Dr Newfie

Who Reads My Blog?

2010-09-29T02:21:00.003-02:30

I've always thought this blog was primarily read by my sister, since I don't publicise its existence too much. A few friends know of it, as well as my immediate family, but otherwise I figured it sat in blissful peace in a hidden corner of the Internet.

Anyway. I was rather startled to discover that the keywords associated with my blog are (in order):

"i hate residency"

"hate residency"

"hating residency"

"hate residency" surgery

"i hate being on call"

"i fucking hate residency"

and - most oddly

"newfie has hard time pissing"

This speaks to the toll residency takes on us... I wrote that post in March 2009 and it remains the most-read post of this blog.

I am so grateful that I am no longer a resident...

To all my fellow-residents who stumble across this blog, try to take some comfort in knowing you will also someday finish the retarded shit-filled journey of residency and come out the other side. Don't ever forget what it was like, and try your very best not to perpetuate the cycle by torturing your own residents as an attending.

Code Lesson

2010-09-29T01:51:00.008-02:30

" “Call it.”

“The Intern looked at me mid-compression, sweat beaded on his brow.

““Sir?” His voice was unnaturally high.

“You heard me. Call it.”

“She can make it,” he insisted.

I heard another crack crack as he continued the compressions. Surprising – I hadn’t thought there were any ribs left to break. The woman’s arms flopped up and down as he pounded on her naked chest. Bloody froth bubbled up the snorkel I’d jammed down her trachea earlier. It didn’t budge despite the violence of my Intern’s efforts. I pushed aside the guilty pleasure this evoked.

“It’s been forty minutes. She’s gone.”

“No.”

I glanced at the watching nurses. Only the Intern - whose name I couldn’t remember – was still working on the woman. The rest of us had stopped five minutes ago. Always in July, when the new interns arrived, we went through this. The medical schools taught them to fight. Here we would teach them how to cope with losing.

I moved closer to the bed. Touched the woman’s forehead. It was cold and mottled. Shining a light into her glazed eyes, I was satisfied – fixed, dilated pools of unseeing black stared back.

I reached out and took the Intern’s sweat-soaked shoulder. “She’s gone,” I said. “You’re not doing her any favours. She deserves a little dignity.”

“She can make it – she’s only thirty, you said the young have a better chance – we can’t just give up – “ His voice broke.

“Look at the monitor.”

We both stared at the machine.

“What is that rhythm?”

“Asystole.” I could barely hear him.

“And what do you do when you see asystole?”

“Check another lead.”

A nurse switched the machine to a second lead. The flat trace on-screen did not move.

He looked down at his hands, which shook from – exhaustion? emotion? both? I couldn’t tell.

“Call it,” I said.

He unslung the stethoscope from around his neck and placed it against the woman’s breast. I knew there was nothing to hear, no textbook lub-dub lub-dub there, but he listened intently for an eternity before he straightened and made his way to the woman’s head. Shone his penlight into her eyes as I had just moments ago. Nothing there either.

He licked his lips, looked up at the clock. Looked back at me. He looked old, his shoulders stooped. Defeated.

He cleared his throat. “Time of death fifteen forty.”

The nurses moved quickly, an army of worker ants covering up the dead. I watched as they removed all the things with which we had invaded the woman’s body. Lines, catheters, leads – a finger or tube in every orifice was the protocol – with them gone, she looked startlingly human.

The nurses covered her with a blanket, tucked in at the sides. I lingered behind, alone with the woman and the Intern. I watched as he moved to the head of the bed where she still stared at the ceiling. Putting a finger on each eyelid, he nudged them closed.

“I’ll be outside,” I said quietly.

He nodded, unable to meet my gaze.

As I slipped out, I heard him begin to cry.

---written for Creative Writing (Fiction) course

Alzheimer's

2010-09-29T01:50:00.002-02:30

Have you seen your mother, Barry? She was just stepping out to get a cup of tea. You know how she is, her and her tea. She’s always been a fan of tea. Now me, I’m a coffee man. I forgot to ask her to make me a cup of coffee. I should have… God, I’d kill for a cup… But she should be back soon. Maybe she’ll have remembered to bring me coffee. She’s a wonderful woman, your Ma. Oh we had some good times…. We met in – in… gosh, I can’t remember, where was it we met?

Jakarta, Pa.

Jakarta… you know, I’ve always struggled with that… sounds too much like that other place, that island one, the one that’s sunny –

You mean Jamaica?

Ja…may…ca…. It doesn’t sit well on my tongue, no sir! But those were the days… Oh! I’m sorry, sir, I was just lost in my thoughts. Are you here to visit someone? I can someone to help you. There’s this little button here, I push it when I need help. Marvelous thing. Who are you visiting? Funny, you look like someone I used to know… a long time ago, it was –

Pa, I’m Peter. Your son, don’t you remember?

Peter? Is that really you? You’re so tall! Your ma would be so proud to see you. Where is that woman? May! May! Peter’s come to visit! She was just here a moment ago. May! Oh, I think she’s gone to the store to get some milk. Anyway, how are you? It’s been such a while since you came to visit. You know, this place isn’t the same without you… it gets so quiet here. I don’t like it but they won’t let me turn on that – that thing – the one that shows pictures, I forget the word –

The TV?

Yes, that’s it. Anyway, they don’t let me turn it on. I bet if your mother was here she’d say screw ‘em and turn it on all the same. Where is she? May! Gosh, will that woman ever come? Have you seen your mother, Barry?

Pa – I don’t know how to say this – she’s gone two years now….

Gone? Oh my god! It’s not true, tell me it’s not true! May! My May… How’s that possible? What will I do without her? Oh, I must call the boys and tell them… whatever will I say? May…

Why, it’s you, Barry! When did you arrive?

It’s Peter, Pa….

So it is! Peter, would you go get your mother? Outside, at the nurses’ desk, they’ll know where to find her. I think she just stepped out for some air. She loves to socialize, you know. Most days I have a heck of a time tracking her down, always did. Be a dear, Peter, just pop out and ask the nurse where your Ma is.

All right, Pa. You stay here. I’ll go ask in a minute.

Ah, what a good fellow! I hope you find that woman. May! I swear she doesn’t pay me any mind at all… women! I wonder if they’ll let me turn on that thing… that – what did you call it again? The one that shows the pictures. I wonder if they have pictures of that place I liked so much. The one with the beaches. That’s where – why are you crying, Barry? Don’t cry… your old Pa is here… it’s going to be all right. Did you skin your knee?

---written for Creative Writing (Fiction) course

Sore Nostril

2010-09-21T08:18:00.002-02:30

0200hrs

It is raining heavily outside. Hurricane Igor is approaching, and the roads are slick and wet. The ER is empty - and rightly so, considering the weather conditions.

Then a bedraggled, drenched man in his 30s walks into the department. He checks in at the desk and is triaged. I keep an ear open from my hidden place behind the triage area.

"What brings you out in this awful weather?" the triage nurse asks.

"My bed has bedbugs."

"Yeah, there's an infestation across Canada. But what can we do for you today?"

"Get rid of the bedbugs."

There is a short silence as the triage nurse ponders this serious predicament.

"Sir," I hear him say, "we unfortunately do not exterminate pests here. Go home. Open the Yellow Pages. Look under Pest Exterminators. This is not the place to be coming for bedbugs. Or rats, or insects or wasps for that matter. Now, go home."

And with that, the triage nurse ushers him out the door and gently shuts it.

0400hrs

A 19yo woman checks in at the front desk. I pick the chart up. "Nose Problem", is the chief complaint noted on it.

I read the triage note. The triage nurse is having a hard time keeping a straight face, as a look of utter disbelief is written all over mine.

I call the patient in and wait as she sits down. She is soaked from the sheets of rain pouring down outside.

"What's going on?" I ask, in as neutral a tone as possible.

"My nose hurts. I was picking it all day and now the nostril hurts."

I can't think of anything to say.

"Can I have some cream for it?"

Silently, I stand and reach for the otoscope. I shine the light up the nostril she points at. The mucosa is raw and red.

"You don't need a cream," I say, replacing the otoscope. "You need to stop picking your nose."

"There's no cream that will fix this?"

"No, there's no cream for this. You just have to stop picking your nose."

I can't believe I'm having this conversation - in the back of my mind, I wonder how it's possible that I spent 5yrs in medical school, 3yrs in residency and am now sitting in an ER at 0400hrs advising a woman not to pick her nose.

She's not happy, but she leaves. The triage nurse waits until she is out the door, then bursts into laughter. I roll my eyes at him and go back to my game of Jumbline on my iPhone. Darwin loses another battle.

Feather Shedder

2010-09-20T03:55:00.002-02:30

"I'm dying", she said. "I need to be admitted so I can spend my last days in comfort."

I eyed her dubiously, a thirty-something year old woman who looked unkempt and smelled rather noxious.

"What makes you think you're dying?" I asked.

"I saw it in the newspaper," she said. "It announced I was dying."

While I searched for an appropriate response, she dug a piece of paper out of a pocket. Unfolding it, she handed it over to me.

"See?" she said. "It clearly says I am dying."

I perused the ragged piece of paper:

SALE! SALE! SALE!

TIME IS RUNNING OUT!

IT ENDS IN ONE WEEK!

"I don't understand," I said. "Where does it say you're dying?"

She sighed impatiently and pointed at the words. "Don't you see?" she said, as if speaking to a child. "Time is running out! I'm going to die in one week!"

I scratched my head.

"Hmmm. Are you feeling ill? Is anything out of the ordinary happening?"

She bit her lip. "My body is collapsing."

"Oh."

"I'm telling you - there's something terribly wrong with me!"

"Can you describe what's happening in your body? It might help me understand better."

Wringing her hands, she stood up and began pacing about the small examination room. "I'm shedding feathers... everywhere I go I'm shedding feathers. And I'm passing out often. And when I use the bathroom, I'm pooping feathers!"

"Feathers."

"Yes! It's a sign! When angels die, their feathers start falling off! That's what's happening to me!"

"You're an angel?"

"Are you one of them?"

I frowned. "One of whom?"

"Them. Are you one of them?"

"I'm not sure. Tell me... have you been taking your medications lately?"

"No, I won't take them! I'm supposed to take my medications as cold fusion monotherapy, and my medications are warm so it's poison."

"I see."

I pondered the situation for a moment, and then a brilliant idea seized me.

"Listen, I think I know what we should do."

"You think I'm crazy, don't you?"

"No," I lied smoothly. "I don't think you're crazy, but some of the things you're telling me sound quite unusual. I think that the best thing to do would be to have the psychiatrists declare that you're NOT crazy, and once they see you and decide you're not crazy, maybe we can look into finding you a nice place to spend the last days of your life in comfort. But, you see, this would be difficult until and unless the psychiatrists declared that you aren't crazy first."

Even as the words left my mouth, I was uncomfortably aware that I didn't make sense to my own self. I hoped she wouldn't pick up on it.

"Oh," she said. "So if I see the psychiatrist and they realise I'm not crazy then I can get some help?"

"Yup."

"Okay," she said.

So we sent her to the psychiatric hospital, where they admitted her and medicated her such that the problem of her feather-shedding resolved.

Creep

2010-06-22T20:24:00.002-02:30

Him: "Doctor, I've been having pains in my stomach."

Me: "How long have you had this for?"

Him: "Two months, Doc."

Me: "And why are you in the ER at 3am instead of calling your family doc??"

Him: "I couldn't get satisfaction from the GP."

Me: (eyebrows raised) "Can't get no satisfaction."

Him: "Yes, I can't get in till tomorrow!"

Me: "OK... any nausea? Vomiting? Diarrhea?"

Him: "No."

Me: "Problems peeing? Bowel movements?"

Him: "No, that's all fine."

Me: (palpating his abdomen) "Tender at all?"

Him: "No."

Me: (pulling the drape back over him) "Well, your belly is nice and soft. I don't think there's anything terrible going on in there, you know?"

Him: "Wait, Doc! Can you press here again?" (he gestures towards his lower abdomen, near his pubic area)

Me: "I already did that."

Him: "No, I'd like you to do it again."

Me: "I'm sorry, but I'm not repeating that exam."

Him: "But really, Doc, can't you just press there again?"

Me: "Sir, I don't think there's anything wrong with your belly. I'm discharging you and I am not pressing there again."

A Long Hiatus

2010-06-22T20:10:00.002-02:30

I assumed that nobody really reads this blog, but having taken a long hiatus from writing in it, I kept getting asked by some people as to "what happened" to my writing!

Life has been BUSY leaving me little time for "creative" writing. Since I last wrote, I began taking a course at Memorial University in playwriting. And being required to write about 3 pages of dialogue and scenes every week has taken its toll on any other writing. Thus, the paucity of entries lately.

That's not to say that work hasn't seen its fair share of "odd cases" - I simpy haven't had the time or wherewithal to document them for anyone's reading pleasure! It still amazes me how much variety I see in my line of work. Scattered among the bread-and-butter is always something weird and wonderful. In the herd of horses that come my way, there is often a zebra hidden somewhere.

Outside of work, I recently played at my first-ever cello recital. It was an awful affair. First, I arrived late. (The Starbucks line was unusually long, I was sleep-deprived and needed one desperately, and the venue for the recital was someone's house in an area of town I had never been to). I was third on the program, and had a terrible case of the nerves. All the other cellists seemed to acquit themselves marvellously, but I have an unfortunate habit of making faces when something is out of tune. This habit also manifests itself in choir practices and even performances so the recital was no different. My terrible playing was thus accompanied by (potentially more) terrible faces. Thank God for my teacher's wife who gamely accompanied me on the piano. Her lovely playing at least offered some redemption.

Oddly, I got numerous gracious compliments from the people at the recital. I think it is probably because I out-age the other cellists by a decade or so. Adult beginners, apparently, get cut more slack. People admire us for our guts in picking up an instrument about 25yrs later than most - and then playing horribly in front of guests. The other thing I learned from my cello recital was that I shall still be making "noise" in 10yrs time. It really struck me that some of the students, despite having played for 10yrs, still don't have as fluid or wonderfl a tone on the cello as, say, my teacher. Of course, he is a professional cellist (and the principal cellist of the orchestra, no less) - but still... after 10yrs of playing piano one can play some pretty impressive pieces, no? Not so for the cello.

In any case, I guess - to use a rather grotesque term - I "popped my cherry" in the world of recitals. Amazing that I did so with the cello. I'd never played at a recital, not even the piano which was what I was originally trained in. It's always hardest the first time around, so maybe next year will see me pulling off a maestro-like performance. Ha.

Anyway. Back to the original purpose of this blog. Because I'm sure you all can't wait to hear more tales from the land of the ER. No promises for regular updates, though!

Bright Things Die

2010-03-04T19:15:00.003-03:30

I don't understand the world today. But I know I will get over it. My heart feels heavy because in my head I can still hear the awful sound that her mother made when I broke the news to them. It was an animal sound. The sound of grief beyond bearing. These are things you never get used to. She begged me to save her child but I could not. Two days ago, I saved a woman who had attempted suicide not once, not twice, but three times. Three times her heart stopped and I brought her back, and she woke up today none the worse for wear. But yesterday I was helpless. I don't understand the world today. The young die. The old live. Those who love their lives lose it. Thoe who hate their lives keep it. I know I will get over it. But today as I got ready to go to work, I could still hear her mother's voice in my head. Please, please save my child. Save my daughter, please. But it was not within our power.

Pantshitter

2010-03-01T07:51:00.004-03:30

"You have gastroenteritis."

I deliver my diagnosis confidently and in a tone that strives to quell any disagreement.

My patient, a 55yr old woman, looks dubious. She's had nausea, vomiting and diarrhea for three hours. It's terrible, she says. Especially the diarrhea. It's uncontrollable. Explosive. She hasn't travelled anywhere, taken any antibiotics, been exposed to anything that would put her at risk for C.Difficile diarrhea.

"It has to be more than that," she insists.

"No, I'm telling you, it's gastro. You feel miserable and awful, but your bloodwork is perfectly normal and your belly exam is nice and soft. There's nothing here that would suggest something awful or life-threatening or indicate that there's something worse going on than gastro."

"I want a scan," she says.

"I'm sorry, but I don't scan people arbitrarily. There's nothing to suggest that the benefits of scanning you outweigh the risks. Scans aren't benign, you know. The radiation is hundreds of times that of an Xray and if there isn't any reason to expose you to that, I won't."

"So I'm just supposed to go home like this?"

"This will get better in 24-48hrs," I say.

"You can't send me home like this," she pleads, "you have to fix me."

I remain unmoved. The nurse removes her IV. We get her dressed. Still bitterly complaining, she leaves the department.

.

.

.

.

45 mins later

.
.

.

.

"There!"

I look up from my charting to find myself face-to-face with my patient. A dreadful smell fills the air.

"I told you I was having diarrhea."

She's waving something around in the air. It's her pants.

Brown liquid shit drips on our floor.

I've had enough.

"Mrs X," I say curtly. "I didn't doubt you are having diarrhea. Bringing your shatpants as proof doesn't change my diagnosis. You have gastro. Go home."

Defeated, she slinks away with her little trophy.

This time, she does not return.

Random Vignettes

2010-02-28T08:41:00.004-03:30

3.30am

"I want to see the doctor."

I glance at the speaker briefly from my hidden vantage point in the room adjacent to the triage desk. He is a middle-aged man, unkempt and dishevelled with wild hair.

"The doctor will be with you shortly," the triage nurse says, "but first I have to ask you a few questions. What brings you to the ER?"

"I want a full body checkup."

"Ummm okay... we don't do full physicals in the ER," the triage nurse says. "That's something you need to speak to your family doctor about."

"OK, but can I still see the doctor?"

"Yes," the nurse says, "but I'll have to do a set of vital signs on you first."

He acquiesces and she performs the necessary before slipping into my room and handing me the chart while rolling her eyes.

I set aside my charting, pick up the chart and enter the room where the man is waiting.

"I'm the doctor," I say. "What seems to be the problem?"

"I want a full physical," he reiterates.

"Why do you want a full physical?"

"For my own peace of mind," he says. "I was drinking downtown and the next morning I found this. It's bothering me a lot because I don't know how I could have gotten it."

He rolls up his sleeve and shows me his forearm, where a small bruise about the size of my pinky fingernail is evident.

I arch an eyebrow. "Perhaps you banged your arm accidentally."

"No, I don't remember that."

"Well," I say, "I don't think that's anything I would be terribly concerned about."

"Still," he says, "I'd like a full physical exam just to be sure. Bloodwork, tests - "

"Sir," I say firmly, "we don't do full physicals in the ER. That's something you need to talk to your family doctor about."

"Okay," he says. "I just thought I'd try."

And with that, he flashes me a crooked grin, grabs his coat and walks out.

4.45am

Hic.

Hic.

Hic.

My patient's problem is evident almost at once.

"I - hic - can't stop - hic-cuping," he says forlornly.

"How long has this been going on for?" I ask.

"Hic - two - hic - days and I can't - hic - sleep."

He outlines the things he's tried - every old wives' tale one can imagine.

The triage nurse, I'm told, had also tried her version of scaring his hiccups away, asking him if an 8hr wait to see me might help. Alas, her efforts have been in vain - and anyway, the wait tonight is only an hour. I scribble some orders in the chart for some Maxeran, then return to tell my patient what the plan is - an intramuscular injection to stop his hiccups.

Forty seconds later, when the nurse arrives to give him his shot, he's stopped hiccuping.

She gives him the shot anyway.

A Good Call

2010-02-27T00:25:00.004-03:30

Having gone home recently for two weeks to spend some time with my family, I was informed that my blog has of late become rather depressing. While it is true that the last few entries (scarce as they have been) have been somewhat macabre and morbid, it is also true that I simply haven't been writing as often and when I do write, it is usually because I need to get something off my chest. And typically that something is not something happy. Today, though, was a good day.

When I was training to become an emergency medicine physician, there was something I occasionally saw written on my evaluations. "Has good gestalt for the field," it said. Though I never did look up the meaning, it apparently referred to the "gut feeling" which, it is said, is important in the field of emergency medicine. Trust your gut, I was always told. But this is easier said than done. After all, medicine should be less about gut and more about science. Evidence, bloodwork, lab results, CT scans, Xrays - don't all of these trump this "gut"?

Eight months into practice, I've learned that they don't. I've learned the hard way. Just about every single time I've ignored my gut and proceeded to send a patient home based on their normal bloodwork/labs/CT scans/Xrays/physical exams - I've been wrong. It's hard to trust your gut. It's especially hard to trust your gut when you are a fledgeling newbie in the field. It's even harder to trust your gut when you have to consult an irate specialist and say, "I have a patient complaining of X. All the workup is negative but something just isn't right and I'd like your opinion." You feel like a schmuck. You absorb abuse sometimes. You know that the specialist thinks you're an idiot. In fact, some of the more grizzled ones will tell you so too. But I've learned to trust my gut a little more than I did when I first started. Sometimes my gut is wrong and there really is nothing wrong with the patient. But it's better for my gut to be wrong than to be right. Because some really bad things have happened when I've ignored my gut. If something doesn't feel right, I've learned to look harder.

Today I saw a young patient. Something didn't feel right. I could have sent this patient home, written it off as an asthma attack. It looked like asthma. Sounded like asthma. Wheezed like asthma. Coughed like asthma. But something didn't fit. My gut said it wasn't asthma. So I started looking closer. And it turned out in the end that it wasn't asthma. In fact, it was a pulmonary embolism. Something potentially fatal. People get sent home with PEs not all that infrequently and some of those patients drop stone cold dead shortly after.

So today I made a good call. And I learned again to put faith in my gut. And today making that good call makes me feel good about what I do. And it's the things like this, I guess, that make me love what I do even when there are many times when I question whether what I do makes a difference. Because I know that I made a difference in my patient's life today - about as big a difference as the difference between life and death. And it doesn't really get much bigger than that. I get to be a hero today even if it's just in my own eyes. It sounds grandiose, it sounds stupid and egotistic - but it's important to me to be that once in a while, because it's what makes the rest of the work tolerable. It's knowing that despite all the other crap that we have to absorb and face, despite the gruelling and often disheartening parts of the job, for all the people that we lose, sometimes we also win. And even if nobody else is watching, if nobody else sees it, if no cards come in the mail nor letters of thanks appear in the paper - I know that I made a difference in this young patient's life. And that's enough for me.

When is it time to quit?

2010-02-01T09:55:00.002-03:30

It's been so long since I've written, and so much has happened. I just got back from a shift that has me thinking and this is my outlet I suppose. In the last few months, I've settled into life as an attending physician, received my final piece of paper that affirms my credentials and everything has gone on as usual in the ER - life and death, hopes affirmed and crushed. Many days I wonder if the constant parade of tragedy and drama in the ER is something that will eventually fail to move me, and if so, will that be my cue to leave or a sign that I have finally come into my own?

Tonight I watched someone die a slow and painful death. I tried what I could but in the end all my trying amounted only to prolonging suffering. It wasn't my fault my patient died that way, but the system - which includes me - could have done better. We could have done better and yet we didn't, because of politics, miscommunication, a tragedy of errors from start to finish. Nobody was to blame - yet everybody was.

I have seen people come and go in the ER. I have seen many die...and many more live. I've agonised over decisions, told countless families that their loved ones are dead, put myself in that place as the doctor they will always remember as the one that told them that terrible news. I do it all the time. Week in, week out, I've told patients terrible things in the ER, broken devastating news to families. I've sat through awkward silences, through crying, through screaming, through breakdowns and more. It gets easier each time I do it. But it never gets easy.

Sometimes, though, I wish it would be easy. Sometimes, I wish I would be unaffected by it all. It is hard. It is hard, what I do. It is hard to be that person that is the bearer of bad news. I am almost never the bearer of good news. I am not the surgeon that beams with pride when he tells families he got all the tumour on the first go-around. I am not the medicine physician that the family thanks when their loved one finally goes home well. I almost never have wonderful news to break. All the patients I "save" leave my department alive but only barely so. All the patients I "lose" I have to bear the burden of breaking the news. I am never the hero. And I'm all right with not being the hero. I'm all right with that because I know that what I do matters.

But sometimes, like today, I find myself feeling something odd. I find myself feeling grief. It's a grief I don't understand. Maybe it's because I'm only human and what I do is hard. Maybe it's because so many of patients die with nobody beside them except the ER staff - because death in the ER is usually unplanned and sudden, and families have usually not arrived in time to be there. Maybe it's because I still have a heart.

I ask myself if I will ever recognise the day that it becomes time for me to quit this field of medicine which I love more than any other field of medicine I have experienced. Is it the day that I realise I no longer feel any grief, however terrible and tragic the situation? Is it the day when I can do all the things I do and face all the things I face without feeling a thing myself? Will I recognise it as my time to go, or congratulate myself on finally having come to a place in which I have become so experienced, so senior in my position, so established in my skills that I no longer feel regret?

ER physicians burn out at an alarming rate. The ones of us that do make it a lifetime career - I've seen it in my colleagues, in senior physicians that never seem affected by what goes on. Do I want to be like them? On the one hand, I can't imagine never doing this work, I can't imagine pursuing a different field. And on the other hand, I wonder whether to lose the heart that lies somewhere beneath my professional shield is to lose my soul.

I love what I do. But what I do is hard. And days like this - after shifts like this one - I ask myself if I will know when it is time for me to quit. It is not now. It is far off yet. But I wonder how many more patients it will take, before I no longer experience grief however terrible the situation.

I wonder if that moment will signal the beginning of the end for me.

Things I Was Not Trained To Diagnose

2009-10-24T00:25:00.002-02:30

These are some of the complaints patients have had which I fear have had me utterly stumped over the recent months.

Case #1
From a 19yo girl: "Doctor, my belly button hurts."
Me: ?????
(And yes I did have to examine her belly button and it was fine besides having some lint)

Case #2
16yo boy: "Doctor, when I sit on the toilet a certain way, sometimes my legs go to sleep."
Me: "That happens to me too..."

Case #3
25yo woman: "Doctor, my hair feels funny."
Me: "I'm not really sure how that's possible - do you mean it's your scalp that feels funny?"
Her: "No, doctor, I mean it's the hair. My hair hurts."
Me: "Hmmmmm...."

Case #4
From an 81yo man: "My face feels really tight. Sort of like the skin is stretched."
(Diagnosis - too much Botox???)

For all of these, I have failed to provide a diagnosis or a recommendation for treatment. If you have any brilliant House-like ideas to help these patients, feel free to contribute.

Terminal Blahs

2009-10-06T00:09:00.002-02:30

I haven't been writing in here lately mostly because I've developed what seems like an all-pervasive apathy towards my work. Which sounds bad, because shouldn't this be the most exciting part of my career - the part where I take off as a fully fledged attending? Instead all I feel is....well....nothing.

Except the occasional burst of frustration and anger because I forget that my patients aren't as medically savvy as I am (obviously). And because when the shit hits the fan I can't talk reason into some of them. And because I have been running up lately against people who simply don't know how to fade gracefully.

The Western world's preoccuption with life - with life at all costs - is something I doubt I'll ever understand. I'll never understand why people insist on having things done to them to preserve their lives while sacrificing the quality of their lives for a vegetative state. Why don't these people understand how to go gently? Actually let me correct that. It's not the patients that don't know how to do it. It's their families.

There is nothing worse than doing something completely futile to a patient and causing them more distress and suffering and doing so without believing at all in what I'm doing. Doing it because their families are unable and unwilling to ignore their own personal grief in favour of their loved one's wishes or desires. Over and over I have run into this. "Mum would never want that," they say, "but I'm not ready to let her go."

Don't they get that it's not about what they want, nor about whether they are ready?

Instead I feel helpless and I feel forced to act against what I believe in. Mostly because I am afraid of being sued. Because I can't stand in court and have no stomach to do so and defend the reason I did not intubate that 97yr old patient who was in respiratory failure, or explain why I refused to perform CPR on that 88yr old patient with metastatic cancer who arrested at home.

Death is a part of life.

A society that doesn't understand that - I find myself disgusted and unwilling to be a part of this.

But maybe I'll learn... I hope I do... if only because my career would otherwise be shortlived.

Lady MacBeth

2009-09-23T01:14:00.002-02:30

I'm trying to lay out my thoughts but having significant trouble doing so. Maybe I'm not ready to talk about it. Or I've talked too much about it. I don't know which. There are so many questions in my head. Could I have done better? If so, what could I have done differently? And still there aren't any answers.

I watched him die feeling helpless and unable to help him in any way. His wife wanted him resuscitated even though he was frail and old and riddled with cancer. And it went badly. It went badly and he ended up dying. I think what I can't shake most of all is that look on his face. He didn't die easily. He died hard and it was a horrible, messy, ugly death and it was so very chaotic. I felt the situation was not in my control and yet at the same time that it should be, because - after all - wasn't I the attending physician now?

In the end, all I could do was wash the blood off my hands - I hadn't had time to slip on gloves - and go out and talk to his wife. I know it will happen again. It will happen over and over as part of my work. I need to figure out my way to get around it, to get back in the saddle, to keep pressing on. I guess it will just take some time before it fades.

Meanwhile, I just have to suck it up and soldier on.

Exams Over

2009-09-21T21:30:00.001-02:30

It's been such a busy few weeks and the exams ended last week. Since then, it's almost as if I'm not really sure what exactly to do with myself! After the years of residency - and then not being a resident but still reading my face off for the exams - what now? It's all a little confusing really, trying to find my feet. There are things to be done, places to go - but it feels a little alien! The results come out in 5wks. Here's hoping for the best.

Death in Afghanistan

2009-09-05T03:53:00.003-02:30

The photo says a lot. Taken by Julie Jacobson of the Associated Press, it was published in numerous newspapers despite personal pleas from the US Defense Secretary to the CEO of the AP, as well as a plea from the father of the dead soldier - Lance Cpl Joshua Bernard, age 21 - not to release the photo. Apparently, among the reasons cited are that the photo should be withheld out of "common decency" to the dead man's family.

My biggest problem with this argument? Let's see - a picture of a dead US soldier published is oh-so-appalling. Meanwhile, papers everywhere publish pictures of dead Iraqi and Afghan civilians and nobody gives one shit about "common decency" nor does anybody care about what their families might feel or think.

It's not about common decency. It's about showing the reality of wars. People die. Including nice, clean-cut soldiers fighting for the supposedly "good" side, and lowly civilians caught in between. All this hypocritical crap about "common decency" makes me want to vomit.

Reminds me of how when Hurricane Katrina hit the US, some newspapers called it "our tsunami!", comparing it to the 2004 tsunami.

Well, pardonnez moi - 1,836 fatalities with 705 missing hardly can be compared to the 300,000 lives that were lost. Unless, of course, some lives are worth more than others.

Just in case this photo ends up in the collective amnesia that often overtakes a society in denial, I'm putting it up here. Hate me all you like, I don't care.

Another Reason To Love Newfoundland

2009-08-31T04:49:00.004-02:30

I was reading the online edition of a local news network tonight in a desperate attempt to avoid studying for the upcoming exams, when I came across this:

The headline? "Metro Moose Tranquilised By Wildlife Officers".

Apparently, the errant moose had been wandering into the local ballpark and soccer pitches of St John's. Newfoundland has a lot of moose - and subsequently, numerous car vs. moose accidents occur all year long here, with many being fatal. (Imagine driving at 100kmh and smashing into an animal that grows up to 2m tall at the shoulder, 3m long and weighs up to 600kgs and can run up to 60km/h... yeah... just imagine!)

Every so often, we have fellow Canadians from other provinces state that our news is "boring". However, in this respect I agree with other Newfoundlanders that we prefer to have stories about errant moose and polar bears than to have stories about the latest shooting and stabbing.

In this case, I was taken aback by the fact they bothered to tranquilise this moose, manhandle it into the back of a pickup truck and then drive it off to relocate it elsewhere. After all, the people here enjoy a supper of moose stew and moose burgers. But it did make me smile. I can't imagine where else someone would bother to go to such lengths to "rescue" an animal of that size, but it seems in Newfoundland that's par for the course as wildlife officers here also tranquilise polar bears, airlift them and relocate them to the Arctic. Compare this to other provinces, that have simply shot said polar bears, citing them as "dangerous" - when they could have - at far greater cost, of course - been tranquilised and relocated.

We loves our wildlife!

I Am An Exception To This Rule

2009-08-29T05:22:00.007-02:30

Physician, know thyself
Veysman, BMJ.2005; 331: 1529

Someone directed me to this algorithm.

For the record, I have an excellent attention - hang on, just gotta go and - oh, never mind...

Dr Bitch

2009-08-12T23:27:00.002-02:30

The first words out of his mouth tell me that this patient encounter is doomed.

Then again, it was probably doomed from the moment I started my 11pm shift only to find myself staring at charts for patients who checked into the ER at 5pm. It's now 3am, and I'm still ploughing through patients from 8pm - and still they keep checking in. I feel resigned - the only alternative is to rail against the ignorance of Joe Public who thinks it perfectly reasonable to stampede the doors of the ER for their hangnails, sore toes and runny noses.

"I need antibiotics," he says. "I have an infection."

"Mmmm," is my non-commital response.

"I have a sore throat and a cough."

"OK," I say. "How long have you had these symptoms?"

"Three days."

"Any fever?"

"No. Listen, I'm telling you I need antibiotics."

The rest of the interview goes the same way. He has decided that he needs antibiotics. He saw his GP who refused to give them to him, diagnosing him with a viral illness. His physical examination is entirely unremarkable. There is nothing in his story to suggest he needs antibiotics, besides his conviction which borders on delusion.

"I don't think you need antibiotics, sir."

His voice grows louder. "I'm telling you I need antibiotics and I want them."

"Sir," I say, and I feel a flash of anger and frustration through the haze of tiredness, "it's my medical opinion that you have a viral illness and do not need antibiotics."

"I NEED THE FUCKING ANTIBIOTICS."

His face is growing redder by the moment.

"Sir, you may think you need antibiotics but I don't agree and it is my practice to only prescribe medications I feel are necessary based on my medical opinion."

He shoots to his feet, all 350 obese pounds of flesh quivering with anger. "YOU FUCKING BITCH!" he shouts. "I WAITED NINE FUCKING HOURS FOR THIS?! I NEED FUCKING PENICILLIN AND JUST LIKE THAT OTHER FUCKING DOCTOR YOU CALL IT VIRAL THIS AND THAT!"

"Sir," I say, in what must surely seem to be an infuriatingly smooth tone, "we don't tolerate verbal abuse in the ER."

"FUCK YOU, BITCH!" he screams, his fists clenched. "WHAT KIND OF FUCKING HEALTHCARE SYSTEM IS THIS! I WANT THOSE FUCKING ANTIBIOTICS NOW!"

I feel the adrenaline coursing through me. My heart is pounding - he's much bigger than me and I imagine any moment now, he's going to lash out physically as well.

"Sir," I say firmly, "I am not giving you antibiotics."

"FUCKING DOCTOR BITCH!" he screams.

I am pleased to note the door behind him open quietly and a burly security guard appears, hands on hips.

"Now then," the guard says, "settle down now."

For a moment, I think my patient is going to take a swing at me. He splutters incoherently, his fists balled up at his sides. Then his shoulders sag. He's defeated and he knows it. He's raged like a madman but his anger is impotent. He turns to go and the security guard shows him the door.

Outside, I hear him still spluttering to the guard, but I can't make out what he's saying. I write his chart up, noting that the verbal abuse he heaped upon my head. Under "diagnosis", I print "VIRAL ILLNESS" but in reality I think it should read "POWER STRUGGLE".

It gives me pleasure not to have given him those antibiotics.

Fucking Doctor Bitch: 1
Swearing Patient: 0

And even though I feel as if I should feel some guilt over my little ego trip, over the little stab of pleasure I felt in having the power to withhold from this man that which he so abusively demanded, I don't.

Sometimes, I just gotta admit I'm human too.

The Lame Walk, The Blind See, The Seizing Stop

2009-07-28T18:46:00.003-02:30

There are some patients who, for reasons best known to themselves, enjoy the attention that serious illness brings. In their benign form, they create logjams of the "worried well" in our emergency departments. In their less-benign form, they provoke heart attacks in others who would otherwise have not suffered that fate.

The people who aid young and idealistic doctors like me in identifying these patients, are - as always - that particular indomitable species known as the ER nurse. They are the backbone of the department and an invaluable source of knowledge and learning for the physicians.

He came to the ER for a simple little cough, and his complaint thus placed him at the very end of the list of patients to be seen. Simple coughs are hardly priority medical issues when stacked against heart attacks. Peeved, he took a seat in the waiting room.

Minutes later, pandemonium broke out.

"He's seizing!" someone yelled. "HELP!"

Quick as a flash, the nurses went to see what the hubbub was about.

Our man with the cough lay on the floor of the waiting room, jerking most unconvincingly.

The head nurse, a lady with more years of nursing than I have of living, stepped forward.

"Mr. X," she commanded sternly. "Stop that at once and get off that filthy floor!"

He opened an eye, looked at her, one foot still hopefully trembling.

"NOW!" she said. "Do you know how dirty that floor is???"

Having determined that she wasn't joking, he meekly got off the floor, took his seat, and hung his head.

"Now," the head nurse continued, addressing the waiting room at large, "there will be no more of this business going on!"

And thus another peaceful day in the ER ended for me.

Retail Therapy

2009-07-15T03:43:00.002-02:30

Well, it's official - my first paycheck has led to a bout of retail madness.

I was warned that the first few months out of residency, the sudden payrise would go to my head.

In the last 48hrs, I have bought:

Energy Take Classic 5.1 surround sound speaker system ($449.99, reg $899.99)

A Nespresso machine ($199, reg $399)

Nespresso capsules (1 capsule = 1 cup of gourmet espresso, at $0.58 a pop) - I bought 250 for $145 with freebies thrown in, and am looking forward to drinking 60-cent lattes for the rest of my life (I've been guilty lately of spending $4 a day on lattes)

and am *going* to buy

Pioneer 7.1 HDMI VSX919 receiver for $448.99 at its regular price.

I knew I wanted to set up my home theatre system and my original budget of $2K has been halved - but then the Nespresso deal came along and I have been looking for an espresso machine. Having read plenty good reviews about Nespresso (it's even won the Italians over!) I figure why not.

And so the home improvement continues. Next up, I have my eye on a Dyson vacuum cleaner, but really balk at paying upwards of $600 for it. Also, I need more furniture - another sofa, loveseat, bed for the guestroom, etc etc.

Kaching! Kaching!

The thing I've discovered about owning a home is that although I am the only one living in it and really don't care too much that the place is not fully furnished and has 3 empty (literally, except for my suitcases and clutter) rooms with no bed/wall hangings/curtains etc etc - I feel somewhat embarassed to have any visitors over...

At least I'll have espressos to offer.

The End Of A Chapter

2009-07-01T16:54:00.002-02:30

Where have I been?

Busy as hell, is where. But yesterday, I celebrated the end of a major chapter in my life as a physician: the end of residency. 4yrs of medical school and 3yrs of residency later, I am now out on my own for real. The challenge now begins - no more safety nets, no more hovering supervisors - it's now time to practice the medicine I think is the right medicine, to make decisions and judgements on my own.

It's going to be pretty nerve-wracking at first, I know. But I'm looking forward to it.

P.S. The vast salary jump doesn't hurt either!

Miscellany

2009-06-07T23:42:00.003-02:30

I am sick. In hindsight, I have probably been ill all this week but I just put it off as tiredness, exhaustion or whathaveyou. A little nausea? Perhaps it was just stress. Cold sweats? Ditto. In any case, while at work two days ago I finally decided to make use of the abundant thermometers around the ER and voila! I had a fever. Which isn't surprising - I should probably be more surprised that I didn't catch anything from those sick kids sooner. In any case, I really have been feeling pretty awful - the nausea, cold sweats, dizziness and all-around rundown feeling is starting to get old pretty fast. And it's my vacation... I didn't plan on spending it like this!

I'vec been thinking lately about the fine line that sometimes divides life and death.

I came onto my shift a few days ago to a lot of drama. A young teenager had been out on his ATV. Unlike many young men, he had his helmet on and he was perfectly sober. It was a beautiful sunny day, the kind of day that I've come to think inspires lunacy in some of the denizens of this land in which the sun is a somewhat shy creature, prone even at the best of times to hiding coyly behind clouds. (More often, it tends to shroud itself in fog, snow and even hail). This young man was not similarly "sun-struck" - he was a perfectly sensible fellow, behaving responsibly - admirable considering he was just in his early teens.

In any case, someone else had unfortunately not been as socially responsible. This teen, while riding his ATV, had suffered a classic "clothesline" injury - someone had strung up a wire across two trees - as a joke? as a property marker? who knows? - and it had caught him straight across the neck. He was out in the woods when this happened, far away from any medical help, on his own. He knew that home was just a few minutes away by ATV - if he could get there. So this young man got back up on his ATV and, clutching his neck, managed somehow to get back home. His father - from whom those sensible, responsible genes must have been inherited - took one look and bundled him into the car and raced to the ER.

It had been a quiet day thus in the ER - coughs, colds, viral gastros and the like. That is, until the triage nurse looked up and saw a young teenaged boy clutching his neck staggering into our ER trailing blood behind him. He could hardly speak, and he was spitting up blood to boot. They got him into a bed, applied plenty of pressure to the wound, got the bleeding under control.

When I arrived at the pediatric ER, I found everyone in such a tizzy. Apparently, they had forgotten the cardinal rule of the ER - when the shit hits the fan, always take your own pulse first. Panic doesn't help anyone and it definitely doesn't get anything done...

In some ways, I understood their panic. The pediatric ER in this place is not staffed by emergency medicine physicians. It is staffed primarily by pediatricians who have no emergency medicine training, and by family physicians and general practitioners. 99% of the stuff that gets seen anyway does not qualify as an emergency, so this works for the most part. Unfortunately, every once in a while, a patient shows up who has suffered an injury/illness that is potentially life-threatening. This kid, for example, was an example of that.

In the adult world, the expectation is that the emergency physician will stabilise the patient and work the patient up if necessary before issuing a consultation (which makes sense because one should at the very least know who you are consulting which actually requires you to figure out what is wrong with a patient even if it is as simple as "surgical vs. nonsurgical"). This is generally - though not always - true. In the pediatric world in the place where I live, unfortunately, this was not the case.

High tracheal injuries (commonly seen in these clothesline injuries) compromise an airway. Establishing an airway is vital, obviously, if the airway is compromised. This kid had a laceration to his neck but he appeared to have missed his airway for the most part - the laceration was more off to the side. However, his hoarseness and the fact that he was spitting up blood were red flags. Intubating someone with a high tracheal injury runs the risk of tracheal transection and is a no-no. So if the shit hit the fan and he stopped breathing, that meant we would be committed to a surgical airway.

The nurses were scared; the attending physician was scared.

Scared is not a good thing to be.

"Listen," I said, "if he goes down the tubes I can cric him."

"You can?" they said.

"Yeah," I said, "I did the course."

A cric aka cricothyroidotomy is what you do when you can't intubate a patient and you need an emergent airway. I'd done the course and we'd practised on anesthetised pigs. It's a procedure you might see in Hollywood dramas - all you need, strictly speaking, is something sharp that cuts and something hollow - you find the right spot to cut into the airway and you jam in your hollow tube (a straw, Bic pen, etc...) You can then provide ventilation through that little tube. This, of course, is the Hollywood version - we tend to use scalpels and "cric tubes" instead of DIY materials. However, I actually personally know one physician who saved a life when he "cric'ed" a car-crash survivor before the paramedics arrived, using a pocketknife and a Bic pen. (Later, the man tried unsuccessfully to sue, arguing that he should have been allowed to die).

In any case, this revelation on my part that I was trained in crics seemed to settle everyone's nerves a little. It didn't settle mine since I was now on the hook for potentially having to do something that, in ER parlance, is done only when the situation has become so dire that you are pretty much needing a diaper while you shit yourself.

It also meant that I was then "assigned" to escort the teen everywhere - from the CT scanner to the X ray department, together with 2 nurses and a respiratory therapist. In my opinon, this was overkill especially considering that I brought neither a scalpel nor a cric tube with me on those trips, but ah well - c'est la vie. It did, however, mean that I also got to be by the bed when the ENT surgeon arrived to scope him - and the surgeon was so kind as to keep letting me peek down the scope to see the damage done, which was pretty awesome.

To cut a long story short - my teen escaped with his life by all of 1cm. 1cm - the width of your pinky fingernail.

And that's why I was reminded yet again of how there is such a fine line between life and death.

For this young man, that line was the thickness of 1cm. 1cm more to the left and he would have crushed or transected his airway. 1cm lower and he would have run the risk of severing the jugular or carotid. As it was, he had small lacerations to the airway, but nothing that required surgery. Nothing that required anything really. And his spine was fine - oftentimes, clothesline injuries also lead to broken necks (think of hanging, except in this case it's a horizontal force being applied not the vertical drop) and paralysis and death.

When the ENT surgeon looked up from the scope at last and announced that there would be no need for surgery and that he would recover just fine - although his voice might not be the same again and it might take a long time, he would be fine - the kid fought back tears of relief and his parents began to cry as well.

And I must admit that I too felt myself tear up. Because we lose so often, we lose lives and functionality and mobility when our patients die or end up paralysed and all of that - and this kid, he didn't end up losing anything. He kept his life, his mobility, he kept it all - and by 1 measly cm.

"I don't see people like you often," the ENT surgeon said. "Usually, you come in dead."

And we all laughed, including the parents - laughed with relief, laughed with that huge heaviness lifting off our hearts.

I know that good people die for others' stupidity and malice. I know that well. But lately, I find myself weary of seeing good people die, of seeing people die in front of me and being utterly helpless to stop it. It's one thing to witness a patient die from cancer - it's another thing entirely to watch them die choking on their blood, or unable to breathe, or to die because they made one mistake that day - perhaps they decided to go just that 10km faster, or have just that 1 more beer. It's those deaths that I see in the emergency room, not the types that have families surrounding the frail patient who has said his goodbyes, not the peaceful kinds - in the emergency department we watch the deaths of those who do not want to die, who are not ready to die, who rage against the dying of the light.

I think if that 1cm hadn't been there today, I don't know that I could go out there and keep doing what I do.

It's just been a long few months.

Sitting On The Other Side

2009-05-30T14:10:00.002-02:30

I spent the morning as an examiner for the medical students' clinical exams. Yes, that's right. An examiner, not the one taking the exam. What an odd feeling it was! After years and years, I find myself sitting on the other side now.

One poor flustered student managed to examine the wrong limb in the exam. Being such a neophyte examiner and him being such a neophyte student, I left it to the final adjudicators to decide what to do with his paper. It seems petty to fail someone for examining the left side instead of the right, especially if one is just a baby medical student. But most definitely if one were a surgeon and amputated the wrong limb, this would qualify as a Problem. So, not knowing whether it would be cruel to utterly fail him, I simply checked off all the things he did and noted that he did them, except that it was on the wrong side. I had a word with the adjudicators privately and they say they'll probably dock him some marks but he should still pass (and will likely as a result never make that mistake again).

I enjoyed being an examiner today. Only because most of the students I saw were trying very hard to be competent and professional. They train students well these days I think, to be kinder and more caring. In the past, in those "bad old days", doctors were trained to be like gods. Now they are trained to be humane first and foremost. Especially after it was discovered that the nice incompetent doctor is less likely to be sued than the nasty genius one.

Anyway off to my research project I go... I shall be glad when it is done. We've run into a little snag, being that my co-researcher is out of town and she managed to leave some of the data in her place to which I have no access.... wish me luck!

Why I Am Stressed

2009-05-26T19:06:00.004-02:30

I am under stress. I wish I were understressed but this is not true. I wish I were over stress but this is also untrue. Instead, I am under stress. When I am under stress, I tend to like word games. Word games make me relax.

1.
The house is messy. It is always messy. I have little time to clean it up. Having been to other physician's houses, I have occasionally enquired as to how they keep their places spotless. The answer has typically been that other physicians hire cleaners. I cannot afford a cleaner - not yet anyway. Therefore, the house is messy. I have now decided that come next week I will dedicate two days of vacation time to clean this house up.

2.
I have two days of vacation to clean the house up and three days to do nothing. I was planning to spend it a certain way but those plans have fallen through because someone near and dear is no longer near although he remains dear. Losing near and dear people sucks.

3.
I am doing pediatric emergency medicine and it makes me want to get my tubes tied. Screaming kids. Vomiting kids. Shitting kids. Smelly kids. The only time they ever smile is when I'm not around. I am never as glad to see a kid as when I am looking at their backs on their way out the door. I like kids when they are well. I like kids when they are too sick to talk or cry. Otherwise I don't like kids.

4.
I have a research project due next week.

5.
I made a cheesecake. It was delicious. It needed vanilla extract. The computer did not. I mistook the computer for the cheesecake and now my computer is fried. I smartly backed up my data on my computer on a different drive. Not a different computer.

6.
See number 4 and 5 since they are linked like obligate parasites.

7.
I have exams in September. Yes, more exams. I am currently toxic from overdosing on exams. My exams are so I can get another two letters after my name. I already have 6 letters after my name. Do I really need another 2?

8.
I never feel confident enough to know that I am going to win today. I never know. You can never know. I still never know when that ambulance comes in and unloads that sick sick patient whether or not I am going to win. Not knowing is hard. Not knowing sucks. Knowing that I'm going to lose sucks even worse.

9.
Whenever you win everyone else takes the credit. The surgeons, the internists, they are the heroes. Unconscious patients never see my face or hear my name, so how could they give me credit? Emergency medicine is the most spat-upon specialty, it seems. We are called names: "consultologists" being a favourite one because "all you do is consult". The consultant gets the credit when the patient leaves hospital in a car; the emergency physician gets the shit when the patient leaves the hospital in a bodybag.

10.
I don't have a 100% save rate. Nobody does. But I can save 99 lives and lose 1 and only ever hear about the 1 I lost. See 9.

And yet, and yet, and yet....

I still love what I do. I live for it. I go to work and I love what I do and I don't know why I love it but I do. Nobody else might know that I make a difference but I know I make a difference. Because that consultant doesn't get there before I do. He might have the surgical skill to open up a patient and operate on that leaking bowel and thus save the day. But he isn't there to resuscitate that patient, to start those immediate lifesaving measures. I am. My patients seldom thank me, they seldom leave happy. They want to see the specialist. They want to be referred, not told by the lowly ER doctor who "knows nothing" that they are fine. They think I am "just a GP", what do I know?

It's not the most rewarding job in the world if I'm looking for external validation. I'd be better off being something else besides a doctor. I'd be richer at the very least - and not blamed and scorned for it. Instead, I work my ass off in a profession which the public turns against in times of recession for being "fat pigs" living off "the fat of the land" in lean times - I get to hear doctors being envied for "making tons of money" - while I work my ass off in the emergency room dealing with sick patients, vomiting, bleeding, shitting, pissing patients, aggressive, screaming, angry patients, hostile and abusive families. I get to do that and make $50,000 a year after 4yrs of medical school and 3yrs of residency - half of which goes to taxes.

It's not worth the money.

It's not worth the effort.

It's not worth the time.

It's not worth the abuse heaped on us by patients.

It's not worth the scorn and envy of the public.

But to me, it's worth the 99 lives I save. It's worth every bit of that because I make a difference. So yes, I am under stress. Yes, I am sometimes bitter and always cynical. But I love what I do. Sometimes I think I could have had a better life doing something else. But I wouldn't love something else more than I love this. The emergency room, that is what I love.

I guess I'll just keep doing it until I don't love it anymore.

Idiocy

2009-05-19T03:42:00.002-02:30

There he was, a tiny thing strapped onto a backboard four times his length, his head strapped securely and held in place with foam blocks. An endotracheal tube was taped to his blood-caked lips. His eyes fluttered every now and then as if he was trying to open them. Dried blood covered his face, trunk, arms, legs, every part of his baby skin.

As we worked on him, there was a grim air in the trauma bay - but then his eyes won their battle and opened, and large blue pupils looked at us. I imagined they conveyed bewilderness, especially as I grabbed the ophthalmoscope and shone a bright light into each of his eyes. They constricted. Sluggish, but they constricted. Maybe his brain had been spared after all.

The nurses started IVs on him, the pediatric surgeon's hands ran over his little body - his chest, pudgy little belly, his hips, legs. Then he started to rouse, this little boy - his hands clutched at the air, he kicked away the IV a nurse was trying to start in his foot. Good. Very good - he could move all his limbs. His spinal cord was likely intact. Was he starting to come around? He had been getting sleepier and sleepier on his way to us, the ambulance crew had said. But now he was waking up. A good sign.

"Sedate him," the pediatric intensivist said. "We need him to be still for the CT scan."

So we sedated him. Now that we knew he could move his limbs, open his eyes, we had to protect him by knocking him out. Otherwise, we would never be able to get him into the scanner, and he might even dislodge some of the equipment attached to his tiny body, some of which was keeping him safe.

I provided the in-line immobilisation of his cervical spine while the surgical resident looked in his ears. No fluid, no blood. A large piece of gauze covered his forehead and the resident removed it. A gash across his forehead running along the entire length from temple to temple to temple. Underneath the flap of skin, bone. He had almost been scalped. This was the reason he was covered in blood, then. But the bleeding had now been staunched.

He went to the CT scanner, a respiratory technician bagging him all the way. They CT'ed his entire little body - head, spine, thorax, abdomen, pelvis - all of it. Miracle of miracles - nothing terrible showing up. Imagine that - he might now live with just a big scar across his forehead.

That is, of course, provided his idiotic relatives didn't kill him first.

It had been a sunny day - the long weekend, Victoria Day. A relative of his - perhaps fuelled by too much booze - had decided to take him for a ride, complete without helmet. And it wasn't a ride on a bicycle, oh no - this relative had decided to take this three year old on an ATV. Not only that, this had occurred without his mother's knowledge.

So one moment, someone else was looking after the baby.

And then the next, a blood-soaked little child is returned.

He was lucky to have survived the accident, this boy. He was very, very fortunate. He may never again in his life be more lucky than today. I can only hope that he is never ever unlucky enough again to be exposed to idiocy on the magnitude of that which occured today.

Today was my first day of pediatric emergency medicine, and I learned something that is quite sad and yet quite true. Pediatrics is the world in which the most vulnerable people are sometimes called upon to pay for the stupidity, sins and crimes of others.

I can only hope that today, this little boy's family and his relative learned a lesson. Today, he escaped the consequences of another's unthinking actions. Life may not always be so forgiving.

The Sun

2009-05-17T07:52:00.002-02:30

Sunny days are here again in Newfoundland. They are not a common thing. Perhaps that is something to be grateful for...

The last weeks in the ER have been taxing. Not necessarily because of patient volume, or acuity. But because with the sun, people are throwing caution to the wind. The sheer amount of stupidity we've seen has been mind-boggling. And I don't know whether to be sad or angry at the waste of life I've seen.

Young men on their motorbikes speeding on the highways.

ATV accidents because people ignore their brain buckets.

Near-drownings because a few fail to realise that extremely windy days and canoes and kayaks do not mix.

Cyclists braving the insane roads of St John's meeting accidents because motorists fail to respect their right to be on the road.

People drive too fast, too drunk, too recklessly. They do things that they wouldn't if it weren't for the beautiful day and the clear skies and the dry roads. They speed. They have barbecues - and booze - and they get on their ATVs for fun.

We've seen some pretty awful stuff lately. Young men paralysed from accidents - it's always the men, it seems - others with severed aortas, yet others who die before they even get to the ER. You wonder about their families, their wives and children. It does make me sad. But also angry.

Because it's not as if these people didn't know how to keep themselves safe. But in that moment, I guess, they didn't. Maybe it was a mistake. But the effect is devastating and permanent. I hate standing in the ER knowing what lies ahead for this patient - and not telling them because now is not the time. It isn't the time to tell them they likely won't walk again. That comes with time. That comes with more tests as the patient slowly realises the truth. But I hate standing there and knowing all the same, because I'd like to not know.

Anyway. The sun is out and people are going crazy. I don't miss the dank dreary days so common in Newfoundland. I just wish people would use their brains instead of allowing the sun to addle them...

Bleed

2009-05-08T07:36:00.002-02:30

There are good deaths and bad deaths, easy deaths and terrible deaths. In the ER, we see so many kinds of death we get used to it. We understand we can't always win. We become good at knowing, quickly, instinctively, if we have a chance at winning this time, the way a champion poker player knows whether his cards have a chance of netting him the prize.

But sometimes, against your best instincts, you still find a way to hope. You find a way to hope that perhaps your gut is wrong. Even though you know it's irrational. Even if you know it's futile. Sometimes you meet a patient and something about him or her makes you want to fight, makes you want to rage against the dying of the light.

She came in early this morning during my overnight shift, a frail and thin elderly woman gagging on the blood pouring from her mouth. She had been brought by ambulance alone - her family was on their way - and she looked so fragile lying on her stretcher. No, she didn't have pain, she said, it was the vomiting that was the worst. That was all she really managed to say in between gagging and coughing and vomiting up blood.

Her blood pressure was dangerously low; her heart rate was clipping along quickly. She was obviously in hemorrhagic shock. We put two IVs in her, poured fluids in, called urgently for blood. But I knew - and we all knew - that we wouldn't win this battle. There was too much blood - she was too old to withstand that sort of bleeding - she was bleeding from a place we couldn't get to. Still we tried.

At one point her eyes rolled up in the back of her head and she slumped over and we thought we had lost her. CPR and intubation would have been futile - we got ready anyway while my boss went to speak to her family who had arrived by then. I had my laryngoscope out, endotracheal tube ready - just in case. But I knew as well that intubating this poor lady would be awful. Running a code on her would be awful. We'd break her ribs, shove tubes down her - and for what? My boss returned - the family had decided to make her a DNR - Do Not Resuscitate.

So we kept pouring fluids into her. We poured in litres of saline, bags of blood. We poured it into her veins - she poured it back out onto her stretcher, our floor - blood everywhere. We called in the gastroenterologist - that was the last hope she had, that somehow he would be able to put a scope down her, find the source of the bleeding and stem the red tide. If you have a bucket with a hole, you can never fill it up enough. Maybe he would be able to plug the hole. If he could, she would have a chance. A slim chance, but still a chance.

As soon as he stuck the scope down, she spewed out a massive amount of blood all over the floor and his shoes. We threw hospital sheets on the floor to soak it up. He got in, and looked around - nothing in the stomach but blood. Where was it coming from? He retracted the scope, advanced it again. Flushed the mucosa with water, suctioned blood out, looking for the source of the blood.

And then we saw it and we knew.

At some point, she must have had a gastric ulcer. Left untreated, it had slowly - little by little - been eating its way into the lining of her stomach, the way most ulcers do. Except most ulcers cause patients enough pain that it sends them to the doctor and they get discovered and treated. She had not been so lucky.

Her ulcer had eaten its way into her stomach lining - the way ulcers do.

And then it had eaten its way through that lining.

And then it had reached its final destination. It had eaten its way into her aorta.

She had an aorto-enteric fistula.

"She's done," I said. It wasn't a question.

The gastroenterologist shook his head, withdrew the scope.

"She's done," he said.

There was nothing more to be said. Nothing left to do. There was no way we could plug that hole. Not a hole that size. Not a hole that led directly from her aorta to her stomach. We could keep pouring blood into her - she would keep pouring it back out. There was nothing left to try. Now she would die. Not a slow death - thankfully - but death by exsanguination. Death gagging and coughing on her own blood.

"Give her morphine," he said. "Keep her comfortable."

We put in a request for her admission to a private room in the hospital. The gastroenterologist went out to speak to her family. The nurses cleaned her up - changed the bloody sheets, wiped it off her face. Changed the diaper which had leaked because of the massive amounts of blood she had swallowed, which had sped through her intestinal tract. The nurses are good at trying to give the dying their dignity.

I left the room, stood outside. And I felt something I haven't felt in a long time, in the ER. I felt profoundly sad. I always feel a little sad when patients die. But little by little I've become hardened such that it no longer deeply affects me. I do what I can for them - and then I move on. When I know that the cards I've been dealt are a losing hand, I distance myself emotionally. It helps. It helps me to do my job, to keep fighting the war even when we've lost a battle.

But sometimes, I can't help myself. She was so fragile, and yet she had fought to live - we hadn't thought she would even survive to have that scope put down her. And yet she had - only to have a death sentence pronounced on her. Yes, she was old - she'd lived a good life - it was likely her time to die. But to die by exsanguination - to die choking on her own blood - and for all our skills and knowledge, to not be able to do anything about it... I didn't want her to die like that and there was nothing I could do about it.

So I feel sad. I feel deeply sad this morning, at the end of my shift. I'm tired but I'm sad. I'm sad not that I lost the battle, not that this woman is going to die. I'm sad that I can't change how she's going to die. And I'm sad because when she came in, I wanted her to live. I wanted her to fight, and I wanted to fight for her. Against my instincts and my best judgement, I'd hoped that we had a chance.

But we never did have a chance, I don't think. All the odds were against us from the start. And we knew it. Still, it didn't stop me from hoping. Perhaps I'm naive. Perhaps I'm still young and early in my career and idealistic. But I still hope, sometimes, even when I know the cold hard truth offers none.

I always said that when the day comes that I no longer feel sad at all in the course of my work, that's the day I know it's time to call it quits. Sometimes I fear that I might unknowingly lose my sense of compassion and kindness - because it's so easy to do in the midst of the chaos and everyday suffering of patients in the ER. Today I'm reminded that underneath my doctor persona, behind that professional smile, my heart is alive and well. And I suppose this is a good thing. Even though it makes me sad, even though it hurts.

This patient of mine, she will die. She will exsanguinate and there is nothing I can do to stop it. But we tried. And it is the nurses, in the end, who will do the most important thing for her. They'll keep her clean. They'll wipe the blood from her face. They'll change her sheets. They'll administer her morphine. In the end, they will give her as much dignity as can be afforded her. And when she dies, they will clean her up one last time, tuck her sheets around her, and draw the curtains. And as I write this from the comfort of my home, it is likely that this has already occurred.

Today I watched a woman bleeding to death. And it makes me feel sad. But it also reminds me that I am more than just my title. I am more than just my degree. It reminds me that I became a doctor because I care. I care even when caring hurts and is frustrating and even when it makes me want to curse and swear at my patients. I care about them. And maybe that - more than my smarts, more than my studying, more than all my knowledge - maybe that is what is at the core of being a physician.

Pandemic Schmandemic

2009-04-30T03:16:00.002-02:30

So the influenza virus has mutated yet again. Big deal... the biggest winners will be the manufacturers of Relenza and Tamiflu.

Sometimes I really don't understand people's mentality surrounding illness.

A "pandemic" my ass. There are already pandemics here.

The "smoking pandemic" - just count the millions killed by smoking-related illnesses, and even worse, the millions killed by second-hand smoke - isn't that considered "human-to-human" transmission? (Technically, no - but what's the diff?)

The obesity problem - killing people slowly but surely.

Tuberculosis - still killing millions worldwide and emerging stronger and stronger, but it seems as long as it's only the poor, disadvantaged folks that are dying, it isn't newsworthy.

The regular good ol' flu virus - not the pig type - tons of patients still ignoring advice to get the flu shot. I'll bet you good money you'll find some of the "swine flu panickers" belonged to this category... people still die from the flu!

And on and on the list goes.

So, the newest kid on the block is creating a buzz.

I'm not saying there isn't any reason to be concerned.

I'm calling for perspective.

Yes, this is a new virus.
Yes, it has killed some folks.
Yes, it seems to be spreading.
Yes, one should practise good personal hygiene.

By all means, if you're getting off a plane from Mexico, wear a mask. Take your temperature.

But the everyday Joe needs to keep in mind that there are a lot of things out there that can kill you and swine flu right now isn't exactly the number one most common disease that will be your cause of death.

Before you run out and buy your masks, thermometers, supply of Tamiflu and gear up for a Doomsday scenario, maybe you should stub out your cigarettes, lose some weight, take up a healthy exercise routine and quit boozing...

But what do I know? I'm just a soldier in the trenches.

Lying To Your Doctor Is A Stupid Thing To Do

2009-04-25T19:08:00.010-02:30

This is a boxer's fracture (see double arrows).

It is called a boxer's fracture because you get it by punching something.

It is not called a "I fell on it" fracture.

Or a "I caught my hand in a door" fracture.

It is not a "I twisted my hand" fracture. I do not know how you would be able to twist your hand to such a degree as to give you a fracture of a very specific bone in your hand that usually only occurs when your hand is in a fist. The last I checked, when you make a fist, the only thing you can twist is your wrist.

It is not a "I don't know how it happened" type of fracture.

Or a "I slipped on ice and I must have hit it" fracture.

This, ladies and gentleman, is a boxer's fracture.

Do you think we are stupid?

Maybe you do.

Read on and see what happens to patients who presume their doctor is stupid.

This, ladies and gentlemen, is a "fight bite".

It is called a "fight bite" because you get it from punching someone and grazing your knuckles on their teeth.

It is not called a "cat bite" or a "dog bite" or an "insect bite".

It is called a fight bite.

Usually, punching someone in the teeth is associated with fighting.

You do not get this from grazing your hand against something.

Or from spiders, grass, allergies, wood, diabetes or eczema.

If you stick to your story, we'll give you a prescription all the same for your "fight bite" even though some of us might be too polite to tell you that you are full of shit.

If you decide that you managed to hoodwink your doctors so well and you think that we are treating you for the "spider" bite that you don't have, you might decide not to take your antibiotics and ignore our instructions to come back to the ER in 12hrs for a recheck. You might decide that the doctors are stupid and full of shit and not bother because hell, they swallowed your story whole!

It's always good to remember this, though:

It's Not Our Hand. It's Yours.

Unfortunately, there are some of us who are not graced with triple-digit IQs.

This, ladies and gentlemen, is what happens to a fight bite that goes untreated. Because the human mouth is the dirtiest part of the entire body teeming with bacteria of all sorts.

You would do better to punch someone in the anus than in the mouth. I am of course unable to say this to patients as it seems to bear some very suggestive connotations, but I mean this purely from a medical point of view.

In any case, I provided this little lesson to my patient yesterday, who initially said he had caught his hand in a door. Upon which he finally told me the truth, and the truth was that he had punched a tree.

Tsk tsk. I should win awards for public health education.

Futility

2009-04-23T22:59:00.002-02:30

While walking home last night after a shift in Purgatory, aka The Pit, aka Unit 2, aka "Shitters & Bleeders" aka Hell - take your pick - I couldn't help but think that I had just squandered 8hrs of my life dealing with people for whom medical care appears to simply enable them to continue living their dysfunctional screwed-up lives.

Our department is divided into three general areas: Unit 1 in which all the "major" stuff goes - anything requiring a cardiac monitor, resuscitation and the like goes there, Unit 2 - which I have already described above, and the ironically-named "Fast Track". Unit 1 is usually a mixture of the routine and boring with the weird and wonderful "sickies". It's where all the "action" happens if there is to be any action. Sometimes it can be mind-numbing - 20 heart attacks in a row, anyone? - and other times I still can find my heartrate quicken a little when someone comes in and drops dead.

Then there is Unit 2. Unit 2 is where all the "not-so-sick" and the "kinda sick" and - to some degree - the "not sick at all" or the "sick in the head" patients end up. Some of my colleagues call it Purgatory, others The Pit. I call it Shitters and Bleeders because the vast majority of patients in Unit 2 are either having abdomen-related issues (shitters) or pregnancy-related problems (bleeders). Unit 2 is where you can be lulled into making a mistake, precisely because of how mind-numbing it is to see nothing except "abdo pain" and "pregnant and bleeding" over and over and over again. It's where you can miss a diagnosis and have something potentially bad happen because of that. It's where I spent last night.

Fast Track is anything but fast. It really should be called the Slow Track because this is where we see the people who for some strange reason decide to come to the ER instead of seeing their family physician about their runny nose/cough/cold/sore throat/finger pain/ankle sprain etc etc etc. This is also where most minor lacerations get seen and sewn up. Fast Track is fine for the physician (this is where "moving meat" takes place if/when a physician can be freed up enough to get around to it). Usually, there is a dedicated physician taking care of Fast Track 6hrs a day but if you have made the mistake of visiting the ER for your sore thumb and Fast Track is closed, your thumb will probably no longer be sore by the time we get around to your chart.

Anyway, after spending 8hrs in Unit 2, I have concluded that the ER has some patients who have a life cycle all of their own. An example.

1. Patient abuses over the counter medications.
2. Patient then goes to get bloodwork done.
3. Patient's blood is fucked up by medications abused.
4. Blood machine spits out result.
5. Result reads: **CRITICAL RESULT ACTION REQUIRED**
6. Patient is immediately contacted and directed to ER
7. Patient is seen in ER
8. Patient is given whatever it takes to correct fucked-up bloodwork.
9. Fixing fucked-up bloodwork takes hours and hours.
10. ER becomes more and more overcrowded thanks to patients like Patient.
11. Patient's bloodwork sent again to lab.
12. Patient's bloodwork now fine.
13. Patient sent home.
14. Patient abuses over the counter medications.

See how it works? In the end, the biggest enabler for the patient is none other than yours truly. We fix him so he can go out and do it all over again. And again. And again. And it's patients like this that make me angry because I feel as if I am using this gift of mine to propagate this stupidity. It's different from patients whom we see who have chronic schizophrenia or other such illnesses which make them unable to exercise reasoning choices that promote their own wellbeing. It's different because these patients - the group to which my Patient belongs - know exactly what they're doing and they get away with it.

I'm still young and idealistic, which is why patients like this make me angry. I know that eventually I won't care any longer, at least not enough in any case to be angry. It's pointless, as an older and more senior colleague tells me, to question any longer the things we see. I understand what she means - and yet I don't understand because I really do want to know what on earth we accomplish by saving these lives, fixing these people who don't want to be fixed except for the sole purpose of going out and breaking themselves again. It seems pointless and stupid.

But what do I know, right? I'm just a lowly ER doc. So I'll keep fixing them and sending them on to get broken again. Maybe it's people like these that keep us in business. I suppose it's good for my wallet in the long run?

Sick Satisfaction

2009-04-18T23:42:00.003-02:30

Yesterday I felt somewhat pleased with myself, when a young man showed up in the ER unable to breathe. He was a nice dusky blue, and the decision was made to intubate him. The intubation itself fell to me, and it was an easy one, certainly not particularly challenging from a skill point-of view. The patient didn't improve as quickly as we'd hoped, but he did improve nonetheless. In any case, I then proceeded to place a femoral central venous line into his groin, which gave us plenty of intravenous access.

Placing lines isn't one of my strong points, a fact I'm happy enough to admit. Of all the central venous lines, I like the subclavian best - mostly because it's hard to miss. The internal jugular - pet place of the internists and anesthetists (vs the subclavian which the surgeons all like) - is close to the carotid, and somehow I've always feared going into the carotid more than puncturing the lung. Mostly because I can't fix carotid punctures, but I can fix pneumothoraces.... In any case, buddy needed a line. So I put one in him. And I got it in with hardly any trouble, with my supervisor watching.

I went home after the shift still feeling happy about my performance. Today I checked in on my patient and he isn't doing so well. And now I feel odd - satisfied but odd nonetheless - because I'm not sure if it's "right" that I feel satisfaction even though his life is in the balance. I feel kinda happy but shouldn't I be feeling sad for him? So complex - anyway it just has me thinking that sometimes I think I'm never going to really understand the complexities of being both a doctor and - well, just a person. I guess my identity is sort of split equally between both.

The Case Of The Blue Balls

2009-04-06T00:25:00.005-02:30

After chatting to my brother and sister, I am inspired to record here for posterity yet another amazing medical case seen in the ER in the wee hours of the morning some months ago.

He came in complaining of a "discomfort down below", the triage sheet said, which immediately provoked a deep sigh in me, because I generally don't enjoy dealing the southern states in my line of work. In any case, far be it from me to cherry-pick my patients - so I picked the chart up and, somewhat hopefully, asked the nurses to get a urinalysis. Maybe I'd get lucky and it would come back positive, thus establishing the diagnosis of a urinary tract infection without my having to cross the equator.

A half hour later, however, the nurse handed me a printout with a sympathetic look. "Sorry, you're shit out of luck," she said. "The urine was pristine."

"All right," I sighed. "I suppose when all else fails, one must see the patient."

So off I went to see my patient. He was a middle-aged man who sat somewhat nervously in the room fidgeting with his hands as I introduced myself with title included. (I have come sadly to realise that I typically only whip out this title whenever I am faced with manbits - otherwise, I simply introduce myself using my first name and explain I am a physician).

"What seems to be the problem?" I asked, in the most non-commital fashion possible.

"I have an.... uh - a discomfort down below," my patient said, as he wrung his hands in his lap.

"OK," I said in an even tone. "What kind of discomfort, and how did it start?"

"Well, doctor... it's like this.... I have a girlfriend in Russia...."

His voice trailed off and he wouldn't meet my gaze at that point, but I simply waited him out.

"... and anyway, she came to visit me two days ago - and you see, my mother is in town and uh... so, you know..."

"Keep going," I smiled encouragingly, though I didn't feel very encouraged by this story thus far.

"Well, you see, it's not nice to, you know - my girlfriend and my mother - anyway, so I've been sleeping on the couch."

Since I highly doubted that sleeping on the couch was the cause of his "discomfort down below", I merely arched my eyebrows and made one of those grunts they teach you in medical school, the kind that sounds like "mmmmhmmmm?"

"Well - anyway my girlfriend and I, we wanted to - well, to do it," he said, speaking faster and faster now - "but anyway at the last moment before I - you know - well, we stopped."

At this point, my smile was becoming somewhat fixed, but again I made my noncommital grunt.

"And well, that happened the next night as well. And tonight too. And I have this discomfort." He was now speaking in rapid-fire mode. "I don't know what it is, it just feels - well, it feels tight."

Be the doctor. Be the doctor. Be the doctor.

"Mmmm. Tight," I repeated.

"Yes!" he said, seemingly cheered by my appearance of understanding. "Tight - and I don't know why."

So we ran through a brief sexual history - no discharge, no pain, no high-risk sexual activities. Nothing concerning for infections or other pathology. And then I plastered on the straightest face I could muster and proceeded to examine him.

It was at this point that I realised just how sexually naive my patient was. I never like examining manbits as I have already said, so I have a bad habit of going to my happy place in my head while doing said task - much of medicine can be learned through rote - algorithms that guide decision-making which help but shouldn't be relied upon. In any case, I was clearly not paying attention, because what happened next was unforgivable.

"I'm going to get you to retract the foreskin," I said without thinking. Only to realise, as the words issued forth, that my patient was circumcised.

If my mistake had been unforgivable, my patient's actions were incredible.

Incredulously, I watched as he valiantly tried to follow my instructions by retracting the remnants of his foreskin which, sadly, had long ago been sutured into place.

There are a few moments in a patient encounter when you suddenly learn something about a patient which no amount of history taking will ever elicit, and this was one of those moments.

This was a moment of enlightenment for me, the AHHHH moment in which you perceive a Great Truth. And it was this: my patient didn't have a fucking clue. Quite literally too.

I wanted to laugh but I understood at the same time, that here was a man who - and how awful that he should have done this! - had gone through his life without ever having learned very much about sex or sexuality. And that was no laughing matter, especially given that he wasn't a teenager or even a young man. He was fifty.

I bit my tongue, finished the exam. And then I covered him back up, sat him down and took out a pen and paper. I drew for him his anatomy - it was a quiet night anyway, so I could afford to take the time for some patient education - and explained to him that he was suffering from a classic case of "blueballs" - that becoming aroused by his girlfriend and engaging in foreplay without progressing to orgasm created the "tight" feeling he described. He took it all in, and when I was done, he seemed to get the idea.

Which left just one problem: "But, doctor," he said, "how do I get rid of this "tight" feeling then if I can't be with my girlfriend for the next few days?"

And so - for the first and hopefully last time in my life - I prescribed my patient a course of masturbation.

Never let it be said that I have a boring job.

The Heart Does Not Shit

2009-04-05T23:20:00.003-02:30

Writing this post-call, I feel such relief at finishing the last cardiology call of my life. It has been infinitely boring dealing with issues of the heart for the last month, especially when most of the patients don't seem interested in preserving their own lives, depending on us instead to keep restarting their clogged-up hearts.

Sometimes I feel like sitting some of these patients down and explaining to them that if you keep flushing tampons down a toilet, the toilet will back up. And if the toilet backs up badly enough, you'll have to call in a plumber. And the plumber will unclog your toilet for you. But if you keep on flushing tampons down the toilet, eventually everything will be so impacted no plumber will probably be able to fix the toilet. And so instead perhaps someone might come and fit new pipes to bypass the (tampon)ade - pun entirely intended. And you would think - after spending all that money on your new bypassed toilet, you would stop flushing tampons down the toilet.

But no, no, not at all! God forbid that one should actually give up the convenience of flushing tampons down the toilet! Instead, they go right ahead and keep on doing the same old thing. And lo and behold, eventually the new pipes get clogged too. And because your plumber has sworn a stupid oath to preserve the state of your toilet, he keeps having to come back. But eventually, someday, the toilet will explode in your face and cover you in shit - and it ain't the plumber's fault. He told you so.

Ah well.

The last cardiology call of my life went fairly uneventfully. I got about three hours of sleep in short interrupted bursts, nobody died on my watch and there was only one stupid consult. Said stupid consult was for a lady with constipation who was given laxatives and developed diarrhea. Now, you don't need an MD to follow my line of thought here - it doesn't take a doctor to understand the following:

1. Constipation and diarrhea are problems of shit and the lack thereof.
2. Cardiology is a specialty dealing with the heart.
3. The heart does not shit.

I repeat: The. Heart. Does. Not. Shit.

Given that I'm expected to preserve "collegial relationships" with fellow professionals, I refrained from writing that in the consult, opting instead to point out that "there are no cardiac symptoms suggestive of cardiac disease - in addition, this patient has symptoms suggestive of an infectious cause and I would suggest consultation with a general internist instead."

But oh, what I would have given to simply write those 4 words on the consult. Because the physician - and God only knows how on earth he ever got an MD - sent this lady at three a.m to see me, making her travel two hours by ambulance, no less - to be told that her heart does not shit. In any case, it wasn't her fault so I buffed and turfed her off to general medicine where hopefully they will discover the source of her problems and treat her....

And that, is the end of Cardiology!

Thanks For Death

2009-03-26T05:06:00.004-02:30

"Code Blue, 4 South. Code Blue, 4 South."

I hear the overhead announcement and I'm on my way even before the code pager erupts into a shrill scream followed by the detached mechanical voice announcing the same words. Someone's dead and it's my job to go see if we can get them back. It's 4am and in 3 weeks, I haven't been called to a code.

When I get there, it's evident that we're not going to beat death tonight. CPR is in progress - the patient is elderly and it's not just his hair that's gray. I walk in, take a look. There's no pulse, he's not breathing. I peel back the eyelids and his pupils stare back at me wide and glazed. His skin is ashen and mottling has begun. The torso is still warm - but his hands and feet are cool.

"When was the last time anyone saw him?" I ask.

The answer isn't good: "45mins ago."

The nurses look at me expectantly for direction. One of them is continuing with the CPR - obligation replacing common sense. We all know it's futile, but I have to say so. I want to call it off - but I feel obliged in any case to get at least confirmation of a rhythm - so we hook the leads up to the machine to see a flat line trace its way across the screen.

"Check another lead."

Another flat line - asystole. This isn't a heart that will be easy to restart. And my patient is old and worn down, a frail body at the best of times.

"Call it off," I say.

So they stop the CPR. The record will show that the code lasted just 10 minutes, that I didn't give him medications, put an IV in him, intubate him or shock him. I wonder if that's a bad thing, but experience and life in the ER has taught me that sometimes it's better to preserve human dignity than to look good on paper. Sometimes.

People watch codes on TV and they imagine this is a glorious, glamorous type of thing to perform on someone. They imagine that the handsome patient will suddenly gasp for breath, will miraculously recover and sit up and speak. They imagine all sorts of things but seldom do they realise what it is that really happens in a code.

We strip you in a code - there's no place for dignity.

We often break your ribs in a code - there's nothing quite like the feeling of compressing a broken chest.

We'll shove a large tube down your windpipe.

We hook you up to leads and - sometimes but not always - we'll charge our machine up to 360J and shock you.

We'll do it over and over until one of us decides to stop or you come back.

When you come back, you won't be conscious.
You won't sit up and talk.
You won't do anything at all actually.

We'll cart you off to the ICU where you'll be on life support.
Sometimes you won't come off it at all.
Sometimes you'll be brain dead - that's if you're lucky.

Other times you'll be brain damaged.
Or your lungs won't function any more and you'll need a machine to breathe forever, so we'll give you a tracheostomy to breathe through, but will take away your voice.

And sometimes - just sometimes, rarely, once every so often - we'll cheat death. We'll bring you back and you'll be just fine. You'll live to tell the tale. Our successes perpetuate the cycle of false beliefs about codes. You'll tell your most decrepit friends how you survived - and they'll come in demanding we "do everything" for them even when it seems utterly futile.

But not tonight. Tonight I sit with the patient's wife and I explain to her that we have done none of these things. I explain that I have asked everyone to stop the code. I explain that we have not stripped him, or broken his ribs, or shoved tubes down him. I explain that we've let him die in dignity. I explain that he was already dead for a while when we started. I explain all these things and I hold her hand and let her cry.

And when she's done crying, she thanks me.

When I leave at last, it's past 5am and I can't sleep. So I'm writing this. I can get used to codes. I can get used to death. But 3yrs later, I still can't get used to being thanked by families. Because they always do. They always thank me no matter how bad the news is. No matter that I will always be the doctor they remember as the person who brought them the news that destroyed their lives as they knew it. They always will thank me.

I have been thanked for telling thirty year old women they have cancer that has spread everywhere. Thanked for telling a mother her child is dead. Thanked by widows after breaking the news of their husbands' deaths. Thanked over and over.

I can get used to death. But never to the thanks. And I want to be the doctor they remember as saving lives. Not destroying their worlds with a few simple words.

But I swallow my protests. They need to thank me. So I let them. And then I wander back to my room in this hospital where death is ever-near and I swallow what grief still wells up in me and I get on with the job. And life goes on.

Living In The Hospital

2009-03-24T01:12:00.002-02:30

The word "resident" was coined because at one point, poor sods like me would literally live in the hospital, or in an adjacent wing, all in the name of providing 24/7 care to patients.

But for some patients, they too could be "residents".

Some of them are waiting for a bed in a nursing home.

Some of them are dying in palliative care.

Some of them are destitute, too ill to care for themselves and without a soul who can do it at home.

And then there are those who are so neurotic they would rather live in the hospital under the care of us wonderful doctors who mutter and curse under our breaths when said patients arrive for the umpteenth time and are admitted under for their legitimate but all-too-chronic and unfixable condition because their anxiety is assauged simply by the knowledge that they are now Hospitalised in an Institution in which they will now receive Healthcare.

Tonight I am not feeling benevolent towards this fourth group of patients. They cost our healthcare system tens of thousands of dollars a year, shuttling by ambulance (because they can't afford a taxi) paid for by social services (to the tune of $130/trip - there go my taxpayer dollars) to present to the emergency room complaining of (insert chronic ailment).

In medicine, if you look hard enough, you can almost always find something wrong with someone's health. Myriad investigations get done for no real reason other than to cover one's ass before discharging a patient - and especially in this fourth group of patients, one is almost bound to find some abnormality that is "hospitalisable".

So they get admitted.

And then they stay.

And stay.

And stay.

And nothing you do to "fix" them ever works because - to their minds - it doesn't. They find ways and means to thwart all your efforts at "fixing" them so they can be discharged, because that means losing their secure little place in the bowels of the hospital surrounded by sick patients and various superbugs that inhabit this place.

I think they should have been doctors, then they could live in this place forever...

Just another random posting while on call in this dank place...

Cardiology

2009-03-19T01:11:00.002-02:30

I can't wait to get back to the ER.

The dearth of stories is basically because I find none of my cardiology patients particularly interesting, other than for the fact that most of them seem hell-bent on their own destruction via smoking, obesity and generally awful lifestyles.

Take the Iceman the other day, who was trundled in by the paramedics in cardiac arrest.

While the hubbub of resuscitation was ongoing, I slipped out since there were way too many doctors crammed into the resus room, and got on the computer to pull up what I could of his history. Only to discover, as is typical, that this certainly wasn't my patient's first visit for a heart attack - in fact it was his third. And in the previous discharge note, one of the physicians had recorded that "he told the team in no uncertain terms he did not intend to change his lifestyle, give up smoking or take his medications".

G-r-e-at. Here I go again, making Darwin roll over in his grave...

Anyway we packed him up in ice and off to the CCU where he now lies in induced slumber. It's anyone's guess as to what sort of brain function he will have. Though I have doubts as to whether there was any to begin with.

Not all is lost, though. I had another patient the other day whom I was delighted to see. She had essentially arrested in the pickup truck her friend was driving to the hospital where she had been headed to see us for her awful chest pain. And we brought her back. That was some months ago. Last week, I chanced upon her in the ER (for something fairly benign) and we got to talking. Unlike the majority of our patients, the arrest seems to have successfully woken her up to the fact that she needed to change many things about her lifestyle if she wanted to avoid going towards the light prematurely - she'd lost a lot of weight, was exercising, had quit smoking, etc.

Patients like the first are a dime a dozen - patients like the second are the ones that keep me going. Sometimes, just sometimes, I guess we do save a life for the better and that makes me feel as if I am a force for good.

Newfoundland Mourns

2009-03-12T22:30:00.002-02:30

Today the emergency department was activated when a helicopter went down off the coast of St John's. The reports trickled in, half rumors, half fact. First we were preparing for 18 casualties. Twelve ambulances and a helicopter crowded the tarmac waiting for instructions to go. Then they were told to stand down. The reported number of survivors dwindled. Until finally, only one man was brought in alive.

This island has a long history of losing its folk to the Atlantic Ocean. In a place this small, everyone knows everyone. Everyone is just one or two degrees of separation from the other person. It has hit everyone hard indeed. One of the nurses lost her husband in the crash. When one of the physicians walked into a room to speak with the family of the sole survivor, it turned out that she had grown up with that same person's mother. And so on.

I'm feeling sad today. I've come to be very fond of this place and today you can feel and see the sadness mirrored in the face of every man and woman in this town.

I Hate Residency

2009-03-08T22:04:00.002-02:30

I. Hate. Residency.

I. Hate. Residency.

And, just in case you didn't get the idea...

I. Hate. Residency.

I thank god that I did not choose surgery because that would be 5yrs of residency, not 3.

I ask myself sometimes why on earth I chose to do a 3rd year of residency when I could still be doing emergency medicine somewhere without obtaining more specialised training. Yes, maybe I wouldn't be as good at what I do but I'd be paid a shitload more than I am right now and I wouldn't have people watching over my shoulder at every turn and I wouldn't have any more rotations in things I have little interest in just so that perhaps, just perhaps, I will learn something relevant to what I'm going to be doing.

Starting cardiology tomorrow, I am not feeling optimistic. I hate being on call any more. I hate being off-service instead of in the ER. I hate working 32hr shifts. I hate being paid $70 to work said shifts. I'd make more working at fucking McDonald's. I hate hate hate hate having to play the stupid fucking residency game of changing my practice of medicine to suit whoever whenever whatever wherever whyever.

I love emergency medicine I just hate having to play the fucking residency game for another fucking year. Well, more like four more months. And I hate having to fucking study for another stupid exam in September. I am sick of writing fucking exams. I will so fucking burn the thousands of dollars' worth of textbooks when I receive my exam results, assuming I pass. I am just so done with my fucking edumacation.

AAAAAARGGGGHHHHHHHHHHHHHH.

Good News Bad News

2009-03-03T16:42:00.006-03:30

"Now, my dear, what brings you into the ER at this ungodly hour?"

It was 3am on a Monday morning and this is my post-midnight spiel, a sneaky way of trying to figure out if I'm dealing with a patient in genuine distress or otherwise. I've always found the answer to this question to be very revealing - the patient who irately says "well I couldn't sleep, I'd run out of my (fill in narcotic name) and where the hell else was I supposed to go?!" is quite different from the one who gasps "I think I'm having a heart attack!"

I like the midnight shifts. I've learned that patients who come into the ER at these hours are either 1) very sick or 2) very crazy/worried/depressed.

This patient, though, stumped me with her answer: "I decided to get in the tub yesterday morning," she cheerily said, "and I decided not to get out."

"Oh," I said, mostly because that was all I could think of.

"Yes," she said, "and I suppose when my son came by tonight, he was alarmed because I was still in the tub."

"Oh," I said again.

"Mmmhmmm," she said, nodding her wizened 80-yr old head.

Wondering if she had a history of dementia or anything that would put her into Category 2 (which I - bad, bad me - call "the crazies"), I took her family aside.

"Is she always like this?" I asked.

"No, doctor," her son said, worriedly. "Never. She lives alone, does everything for herself. When we got there tonight, she was seeing things too."

"Seeing things?"

"Yes, she said there was a little girl with a teddy bear standing in the door."

O-k-a-y...

I went back to my patient, and tried a different tactic. "Tell me," I said, "who's here with you right now?"

"My son," she said. "My daughter-in-law."

"That's right," I said. "Anyone else?"

"Well," she said, "there's somebody standing over there on the ceiling but I can't make out who it is."

Nonchalantly, I elicited more details from my patient about this upside-down person: wears glasses, stands on the ceiling, is female, and "can't make out if she's dressed".

Since there were no naked little female leprechauns prancing on our ER ceilings, she was quite evidently psychotic. But without a psychiatric history? It would be highly unlikely - though not impossible - for someone to never have had any sort of psychiatric problems in their lives only to develop schizophrenia in their 80s...

I ordered my usual investigations for delirium, waited for them all to get back, and, as expected, found nothing. Great. Back to square one: my patient sees things and makes strange decisions to sit in bathtubs for two days but I can't find anything else wrong with her.

"Why didn't you get out of the tub?" I asked.

"I don't know, my dear," she said. "Couldn't tell you. I did think about it, though."

I was desperately fishing for "medical" reasons not to get out of a tub. Was she weak? No. Faint? No. Ill? In pain? Having trouble breathing? Couldn't see? Afraid she'd slip? No, no and more no. She'd just "decided" not to get out after thinking about it.

So I did the last test I could think of: I called the radiologist and asked for a CT of her head.

The radiologist was unimpressed by my request. "It doesn't sound like a stroke," he said.

"Yes, I know," I said. "But she's not delirious, she's hallucinating and behaving strangely and I want to make sure there's nothing actually in her head, like a tumour."

"But her exam was normal," he said.

"Yes, I know," I said. "I know this is a very strange story."

He reluctantly agreed to do it, and two hours later, I had my answer:

"There seems to be a subtle tumour in the right frontal lobe," the radiologist said. "That would explain the hallucinating and strange behaviour."

When I went to give the family this "good news bad news" - good because there was a reason for the strangeness of my patient, bad because it was a tumour - they took it quite well.

In fact, my patient took it better than her family.

"Oh!" she exclaimed, chuckling delightedly. "That's just what I need, my dear - a brain tumour!"

Second Guess

2009-03-02T16:13:00.000-03:30

Some days I go to work and I come home patting myself on the back for making a good call. Other days, I come home troubled with a nagging question - could I have saved that patient, or was it inevitable? Yet I think the real answer is that I do the best that I can do, with the skills that I have acquired and the knowledge I have gained from years of study - and then the rest is up to Fate, or God, or divinity, or whatever it is that one chooses to believe in. And that "rest" isn't within my control. But still I wonder - did I make the right call, was there more I could have done? Inevitably, after a while - a few hours, a day, a week - this questioning fades. Until the next patient comes along.

"Something's wrong," his wife said to me. "Something's wrong and I don't know what it is."

He had seen five doctors in the last month for the same problem - the same complaint of a nagging off-and-on pain in his chest, that no one could explain. All his cardiac tests had been negative - bloodwork, troponins, EKGs, even a cardiac catheterisation and a cardiac echogram, a stress test - none of it had yielded any sort of explanaton for his pain.

Now he was here, in the ER on my shift.

Patients like these are easy to write off. They've been seen by so many doctors that the next on to come along already feels faced with an impossible task. How would I, a young emergency medicine physician in practice for just three years, figure out what older, more experienced cardiologists could not?

I dutifully took the patient's history, did his physical, ordered his bloodwork, a chest Xray, an EKG - and, as I had expected, all of these yielded nothing.

When I gave this "good" news to his wife, she was beside herself. "Something is wrong," she said, in tears. "I just know it is, and what will I do without him?"

What were we missing? Or were we really missing anything? I felt troubled, and also frustrated.

There are a myriad reasons for chest pain. The ones that can kill you are the ones we always worry about - heart attacks, pulmonary embolisms, pericarditis. Others are not as deadly - pneumonias, muscle strains, anxiety, reflux. They say that the history is what guides the majority of your diagnosis, and this man's history was fairly benign except for cardiac disease - and yet he had had every cardiac investigation possible, and they had all been negative.

I ran it by a more senior physician, my direct supervisor L.

"The only thing I can think of, that he hasn't had done," he said, "is a CT pulmonary angiogram."

I was puzzled by this. "But his chest pain has been ongoing for four months, he isn't short of breath, he has no risk factors for a pulmonary embolus, and his Xray is clear."

"I know," my supervisor said, "I'm just saying it's the only test he hasn't had done. I can't think of anything else."

We discussed it further, and in the end elected to re-consult him to cardiology, if only because one of his cardiac enzymes was minimally elevated.

My shift ended, and I thought nothing more of it.

The next evening, I ran into a colleague.

"Did you hear?" she said. "That man you and L consulted to cardiology yesterday?"

"What happened?" I asked, but already I knew it wasn't good. It never is.

"He died," she said. "Cardiology sent him home yesterday and he came back again this morning and he arrested in the ER."

I was shocked. He had seemed fine the day before, and his investigations had been normal - we had sent him to the cardiologist based solely on a troubling feeling that there was something here we were missing. Surely he couldn't be dead.

But he was. He had been sent home, and the next morning, he had felt worse. His wife had brought him back to the ER, and he had been awaiting a repeat consultation with the cardiologist when he had suddenly arrested. They had worked on him for a long time - they always do on the young ones, and he was barely 50 - but to no avail.

They think now that he died of a massive pulmonary embolus. And it leaves questions in my mind. Would we have discovered it if I hadn't pointed out to L all the reasons not to do the CT, the only test that would have picked it up? Could this have ended differently? My colleagues, the ones of us who saw this man over the last month, they've asked themselves these questions too. And I think that all of us feel sorry. But still, we know - we have to believe - that we did all we could.

Yet in my head I can hear his wife still:

"Something is wrong, doctor - and if you can't find it, what will I do when he is gone?"

And I feel like saying, I'm sorry. I'm sorry that I couldn't find it. I'm sorry that despite all my skills and my knowledge, all the years of training and the years I've dedicated my life to medicine, that I couldn't find it.

Sometimes I think patients will never know how sorry I am that I am not God. That I don't control the "rest". But I know that this will fade. And I'll pick up my stethoscope again, tomorrow, and get out there in the trenches and maybe, just maybe, I'll save someone this time around.

Defeating Evolution Yet Again

2009-03-01T01:56:00.002-03:30

A good rule of thumb in emergency medicine is that it's the nice, sweet, polite patient that will die. The assholes never do. Today I was reminded yet again of my role in defeating the laws of natural selection.

He was brought in fully immobilised on a spinal board with a cervical collar on, his obese frame strapped (barely) down. Despite the copious amounts of blood splattered all over his front, this didn't seem to have dampened his spirits since he was regaling the paramedics with the tale of this, his latest exploit. I thought perhaps his joviality was secondary to intoxication, but there was certainly no smell of alcohol on his breath. When he had been settled into our trauma bay, I introduced myself to him, and proceeded to elicit the story.

Apparently, the trouble had started with a fuss over garbage disposal. Our good patient - we shall call him G - had decided that since he was disinclined to dispose properly of his bulk garbage, that he would simply place it in a common area by the road, where he presumed someone would come along to pick it up. Unfortunately, given the fact that our roads at this time of year are narrowed by tall snowbanks on either side, his garbage had ended up encroaching onto the road itself.

Enter B, a passing motorist who decided to take it upon himself to heckle G over his un-neighbourly behaviour. Feeling somewhat put upon, G decided to "defend" himself. Crossing over to B's car, he had stuck a fist into the latter's face. Shouting and punching on both sides ensued. At this point, apparently, G had forgotten that although he must have outweighed B by quite a bit, B was in possession of a weapon: the car. He had grabbed B's collar and was shaking him when B, decided he had had enough, proceeded to floor the accelerator.

Not to be outdone, G ran alongside the car for quite a few meters, still hanging on to B's collar. His stubbornness was to be his undoing, as B - perhaps alarmed by G's tenacity - accelerated even further.

"I told him, "Stop! I'm losing my footing!" but he just went faster," G said, "and then I fell."

"Uh huh. So... you were holding on to him and got dragged that way?"

"Yeah, the asshole! He wouldn't stop!"

Needless to say, the result was not pretty - gashes to his head, hands, knees and lots of roadrash. At one point, examining my patient's knuckles, I asked if the wounds were from the punches he had thrown, or from the road - since if the former, he might have required antibiotics as the human mouth is the dirtiest place there is, from which to incur a cut.

"Oh, no, that's the road," my patient cheerfully said. "Though I wish it was from his mouth! It would make me feel better, haha! The idiot should have minded his own business!"

He kept up this barrage as I patched him up, and finally I couldn't resist. "Sir," I said, "what do you think is the moral of the story tonight?"

"Oh," he replied, "ummmm.... don't put your garbage on the road?"

"Yes," I said, thinking perhaps there was hope after all for my patient, "that would be one lesson."

"Ah, but if it was just me I'd understand, but hell, the man down the road does the same thing and nobody yelled at him!"

So I gave up and let him continue to wear my ear out. And by the time I had finished sewing him up, I must have heard a hundred reasons why it wasn't his fault at all, and instead it was entirely, utterly and totally B's fault. I almost wished he were drunk or unconscious by the time I was done - and that was the start of my 8hr shift.

Just before G left, I bid him goodbye and told him that I hoped not to see him again in the emergency department.

"Well, Doctor," he said, "I must say - if it ever happened again, I can't say I'd do anything different except maybe punch him harder."

Sometimes I think I make Darwin roll over in his grave.

Strange Terms

2009-02-28T00:25:00.004-03:30

"Stunned"
As in: "you're stunned, 'by!"
Equivalent to "blur sotong"

"In't dat foolish!"
In English, this equates to "Isn't that foolish!"

"Oh me nerves, dey got me drove!"
This usually makes me feel my own nerves become driven...

"Arse foremost"
Backwards

"Now luh, da arse is gone right out of er"
Not a medical term, refers to the lagging economy.

"A pain going up through me."
Does not carry any significance regarding origin of pain - is simply a term used to convey the fact that the speaker is in pain.

"The gentleman's passage."
I still haven't figured out exactly which passage this is, but it's a 50-50 guess.

"A nish pain."
Nish: moderate - neither severe nor trivial, tender.

"It's a hard pain, a hard pain, 'by!"
I presume this means "severe" but I could be wrong.

"Hexcellent!"
A version of "excellent" used by witch doctors. Alternatively, an effusive exclamation.

"Wrestling wi' me 'usband."
A patient with a dislocated kneecap related this as being the mechanism by which she had sustained the injury. Somewhat incredulous, I asked her if she did this often. She turned a deep crimson and nodded, at which point the light dawned on me as to what she meant.

"Me water."
As in: "makes me water", "me water is dark", "hurts to make me water"
Refers to micturition.

"Passage"
As in: "back passage", "front passage".
See "gentleman's passage".

"Pains in the backs of my lungs."
I still haven't figured this one out, I simply ask the patient to point.

"Hammeroids"
Hemorrhoids presumably producing great amounts of pain. Sometimes called "hamroids" which may refer to pumped up hemorrhoids?

That's it for tonight, but there are plenty more I've heard... there is never a dull day here interacting with the good salt-of-the-earth types that I've met here!

The Blackened Member

2009-02-27T23:59:00.002-03:30

The triage nurse placed the chart in the "IN" box and gave me a sympathetic look before walking away.

I picked the chart up. "Blackened penis," it said, under "chief complaint".

I guess the look on my face said it all, because the other nurses crowded around, wanting to know what wonderful medical mystery chart I held in my hands.

"What is it?" they asked, "anything interesting?"

"Manbits."

"Oh, really?"

"Yup."

The aforementioned "blackened penis" sat in a private room looking rather sheepish. Sticking on a straight face I introduced myself, making sure to use my title. One can't have too many titles in these sorts of situations. Slowly, the story emerged: he had been having sex the night before and had awoken in the morning to the alarming sight of his somewhat swollen penis which was now quite a few shades darker than it had been the night before. I suppose when you are a male Caucasian man and your penis turns the colour of ebony, this qualifies as a Problem.

"Any pain?" I asked.

"No," he said. "None at all."

"So.... any unusually vigorous activities that would have caused this?"

"No." He was sticking to his story. "I have sex maybe once or twice a week, but just the usual."

"No trauma?" I was fishing now.

"No."

O-k-a-y.... Time for the clinical exam.

The offending member made its grand appearance, then - a gloriously bruised, somewhat swollen species of penis. Quite evidently, something must have happened to give it this wondrous shade of purple, but damned if I was going to be able to discover what exactly that had been. However, he was quite right in that he didn't seem particularly tender, nor were his jewels deformed and so, after some mulling over the Purple Penis Problem, I decided to discharge him.

"Now," I said, "I want you to rest for a couple of weeks until this problem clears up."

"Oh," he replied, "that's not a problem - I'm not working anyway this month."

I couldn't help it - my eyebrows arched. "When I say rest, I'm not talking about work."

Understanding dawned on him. "Oh!" he exclaimed, and blushed. "Okay."

And so ended another day on the job.

As if nothing else could go wrong...

2009-02-24T22:30:00.002-03:30

I hit a car.

No, make that a truck.

This really screws things up because I am utterly broke and am going to have to eat the repair bill if I don't want my insurance premiums to skyrocket. St John's has been walloped by three snowstorms in the last two weeks, and driving in a blizzard at 30km/h I thought I'd make it home safely - till I hit a snowdrift and slid right into the back of a truck.

The other driver got out, looked at the back of his truck, looked at my car, shook his head and said, "I think you got the worst of it" before hopping back into his truck and taking off. Which, in all fairness, makes me one fortunate person since there isn't going to be any damage to cover from his end of things. The car, though, is a different story - it needs a new front grill, the radiator is partly exposed (as a result of the grill falling off) and the bumper needs some major work. The bill? $1118.

This poses a problem, considering I just bought a house with over $4000 worth of appliances and furniture, reducing my savings to almost nothing. Certainly not enough to cover that amount. Which means, for the first time in my life, I am going to have to incur credit-card debt. At a whopping 19% annual rate, this kills me but I have no choice since I have no lines of credit or overdrafts to fall back on. It makes me feel vulnerable, partly because it reminds me how something completely unexpected can put me in such a sticky spot.

Oh well. That's life. As a result of this unforeseen accident, I've had to cut short my month-long rotation in orthopaedics out in Corner Brook. Is this a bad thing? Not really because I wasn't enjoying it. But I'll have to go back out there sometime to finish it. I'm kind of glad to be back in town, though I wish it hadn't happened this way.

In other news - life outside of work looks like it's becoming fairly interesting - and busy. I need to study and I know this and I tell myself every day I need to get down to it but I just feel so.... uninterested in studying medicine these days. I think I'm just tired of the continuous grind of working and yet having to balance the learning with the working. But the exams are in September - and I'll be the attending in July. So I have to. But where oh where is there the time to do it in between sleeping, watching TV, going out, playing cello, singing in the Philharmonic Choir and snuggling with Miko?

OK, I admit - there is the time. The inclination though is lacking. I have to buck up. Must. Buck. Up. It would be such a shame to flunk these exams now after so many years of work. As my friend said, it's sort of like being pregnant. The closer you get to the end, the more you can't wait for it to be over with.

Blah.