completely wiped me out, but the daytimes spent in the sun and with my kids have helped bring some joy to the mix.  Working so much with so little down time and minimal sleep does unfortunately affect how one approaches cases at work; picking up a new chart often feels like lifting a leaden object that I would rather just leave alone.  Never mind the negative vibes I feel, the resentment, leaving my home yet again on a summer afternoon to take care of other people when all I want to do is take care of my kids and myself.

 

Walking into the department with this angst in my heart, I enter the locker room, strip and pull on my scrubs.  I become someone else, the other version of me, the Physician.  I have described this before in my writing; the sensation of snakeskin, a smokescreen I conjure to Become another self.  It calms me, helps reduce the frustration, as I sling my stethoscope around my neck and fill my pockets with what I need for the day.  I take a moment, breathe, center, and reframe.

 

I walk from the quiet into the chaos and am met with hellos and smiles, colleagues, nurses and even sometimes patients from the day before all greeting me.  This feeling of friendship and collegiality pulls me higher out of the lake of regret in which I have been wading, wishing I were home with my kids.  The faces of patients expectantly waiting to be treated remind me why I am here.

 

Every now and then I meet someone who makes my doctor day worth doing.

 

A little while ago, I met one, a young woman who should have been enjoying her youth, waiting in a room for me to assess.  On my approach she was sitting in the stretcher in no apparent distress.  Without much emotion she described to me how she was assaulted by a client who wanted sexual services.  When she denied this, he picked her up and threw her; she slammed her head and lost consciousness briefly.  A friend saved her and brought her to the ED, dropping her off at the door.  After a thorough, gentle examination I quietly asked her if she has any social support.  She began to cry, admitting that she has no one.  No family, minimal friends, she lives alone and has no one to turn to in times of need.  I asked her if I could help find her support, e.g. with social services, or if she wanted to report this to the police.  She declined, as I expected.  Girls like this, so beautiful, so fragile, so vulnerable, they usually refuse the help offered.  It breaks my heart; she is someone’s daughter, and even if not appreciated by a parent, she is a soul, a person, and she matters.

 

Even in my line of work, where I see awful things often, it still shocks me that a person can harm someone else intentionally.  Call me naïve, innocent, idealistic, but I don’t understand how a man would pick up a woman and throw her into furniture.

I say this, but then intrusive thoughts make their way to the forefront and remind me of the unstable angry men I often see in my emergency department.  I have met scary people; men (and sometimes women) that I would run from if encountered on the street.  This young woman works in a place that exposes her to harm, and as a physician, there is nothing in my power to help prevent pain to her in the future.  All I could do when she was in my emerg, was keep her safe for a few hours; give her support and succor until she decided she wanted to leave.  I gave her a stretcher, pain medications, a blanket, and an ear to listen.
Tonight, tomorrow night, she may get harmed again or worse.  It pains me, as a doctor, a woman and a mother, but her choice is her choice.  Her life is her life.  I only wish the best for her and hope for her one day to get out of the life she is in and into a safer one.

 

So, coming to work even when work is the last thing I want to do, is important.  It teaches me, it opens my eyes.  It takes me out of my existence and into the lives of others; it gives me compassion and understanding.  It reminds me that there is so much more going on in this world than most of us see; there are so many layers, so many spaces, so many worlds within worlds that we as physicians are privileged to witness.  It might hurt, it might change us in ways we don’t expect, it may gnaw at our insides when we see the pain that is experienced by others.  But it can also enlighten, and brighten, and enlarge our souls.  For that, I thank this work, and the heavy load that it sets on my heart.  Without it, I would not be me, and my children would not learn what I, and only I, can teach them.

Feeling Well

It’s peaceful out here,

sitting at a picnic table,

the breeze over the water lifting my hair.

 

It’s quiet out here,

children’s voices as they play on a sandy beach,

flapping of grasshopper wings,

ducks honking at each other as they swim.

A dragonfly lands on my shoulder, and starts to walk up to my face

until I gently tap him away.

 

It’s joyful out here,

a father takes his son out in a canoe to fish, they wave and say hi,

continue on their way.

 

It’s pleasant out here,

waiting for my daughter to finish her day at pony camp,

sitting in sunshine with nothing to do but read and write.

 

Physician wellbeing, something we search for,

something so intangible much of the time.

Yet here it is:

I worked until midnight, went to bed around 1, up at 6 with my kids

and working again at 4

 – but I am sitting in peace by water and wind.

 

Wellness is this;

taking a moment,

a few stolen hours between responsibilities,

to do what makes one happy.

 

My summer feels as if a thief caught it by the tail

and yanked it out from under me.

Running, the burglar trails happiness away

and laughs when I reach out for it.

Sometimes, we have to steal back what is taken.

These brief minutes are just that;

leaning out further to snatch what seems gone.

 

Magic

Tonight we watched the space station fly over our house, with a sliver of yellow new moon shining nearby.  Wide-eyed the children listened to me describe the astronauts living inside, looking down at us from up high.  The wonder, the innocence of being so little and not knowing at all what the grown up next to you is telling you; imagining a reality you can’t even begin to perceive – it’s magical.

When I was a child, I believed in magic.  I trusted bees not to sting, carried ladybugs on my palms, sheltered worms in mud filled tupperwares in the backyard.  I thought the world moved around me, that somehow all was good and right.  When kids began to tease me at day camp and suddenly my world wasn’t safe and perfect, I still truly believed that if I was just nice, and kind, the boys wouldn’t push me off my bike at speed on the street.  If I was sweet, they wouldn’t hold my head under water at the pool until the lifeguard whistled.  If I asked them to stop, they wouldn’t spit on me or chase me down the street till I fell.

As I grew up those boys faded away; at eighteen I left for university and forgot them, left them behind.  They weren’t important, they were shadows in the past of a childhood that was light and air and sunshine around the corners of their nastiness.  I was a happy, free, innocent and playful kid with lots of other friends, so as I grew up the bullies occupied only the tiniest part of my memories.

But I never forgot their names.  Three, in particular, still sit at the tip of my tongue.  K., R., and J. were the meanest of the mean back then in those sun filled sticky summers, and every now and then I did wonder where they went.  Did they grow up good?  Did they end up in jail?  Who did they hurt after me?  Did they regret being the bullies they were?

Today, I learned what happened to one of them.

My day was somewhat remarkable at work; early in the day I encountered an old teacher of mine, from grade school.  A lovely lady, poised and elegant, always pleasant and warm in my memories, she accompanied her elderly husband for a relatively benign reason, to my emergency department.  Seeing them was a rose, a sweet moment in my day, lighting my morning with joy.

In the afternoon, a punch to the gut when I saw his name on the next chart to be seen.  No way, it can’t be, but I knew with a glance at his birthdate that it was.  The bully of my childhood, now a man, a troubled one, waiting to be assessed in the psychiatry back hallway.  He had been suffering for years with a psychiatric disorder, at times aggressive, at times psychotic; his disease made sense to the little girl inside me who suffered from blows and knocks off her bike.  A bad boy grew into a man with a mental illness; how long was his illness undiagnosed?  Was he sick when we were young? Is that why?

 

Prepared for anything I did what I always do when I go into the psych rooms: I removed my stethoscope from around my neck and placed it in a pocket, hid my pens in back pockets or underneath clothing, took all the precautions not to be injured by an errant patient.  My stomach in knots, doing back flips of nausea from recollections of pain, I pushed it all away and went to face my patient.

 

“Hi sir, my name is Dr. A., can we sit over here and talk about why you’re here?”

Calmly and quietly he joined me, meek, eyes cast downward, he spoke softly.

“I don’t feel right.  My heart feels weak.”

Slowly I drew out of him the story, learned he has been unstable, not well, needing help.

Stethoscope out, I touched my patient, one warm hand on his shoulder as I heard for the first time the beating of his heart.  The same heart, that beat when his fists hit me, so many years ago.  The same heart, that carried him from a troubled childhood to an even worse future.  A strong heart, a beautifully beating musical heart giving life to this tormented, beaten down, sad man seated with his health in my hands.  His heart knocked the breath from my own chest, and I planted my feet solidly so not to fall.

 

The magic of my childhood felt palpable in my fingers; the silvery string of time and fate shimmering between us as we spoke.

 

I wish I could feel like he deserves this life.

I wish I could feel vindicated.

I tried to feel like “karma’s a bitch”, I even said it to myself, but I couldn’t feel it.  I don’t feel it.

No one deserves to live a tortured life.  Mental illness, untreated likely in childhood, now eating him up inside – how devastating.

 

I walked out of that hallway feeling quite empty.  His sadness like acid in my mouth, his loneliness like stones in my belly.

So now I know where he went, when he dissolved to shadows in my frame of existence.  But knowing, and knowing what I know as a physician, only makes the memories even more sorrowful.  I wonder if anyone knew, when he was young, and if anyone could have helped.  It’s all speculation, hidden in the fabric of time, and I’ll never know.

 

Looking at the cosmos tonight with my children, watching their eyes sparkle in the moonlight, hearing their laughs and feeling the music of their souls, I made peace with that little boy in the past.  He sleeps quietly in my mind, and I pray for the same quiet in his all grown up soul, tonight and always.  If magic exists, I hope my hand on his arm passed some of it inside to heal him, in ways no medicine ever could.

Mortality

“Every time I see you, I feel like I’m lost, wandering around aimlessly” says the young, fresh faced new resident as we bump into each other for the umpteenth time on this night shift.

He is lost in this place, and I am lost as well.

Lost, because this year, for the first time, I feel old.

I turned forty, and suddenly mortality hit me in the gut like a linebacker on a football field. The sucker punch of age left me reeling, unable to catch my breath.

When I teach students these days I realize they could be my children. I am that old.

When I brush my hair, a thread of silver peeks out, laughing, from the most obvious part of my scalp, laying itself firmly in the sunshine for all to glimpse.

My hands, my face, showing weather and sun and the years of my life passing like the river that surrounds my city. The years pull away from me, stretched out behind like the shadow my son likes to make on the wall with my phone light at bedtime.  I play with my children and have to push myself back up to stand, partly due to obesity but also due to my old lady self.

Forty, I feel old, I feel sad, I see time speeding up and away and I don’t know how to slow it. And suddenly, this year, I no longer feel secure in what I always believed – that the end is comforting, present, that when we die our souls look down on family and friends and stay close. Out of nowhere I have started to doubt that anything truly exists when we die. Will the end just really be an end?

I watch his young back and unlined face as he strolls away down the hall, and I wish him many more years of youth and innocence and dark hair. I wish him joy and excitement and the wonder of discovery.
And I wish myself peace, as I kiss my own youth goodbye.

—————

Working a full moon night shift in a large academic tertiary care emergency department is an adventure.  The full moon brings out the worst in people, the crazy, the anxious, the sad. And those people bring all that to the EDs in cities across the continent, where people like me have to help them come to terms with and deal with what the moon brought out. Well, not the moon really, but that’s how it feels.

Doing what I do, I am confronted by mortality – my patients’ – but also my own – every shift.

Tonight, teaching young residents, I felt old. So old. I visited the darkness of age in my mind. Then a few minutes after composing an ode to my own angst while taking a bathroom break, I reassessed an older lady I have met multiple times in the ED. She, a strange cat, but kind, told me that every time she sees me here I grow better looking and get younger. Suddenly, my hair felt full, my face clear of wrinkles, my steps a bit lighter. In her own bizarre but sweet way of self she gave me a gift. Mortality moved further from me and quieted its steps on my soul.

Ruthlessly however the spectre returned later in the long night, when a psychotic, angry, awful man began screaming obscenities at me from his locked room. As he called me unrepeatable names and told me to get on a treadmill, I forced myself to type my notes and keep my cool.

When he yelled “I’ll remember your face”, and threatened to harm me, the knot in my gut twisted. Fear returned, took hold, solidly placed its’ teeth in my belly. This man and many like him walk our streets. We don’t know who they are. Tomorrow, he could be next to me in a cafe, or behind me on the street.  Him, or someone like him. Maybe he will remember my face, maybe he will just see a woman and want to hurt her. This man, and others like him, are the reason I fear. And I see them, every day. They come to me, where I work, and they demand to be acknowledged. Maybe they are sick, maybe they are just mean, maybe they should be in prison. But I, and those like me, must treat them with respect, kindness, like any patient who comes through the door. So I do, and I pay the price by hearing his abuse echo in my ears. I carry a “screamer” on my ID tag, an alarm that emits a high decibel siren if I pull it; it’s sad to think I as a doctor feel at risk enough to carry such a device. But just last week, a health care worker in my department was attacked in a horrific way, out of nowhere. So I take no chances.

Mortality. Death. I know it, I walk with it. I recognize it. I fear it.

Delightful

When you tell me your story I often resist making you stop.

I hold myself back from truncating your words.  I stand by you or sit on the bed and I listen, as you say so much and yet so little.

Usually I get only a hint of what I need to know, as your physician, to heal your wounds (the physical ones).  But through your narrative I learn you; what drives you, how you think, where you come from, why you are really here.

If I stay silent long enough you will tell me of your uncle who died last year of brain cancer, and now I have a better idea of why you are here in my emerg at 4 a.m. with a mild headache.

Though I may stay with you longer than perhaps I should, for the sake of efficiency, I don’t sacrifice these moments because I am truly delighted to be someone you can trust, to tell me your story.

I will take your words and write them down, first in your chart and then in my heart, as I learn what it is to have fear.

 

Written at a wellness conference for Canadian women physicians.

Home

Home is the heartbeat of my patient as they roll off the ambulance; rapid, pressured like the speech of the lady in the psych back hallway.

Home is chaos, a tumult of sea-salt smelling air rushing off the ocean as we arrive at the coast.

Home is warmth, a hot chocolate after a long ski day when the kids’ cheeks are apples and my hands are frozen meat.

Home is delicious, spicy, sweet all at once like moroccan salmon cooked by my husband after a long shift, the taste of my son’s cheek in bed in the morning.

Home smells like my daughter’s breath as she sings pop songs off key with such joy and lack of self-consciousness.

Home is pinks, oranges, greens of orchids and lettuce we planted last night, watermelon fresh cut dripping sticky juice on just washed counter.

Home is all of it, and when I stick out my tongue in the backyard to catch snow with my children, home is the hearts we have woven together that I can hear beating in the quiet of night bringing peace to my mind and joy to my heart.

Home is knowing, just knowing, that all is safe and right.

 

Written at a wellness conference for Canadian women physicians.

Sunshine and truth

I want to write.  It’s a sunny day and the world is bright, there are kids cheering at a school across the street, the sidewalks are filled with people dressed like spring and with a spring in their steps.  I have the day off, which doesn’t happen very much lately, and so far I’ve used it to my advantage.  This morning I woke up at 6 as usual, with my cozy, sweet smelling four year old boy snuggling me and his dad still quietly sleeping nearby.  My beautiful, growing, pre-tween nine year old girl joined us a few minutes later, and the peace and joy in my heart almost made my inner balloon burst.  Lots of hugs and kisses and laughter later, with some loss of temper sprinkled in as per usual, the kids were fed, dressed, hair and teeth brushed, shoes on and out the door with their dad to start their days at school and daycare.  After waving goodbye, I closed the door softly on the chaos and fled back upstairs to my still warm, undemanding, restful bed.

 

A nap, then a cleansing, thought filled shower carried me to a lunch date with a best friend.  Lunch with a friend is underrated in the technological hullabaloo of this world; many of us have forgotten the quick ease of conversation and the value of a venting session with someone who knows us well.  I have not neglected the worth of good friends.  Though my life is packed and full, I make time like this in order to make space for calm in my soul.

 

Now here I sit, giving myself the gift of sunshine and a clear mind.  When I write, I open myself.  I reflect, I build rooms in my memory that get filled with words, accessible for a lifetime or more.  I take the stories around me and translate them from biochemical connections in my brain into tangible things that I can share.

 

For instance, today is a good time to digest the story of a young woman I met recently, who is not unlike many women I meet in the Emergency Department.  She came to see a physician because in her 6th week of a very wanted pregnancy, after years of trying, she was bleeding.  The evening before, she had first presented to the hospital, and after an initial evaluation she was asked to return in the morning for a pelvic ultrasound.  Therefore, when I met her it was in the context of giving results.

 

In these moments, I often reflect before and after the visit, on the fact that the power I wield as a physician is astounding.  And not necessarily in a good way.  I can walk into a room, and change someone’s life profoundly.  When I entered this woman’s room, we had never met.  I was a stranger with all the knowledge and the answers; she was an anxious woman waiting for what would prove to be a harsh sentence.  I stepped into her world and ruined her life, shattered her dreams, brought tears and bitterness with my words.  Her pregnancy was an ectopic; the egg and sperm had joined in unity and created the spark of a new life, but that potential new baby had settled outside the uterus and alongside an ovary.  By getting lost in this way, the collection of cells though formed into a gestational sac and beginning to divide into a new world, would not have a chance to continue it’s growth.  An ectopic pregnancy if left to develop, could very possibly result in the death of both fetus and mother.  It is a leading cause of death in women in the first trimester of pregnancy, as it can cause rupture of the pelvic organs and massive bleeding.  Therefore, when I opened the door to her room, I closed the door on her dreams.

 

The responsibility I carry as a physician is not lost on me; every day I feel this acutely.  It is at once a burden on my soul and a blessing; I help, I heal, but I hurt as well.  However, I find myself often having to remind my heart that I am not the cause of a patient’s illness.  I am not the reason this cluster of sperm and egg took a wrong turn.  I did not choose to harm.  I am the messenger, and one whose face she may remember forever for the truth I had to tell.

 

So, writing out her story, I find my way to forgiveness.  I learn about why I feel so tired, so drained, when I finish a day at work.  I remind myself that the power I hold is not to be considered lightly.  I reflect and find insight, and I heal myself.

 

The sunshine outside shines too on my patient; I hope she finds her own way to heal, and to forgive herself and her body for the mistake she had no power to fix, and medicine had no power to change.

Burnout

There’s always so much to write about, and there’s never any time.  I work too much; it’s become evident recently that I need to cut down.  I have started noticing that things affect me much more than they ever did; there are days I hide my tears, and days I show my tears, when before the tears would have waited for the occasional (yes, occasional) shower.  This is a function of my level of exhaustion; if I were to plot it out on a bar graph like the kind my daughter is learning to understand in third grade, the intersection between the extremes of “time at work” on the x axis and “lack of me time” on the y axis would be the way I feel right now.  Burnt out.

 

Burnout: a small word we use a lot recently, to describe a very complex situation.  Physicians (and I can only speak for this category of person as I am one) are suffering.  Many of us won’t mention it, won’t give it breath to solidify itself in our lives.  If we say it, we make it real, when it’s often easier to just push it away and deny it’s existence.  Burnout.  There, I said it again.  To be honest, I’m not always sure this is where I am; but I’d like to learn how to prevent getting there.

 

Physician wellbeing is another catchphrase, like “wellness”, that is getting a lot of air time these days in conversation and at conferences.  This is something I can hang my hat on, that I want to be a part of.  In my little corner of existence I am going to step up and start working on improving my, and my colleagues’, wellbeing.  How?  Well, I have plenty of ideas.  Whether I can bring them to fruition is a good question, but I’m ready to try.

 

How can you help?  Can you help?  Can anyone?  I think so.  Here’s an idea.

Next time you’re in the emergency department, or your family doctor’s office, or visiting a specialist in clinic, try to think about how hard those individuals are working for your benefit.

Put yourselves in our shoes, for a moment, and see through our eyes.  See the way we have to hide our own emotions in order to help you get through yours.  See how we stay late to take care of your children, while our own children miss us at home.  See the glassy look in our eyes when we try not to cry as we tell your mom she will die within the year of a cancer we discovered by accident when we did a CT scan for kidney stones.  Look at my hands clasped tight, white, before me as I break the news that your brother did not make it after I worked for hours to the best of my ability, to save his life.

Look at all of us, stretched far beyond what we ever thought we signed up for, in a system where more and more sick people come to our door but we can’t hire more physicians to help see all of you faster.  When you have waited six hours and it’s 4 AM, and I finally walk into the room with an exhausted look on my face and a droop in my shoulders, but I put on a smile and say “hi, I’m Dr. A., how can I help you today” – please don’t crush me with your anger and your frustration.  Please understand we do our best and work our hardest to navigate fear, exhaustion, panic, sorrow; that we search to balance these with moments of joy at a new pregnancy diagnosis, or a hard fought save in the resuscitation room.  We try so hard to give you good news, or break the bad news with empathy; to see you faster, more efficiently, without skimping on the care we give to each of you.

Please, look at me and see my heart, see my humanity, treat me as you would like me to treat you, with kindness.  Just because I am a doctor, wearing scrubs and a stethoscope and a messy ponytail with pens sticking out from all pockets and phones ringing every few minutes, just because of this garb I put on when I come to work, don’t decide I am any less of a person than you.  I feel what you feel.  I hurt as you hurt.  I bring your stories and your pain home and I feel it over and over with you as you lie in the stretcher where I left you, and feel it yourself.  We feel this together.  You are not alone.  But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you.  Those moments we had together, that changed your life, don’t think they haven’t changed mine.  They have.  I am changed, by you, and you by me.  And it hurts.

 

So please, be kind to your doctor.  We need it.  We need kindness, and compassion.  From you, from each other, from ourselves.  Help us heal, the way we try to heal you.

The monster inside

I met such a brave woman the other day, and a brave family.

Fully aware of her disease, my patient told me calmly of the death sentence handed down to her by a higher court than human justice. Nothing just about it, this too young woman had not one but many ways to die all sitting and waiting within her like bombs ticking relentlessly.

She had come to the Emerg that day for a new pain, a different pain from her every day suffering. After clearly telling me that she no longer wished any extraordinary measures, including resuscitation or surgery, she allowed that she would like to know the diagnosis for this new agony. I treated her pain with analgesics, and ordered a scan.

The images were astounding. My lovely, sick, profound patient had a monster inside of her. A creature already known to be laying in wait, it had now grown into a true threat putting my patient’s life in imminent danger.

I came back into the room, met by my patient and her wife, who wanted to take her home to die in her own bed. In the most compassionate yet direct way, I explained what I had seen on the scan. I told them the story of her impending demise. I illustrated in colour the beast she was facing, because to do anything less, to hide the truth, would have been cruel and the wrong thing to do for this family.

I can barely express in words the way I, as a doctor and as a person, feel, when having to break bad news to patients and their families. To look good people in the eyes and tell them they are soon going to be separated from each other in the most permanent way, is heartrending. To explicitly tell a patient that he or she will die very soon, is harder than one can imagine.

And this death. This death would be agony. Of the four bombs set to detonate in this woman’s body, the growing goblin on the scan would certainly be the most painful and frightening way to go, for both the patient and her family.

I explained this. In quiet words, simple, straightforward. I asked, do you want to stay here, where we can make you comfortable, take away your pain as you pass? I told them I would leave the room and give them time to decide as a family. I involved the palliative care team to assist. By an hour later, the decision was made to allow the family and the patient to go home, armed with medications to take when the pain will become too much to bear.

Saying goodbye to my brave, kind, doomed patient with the grizzly bear in her belly tore my heart out. They thanked me for coming back in the room. I almost hadn’t, I had almost let them leave without going to say goodbye. But I couldn’t. This woman, her family and her story touched me, and I needed to look once more in their eyes. I knew I would never forgive myself if I didn’t say goodbye before she died. I needed to close the door that I had opened in my heart. But how do you do that? How do you express to a person you just met, that you’re heartbroken that they will very shortly die? How can such a strong connection be formed in such a short timeframe, within one encounter in a busy emergency department? Well, those bonds form and break every day in my world. I am grateful for this, because it teaches me humanity and grounds me on this earth. It makes me appreciate health and my family’s health. My patients’ suffering and deaths make my life somehow so much more worth living, if that makes any sense. Their pain and loss opens my eyes to appreciate the state of comfort and joy I experience in my own life.

So I said goodbye, I put my hand on her arm, I looked her in the eyes, and I wished her the best. And then they left, and I left, and our lives will never be the same.