Learning

Many of you know, and many don’t, that sixteen years ago I spent a year and a half volunteering as an ambulance medic for Magen David Adom, the national ambulance service in Israel.  It was a time of terror, fear, and death, but also a time of incredible joy, discovery and growth.  The people I worked with, the patients I met and took care of, prepared me in unexpected ways, for my career as an Emergency Physician.  Here is a piece I wrote back then, about a patient who affected me, tore at my heartstrings, and helped me become who I am today.  Many of my patients teach me not only about medicine, but also about myself and my place in this world.  I hope that this young woman that I met so many years ago can perhaps teach you something as well.

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January 29, 2002

Beit Hanina, Jerusalem, Israel

The second call of our day was one of the most distressing I’ve had to deal with.  My other hard calls – bus bombings, major trauma (car accidents), attempted suicide (two weeks ago, a young mother, OD’d on pills), DOA (man who fell/jumped/was pushed from a roof in Haifa and his brains were on the sidewalk) – were hell as well.  But today’s call was painful for different, deeper, reasons…

We were taken by police escort to Beit Hanina, in East Jerusalem, where we followed a car of men who took us to a residential building.  We climbed the six flights of stairs to find a locked door and a woman screaming behind it.  One of the men (a cousin of the patient) had keys, and unlocked the door.  Inside was a 17 year old girl in her second month of pregnancy.  She was hysterical, crying and screaming.  In the other room lay the heavy black bat that her husband had beaten her with – it was obvious that he had obtained this weapon with the pure intention of hitting his wife with it.  There was no other use for such a bat – it was hewn off at one end and covered in duct tape; the perfect length and size for a strong man to handle as a club.  The young woman was beaten all over her body, from head to feet.  He had punched her repeatedly in the back and in the face, and hit her with the bat in the legs, arms, stomach…even pregnant.  This was not the first time; apparently a similar incident had occurred last year but the police didn’t do anything to the husband.  So the girl stopped calling the police, figuring that her husband’s repeated beatings would just be shrugged off.  This time however, he didn’t only beat her and kick her and step on her – he took her passport and her 1.5 year old daughter’s passport, and dragged the child from the house.  He ran off with her, and the police are out looking for them.  This poor girl, Arab American, far from home and parents, now beaten badly and with her daughter kidnapped by an abusive man.  What a horrific situation.

The girl only spoke Arabic and English, so I became the primary caregiver.  In the apartment I tried my hardest to calm her down, regulate her breathing, and prevent her becoming even more hysterical.  When we finally convinced her to come outside with us, there was a group of men waiting who began to laugh and point at her – these were her husband’s friends.  A bunch of sick, twisted animals, reveling in the pain of a woman.  We took her in the ambulance and while the other medic took her blood pressure and pulse, I held her head in my hands and tried to keep her breathing slowly.  I treated her like I would my sister, stroking her hair and cheek, reassuring her.  She began to calm down, and lay there quietly, crying.

Once at the hospital, we put her in a bed and her aunt was there with her.  I can’t express how incredible a feeling it is to be able to communicate non-verbally with someone – her aunt only spoke Arabic, and she thanked me.  I understood the intention behind her words, and the kiss she blew me from her seat by the bed.  I connected with the look in her eyes, and I felt the emotion behind the hijab she wore.  Those last few moments in the emergency room were intensely beautiful, because I truly felt that connection between people that overrides any cultural, religious, ethnic or political walls that we’ve constructed between us.  Working in Israel in this time of conflict and unrest is amazing because of these moments of connection.  I feel my soul working through my hands when I put those latex gloves on; I can feel my innermost spark reaching towards every person I help.  There is a link forged between souls when my gloved hand touches someone; with healing I reach past concrete and steel walls to touch goodness on the other, hidden, side.

What I felt when I touched that girl today tore me up inside.  I felt the agony of a child stuck in a cage she cannot escape, tormented by the animal of her nightmare world.  I sensed the raging of a captured lioness, unable to free herself or strike back at her oppressor, and incapable of finding her stolen cub.  How helpless she felt, her daughter in the hands of a sadist and her own body hijacked by his fists.  There is only so much I can heal when I come to a scene; I never learned and will never know how to fix wounds of the soul.

My young patient reminded me of my little sisters, and I wanted to take care of her like I take care of them when they cry and need my strength.  I wanted to take her in my arms and rock her like a baby, stroke her hair and tell her ‘everything is going to be all right’.  Unable to reach out to her like that, I settled for stroking her hair and cheek, holding her hand, and making sure she knew I was there and taking care of her.

Why do people do such awful things to each other?  How can a man take a club to his beautiful young wife who is feeding his first child outside and his second child within?  Did the police find him, is the child all right, will he be punished?  Will she go back to him when the bruises fade and her humiliation is but a memory?  Did she lose the baby?

 

Today was a hard day, but also filled with sunshine.  The rain only started when my shift ended.  The wind woke me up this morning even before my alarm, and stepping outside I was greeted by a sliver of crescent moon and one bright star hanging over Jerusalem.  Perhaps the rain can wash away some of the pain shed on the streets of this city; perhaps the blowing wind can cool down the scrapes on the knees of a hurting nation.  This weekend is the first day of a new month, the new moon.  The month of Adar, the month of joy in our Jewish calendar; the first day of which is my Hebrew birthday.  I will be 24 years old on Sunday.  I will celebrate my birthday.  I will sing with joy at being here, in Jerusalem, in Israel, with my people and our cousins and extended family.  Yes, we try to kill each other, and there is hatred and destruction and murder; but I cannot stop it myself.  I cannot continue to work as a healer and at the same time take in all the pain; I must feel that agony and understand it, but not absorb it.  I must touch it, grasp it, examine it and recognize it; but then I must brush it off my skin like mustard gas.

Instead of putting it in the trash I have immortalized it on these pages.  You know what it is, you know that I have felt it and will feel it again; you are all my witnesses.

If one day I am heartless or cruel, place these words before me and remind me of my own testimony.  In such a way can I help this young patient and the others I will encounter.  My healing skills are not good enough to help them any more than that.

 

Leave them alone

What I do, it’s hard.

Even harder is when it intersects with my personal life, affects those I love.

When it’s someone else’s friend, family member, colleague, it’s easier.  It’s still tough, but eventually the emotions cool down and I can move on.

When it’s someone I know, have known, will know forever; that is when the intersection between work and life becomes a whirlpool and it’s really hard to swim to the surface.

The last month has been like this.

 

It’s hard to write about.

I worry I will traumatize the reader.

Read at your own risk, because no matter what you see on TV or the movies, life in the ER and the hospital is not all sex and drama and magical saving of lives.

 

Life in the ER is sometimes dark.

Life in the ER is sometimes light.

It can devastate

It can elevate

It can feel like torture, ripping out your guts as you fight and battle the system, the sickness, sometimes the patients and their families and even sometimes other health care workers.

It can feel like peace, rapture, working side by side with exceptional people who care deeply for the patients we all try to heal, seeing incredible outcomes at times.

 

But it’s never what you think it’s going to be when you start your day.

 

The last few weeks, medicine has been a maelstrom.  Some days I feel like I’m sleeping; caught in a hurricane in a nightmare I can’t free myself from.  My hair feels tangled and caught in barbed wire, my hands feel shackled, my heart feels squeezed inside a cage I can’t open.

 

People I care for have suffered, died, been diagnosed with conditions I can’t fix.

I am like an engineer with amputated thumbs.

A healer who can’t heal.

It’s devastating.

 

Death, I know you.  We are sometimes friends, we are often foes.  There are times I call you into the room with me to guide my patient to a safer, quieter, more peaceful place.  There are times I curse you and push you out with all my might, tell you that you are not welcome in my resuscitation room.  And then, there are times that I let my patient tell me which of these they want.

 

Some days, a sick woman who I could potentially save will hold my hand and say, “It’s ok. I want to go.  I’m done suffering. I lived a good life”.

Other days, a terminally ill man with dementia, with no real hope for cure, will have caregivers who are the substitute decision makers and ask me to resuscitate no matter the cost and no matter the suffering to the patient.

 

Death, there are days I beg you to walk away.  Withhold your promise of quiet days and calm nights.  Take with you the eternal void.  Let me do my job; let me heal.

I wish you would have listened this week.  You took someone very dear, vibrant, exceptional. You grabbed in your greedy embrace someone who was not done living, and by turning up the dial on her pain you made her ask for release.

I curse you for it.

I thank you for it, at the end, when it was too much for her to bear.

But I will continue to fight you for those we can save.

I promise, to be a shield against your reaching claws.

But I also promise, not to thrust you away when the patient before me needs you.

 

Just please, leave the rest I love alone.  For now.

Unexpected Hugs

It’s been a really rough couple of weeks.

First I had a young woman present with a devastating illness. Her family member is a colleague, and asked me to evaluate her at the end of a long, hectic, flu-filled night shift. The story was flu-like.

My patient said, “Doctor, I think I’m dying”. I laughed and reassured her, told her that she would no doubt improve. I told her, you are not dying.

Then I saw her results.

My heart fell into my stomach and I tried to justify what I was seeing: I couldn’t accept what it was.

A few days later, her follow up notes from the clinic showed cancer.

All I could do was cry and hug my kids close.

Next, illness in my family.

After that, illness in someone who is like family.

I’m struggling.

So having three random people gift me with unexpected hugs, on different days, over these last weeks has really been a life raft in an ocean of tears.

Thank you to my residents, Ortho and ER, for the first two warm and comforting hugs.

Thank you to a small, sweet little one today for that third and warmest hug of all, the hug of innocence and love. The hug of a child is the balm on my heart, it soothes and protects from the monstrous things I see every day.

Lying next to my daughter, holding my son in my lap, having my warm husband next to me each night, and parents and sisters nearby, all this sustains me. When the darkness encroaches, they light my path.

Medicine. It’s what I chose, and I wouldn’t go back. But for all the good I can do, all the people I can help, it’s the ones I can’t save that stay with me. I hope all this is worth it; sometimes I’m not sure my soul can take it.

I found myself wishing, praying for strength; this time, it came in unexpected, surprise, incandescent hugs.

The Other Side

I have stories to write from the last few weeks, but I need time for my brain to process.  In the meantime, please have a look at the one below; this is what I went through two years ago.  I am an MD who understands fully what it is to be a patient.

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It feels like forever since I last wrote.  Events of the last few weeks have compelled me back to my keyboard.  As some of you know, last week I was hospitalized for three days with what turned out to be viral meningitis.  I will never underestimate that diagnosis again in my medical career.  Let me tell you the story.

A little more than two weeks ago, on January 9, I flew to Orlando alone to join my husband for 48 hours as the first getaway since my now 11 month old son was born.  I had been feeling stressed, exhausted and overworked and needed a couple of days in warm weather lounging by the pool.  Two days after returning home, I woke up in the night with rigors (shaking chills) and I began to have a terrible headache.  It began as scalp pain, and progressed into, initially, a similar headache to what I get sometimes.  Usually, Tylenol and advil nip it in the bud; at the worst, a triptan pill takes the pain away.  It never lasts more than a day or two, and I’ve never actually had a diagnosis of migraine.

This time, my headache was intractable.  It wouldn’t go away no matter what.  Finally, on Saturday we were driving up north for my daughter’s ski lesson the next day when I decided to text a neurology colleague of mine for advice.  He said I could see him in clinic Monday if I was still unwell.  That night I hardly slept.  The headache, which was awakening me at 4 a.m. every night already, woke me and as well I felt terrible nausea.  I began to vomit and couldn’t stop.  My mother drove up to get me, and by 8:15 I was in the emergency department at my hospital.  My headache was so awful that I couldn’t think straight, couldn’t function, could barely walk.

I was immediately taken to an exam room and quickly started on anti-headache medication, anti-nausea medication and fluids.  During the day I had a CT scan of my head which showed some signs of elevated intracranial pressure (high pressure in the brain) and finally I was seen by the Neurology service.  They sent me home that evening as I felt better and they thought it was just a migraine.  I spent the next day suffering at home, and overnight I woke again at 4 a.m. extremely dizzy and with a horrible headache.  I drove myself early to work (I was scheduled to start at 8…) in my scrubs, ready to get some medication and work through the pain.  However, upon arrival I could barely walk to triage I was that dizzy (yes, it was stupid to drive).  In a wheelchair being taken to a room I almost vomited everywhere.  I spent another day being worked up by a different neurologist and his team, who decided I had pseudotumour cerebri (benign intracranial hypertension – high pressure in the brain).  This is relieved with a lumbar puncture, so they tried and couldn’t get it.  After lots of medication I again felt better, so they sent me home to come back in the morning to try the LP again under xray guidance (fluoroscopy).

The next morning, I felt like my head was underwater.  My ears and head felt full; as if my sinuses and ears were full of liquid.  I went for the LP in the early afternoon.  Let me tell you; LPs are nothing to sneeze at.  Yes, as physicians we always freeze the skin before putting in the larger needle to go chasing the cerebrospinal fluid, but the freezing is agonizing and even worse are the sharp, burning pains that come with a poorly angled needle.  I had 2 LP attempts the day before and my back was very bruised, so when the radiologist put in his LP needle I cried quietly into my arm.  Thankfully he got the fluid quickly.

As they wheeled me back to emergency, I was lying supine to avoid a worsening headache post-LP (as often happens).  I remember looking up at the ceiling and noticing when we moved from the old building to the new, as the lights suddenly became brighter and cleaner.  I remember little conversations, like someone saying the Habs traded Galchenyuk (not true) and an orderly singing “Oh my darling Clementine”.  It’s a very strange and almost hallucinogenic experience to be wheeled down corridors lying flat on your back, and I felt enormously vulnerable.

Finally, the neurology team came to find me and informed me that there were 400 white blood cells in my CSF (cerebrospinal fluid) and therefore I likely had viral meningitis (an infection of the fluid and space surrounding the brain and spinal cord).  You may have heard of bacterial meningitis – this is the one that kills, and quickly.  But viral meningitis is usually described as “benign”, and as physicians we usually treat it as such.

Let me tell all of you: viral meningitis may not kill, but it is debilitating and remarkably painful.  I had a c-section where my epidural stopped functioning so I felt the whole thing, and meningitis was worse than that.  Worse, because it really really hurts inside the head.  Worse, because I felt that there was an alien organism – the virus – in my brain; I didn’t feel like me, I wasn’t able to process thought as I usually would, I couldn’t handle everything as I usually would.  I felt taken hostage.  Before sleep, during my admission, I was afraid to close my eyes because I would see monster faces there.  Stuck in a hospital room on isolation precautions, I felt helpless.  Away from my kids, unable to breastfeed my baby, I felt hopeless.  It was awful.  And throughout it all, I had such guilt that I couldn’t do my work and that my colleagues had to pick up my slack (and I heard about it from more than one disgruntled physician, which to me is pretty disgusting).

I then spent 3 days hospitalized with IV antibiotics (just in case) and lots of painkillers and anti-nausea meds.  Finally, I was able to be discharged home.  The Infectious Disease staff and the Neuro staff came to see me that morning, and made a big show of ripping down the isolation signs.  We still didn’t know exactly which virus it was, but on arriving home and jumping in the shower, I found that I had shingles under my right breast!  Shingles (zoster) is the reactivation of the latent chicken pox virus from a nerve ganglion in the body, and can cause both a zoster meningitis and an “aseptic” meningitis (where you don’t grow the virus in the CSF, it’s the body’s reaction to the illness).  As well, I was in Florida and had a couple of mosquito bites so this could have also been West Nile.

After finding those lesions, I spoke to ID specialists who started me immediately on an antiviral medication.  Within one day my headache was completely gone and I felt a whole lot better.  My cultures finally grew zoster in the cerebrospinal fluid.  Wow.

Now, I am feeling somewhat better, though going to work three days after discharge did a number on me.  At the end of the shift my head was in agony, but as soon as I rested it got better.  I have been told that meningitis is like a concussion; the brain needs time to recover that can take weeks.  I hope it’s faster than that, as I work tomorrow and overnight Friday.

 

All this to say; I’ll never call this illness “benign” again.  I have a newfound respect for viruses.

Hugs, and hug eachother.  Appreciate life.  I do.

Funeral

There is a funeral today.

I should probably go.

I can’t go.

I won’t get there on time.

I have no one to talk to about it.

I don’t want to go alone.

 

A month or two ago I met a patient, who touched me.  I can’t tell you the medical details, but I’d like to share an outline.  She was an elderly lady, and was brought in to the ED for an acute illness.  She had been sick for a while, and had finally agreed to see a physician.  When I met her, my initial thought was “what a sweet, but stubborn, lady”.  My second thought was “oh no”.

These days, having been working as an Emergency Physician for four years, after a five year residency program and four years of medical school, I have started to make some diagnoses almost immediately.

My patient had signs on history and physical exam that led me to understand the nature of her illness without even having results on paper.

What I didn’t know, was that my CT scanner would reveal something much worse, along with my initial diagnosis.  The “donut of truth”, as some colleagues refer to it, tells all.  It told me a story I didn’t want to retell, and I felt torn in shreds as I pored over the images.

A short while later, I called the daughter and asked her to come back to her mother’s room so we could talk about what the results showed.  I walked back into the room knowing that the calm and peaceful faces in front of me would rapidly be changing into terrified, desperate ones.  As I told my story, which was in English and partially translated for my patient’s benefit, I watched the change come over the room.  I felt the sorrow to my core.  If sadness had a smell, it would be what permeated the air by the time I finished.

 

They thanked me.

Why do our patients and their families thank us for delivering a death sentence?

Why do they look at us with gratitude, when we have just clarified things to an extreme, one that is terrible and heavy and horrifying?

 

It’s so hard to know what to do in that moment.  We are taught in our travels through medicine how to “break bad news”.  But you don’t know what that feels like, having to do it every day.  It’s a weight, pressing on your heart, weighing on your shoulders.  It threatens to pull you under the waves of grief that wash through the room, a tsunami of distress and fear.

It’s all I can do some days to swim desperately to the surface and get my head above water.  I try to remember that for all the darkness, there is always a dawn that breaks.  Night doesn’t last forever.  While I may not be able to save one sweet, stubborn woman or give solace and hope to her family, the next patient may be one I can make a difference for.

That’s why I do what I do, I guess.  For those times when I can change the outcome.  And, perhaps, for the ones when I can’t alter the ending but can make the ride there a bit more comfortable, a bit less petrifying.  Sometimes, I use my smile and my own inner light to brighten up the darkness I bring into the room with me.  I can feel it inside me, wanting to push away the clouds.  I do what I can.  Then I walk away.  And I feel it.  The presence of someone else’s sadness, taken into myself in exchange for any comforting words I could impart.  It really is a give and take, and it is spiritually draining but fulfilling all at once.

So today, there’s a funeral.

A goodbye.

The end of a traveled road.

I can’t go.

But she’s already gone.

 

Thank you for letting me share this with you here.

The Colour Purple

I picked up a chart and prepared to enter the room of an elderly patient presenting with pain, in the Vertical unit of our ED (so called because our patients generally are able to walk in and out instead of requiring a stretcher).  I overheard the nurses near me commenting on how “cute” this patient was, so I was looking forward to seeing what awaited me. 

Walking into the room, I met a spectacular person.  Dressed all in royal purple, she sat like a queen in a low tech wheelchair, with a napping husband in the corner of the room.  She was expertly coiffed, and had on a full face of stunningly done makeup.  Her lashes were long, dark and curled; her cheeks had concealer and blush, and her eyes were lined and dark.  Her full lips were warm and red, and her nails were newly manicured.  A full head of soft white hair pulled back in a bun, sat under a purple bonnet.  A fur collar on a purple peacoat added to the already opulent picture. 
I have never seen such a gorgeous lady in my examining rooms of my urban tertiary care ED, or even in life.

She radiated a presence, a glow, a light of life and beauty.  Her youth must have been something, if at 96 years of age she maintained such character. 

My mind spun with questions, ones I could not ask.  While I ran through my litany of Emergency Medicine related diagnostic queries (where does it hurt, how long, any trauma, any fever, have you had this before…) all I wanted to ask was “did you dress yourself, did you do your own makeup and hair”?  I wanted to know, why did she come to the ED looking so incredible?  Sadly, in my mind, I couldn’t help but wonder if this was her only way to impress the world.  Yet I spun tales for myself, backstories, as I do with many of my patients if not all.  Was she an ex-ballerina, still mentoring young girls as they move through their training?  A Holocaust survivor, making herself beautiful until the day she dies, as a way to spit in the face of oppression and evil?  A blushing young bride now living with an old, doddering husband, but still feeling 18 years old, with a young admirer or two, or a torrid affair?  Perhaps she was a fairy godmother, quietly inhabiting our world mysteriously.

When you work in the field I work in, it is often easier to imagine beauty rather than face reality.  Likely, this lady before me took the opportunity to make herself gorgeous because she was coming to the hospital.  Perhaps this is the only time she gets out into the public eye.  Perhaps an outing to the ED for pain control is her only social life.  But when I think this way, it makes me sad. 

Better to fantasize, imagine the incredible life she lived and lives still.  Better to take the purple she offered me and paint her into a tapestry of joy and warmth, to colour my days with loveliness. 

 

Queen of Vertical, I wish you the remainder of your days filled with bright hues of purple.  Thank you for illuminating my life even for a few moments, and opening my mind to the possibility of magic.

Alive

Sometimes I wonder, what makes me feel most alive these days?

Is it running a resuscitation successfully?

Is it caring for my sweet children?

Is it swimming again during Masters’, after years of avoiding the pool?

Is it time off with my husband, doing something we enjoy?

 

Yesterday I felt it.  I finally felt that rush of being present, alive, in the moment.  It happened most unexpectedly, as I walked out into the cool, dark evening air after a committee meeting at the university.  Suddenly, I felt transported to a time when I was free, without responsibilities, without anxiety, without a ticking clock.  Walking down the steep hill with the city spread out before me and the twinkling lights of dozens of cars, shops, apartments, police cars, lit up my insides like nothing has in a long while.  Perhaps it is because I made that same walk so many times, during my medical school years, and each walk back then felt energizing.  I felt, then, that I was working towards the end goal: physicianship.  I had purpose, direction, and my brain was on fire with learning.  My soul tingled with anticipation of the future.

 

I often find myself missing those feelings, the joy, the wonder, the vitality of being a student.  These days, I am the teacher.  I am the one imparting the knowledge to others.  A few weeks ago, I was the staff evaluating the medical students’ case presentations at teaching rounds.  Watching their faces light up with the excitement of discovery filled me in turn with happiness.  I felt fulfilled by the fact that the students were so intrigued by their cases, their patients.  It made me remember being in their shoes, and how full my heart would get when I finally solved a medical puzzle.

 

Recently, I worked with a very shy and quiet medical student who was nonetheless relatively competent after already having worked some shifts in the Emergency Department.  Partway through the day, we were called to the resuscitation room for a patient who was in cardiac arrest.  He was in his 90’s, had lived a full life, and had dementia.  He was found by a family member unresponsive, and the ambulance technicians had already been doing CPR on him for over an hour with no success.  When he came to our resus room I gave him a fighting chance; continued CPR, pushed epi a few times, but after not too long I chose to call the code after a discussion with his family in the room.  I pronounced time of death, and closed his eyes.  During this whole time my student and resident were both in the room, observing, as I narrated to them what the team and I were doing and why.  Afterward, I took the student aside to debrief, as the loss of life under our care is always difficult to process.  She admitted that this was the first time that she had ever seen a patient die.  She had been present at numerous resuscitations, but the patients had always survived.  This time, her luck ran out.  I was surprised at how unaffected she seemed to be, but I know that this is a defense mechanism.  I made sure to counsel her on talking about her feelings with friends or family after the shift, and told her that I am always around to talk to if she needs.

 

I know how it feels, to stand in the room and watch as a patient passes away, and not have the ability to save them.  I know how helpless one feels, as a student, resident and even as an attending staff.  I also know how the feelings of devastation, guilt, sadness, can haunt us if we don’t take care of ourselves.  Now, as a teacher in medicine, it is my role to help my learners get through these hard times as well as the good.  This, too, is enormously fulfilling.

 

Currently, I am the Site Director for the Emergency Medicine course at our hospital.  I am responsible for orienting, guiding, and evaluating our medical students.  I take this responsibility very seriously, and I enjoy it.  My goal is to take a green, scared medical student and pull them into the wonderland that I see as Emergency Medicine.  I want to turn them around, make them tap their ruby slippers and wake up to a new world, a place they want to lose themselves in because it’s so incredible.  I wish for them a month full of new things, challenging moments, and transformation.

 

Maybe that’s why I felt so content after the Clerkship Committee meeting.  I am finally involved at the undergraduate level, in helping to adjust and implement the medical curriculum.  I am now part of the system that I worked so hard to get into in the first place.  I am back in the “ivory tower” of academia; I am using my intellect and firing up neurons that were dormant during the last few child-bearing years of my life.  This feels really good.  This makes me feel alive.

Balance

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

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

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

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

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

 

How do I do it?

I wish I could tell you.

I wish I knew.

 

Sometimes, it’s hard to make that transition.

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

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

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

Paradox

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

Being a physician, I am trained to solve problems.

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

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

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

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

The other day I had such a case.

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

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

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

 

She will die.

 

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

I solved the puzzle.

I won the game.

I am the messenger.

I am the physician.

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

Soul Searching

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

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

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

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

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

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

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

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