words and images are Dr. A’s original work
except where expressly indicated
Untitled
written June 2020
There’s something strange in growing older
Adult now, you get no taller
Rather than upwards
You grow…inwards
We used to measure ‘getting bigger,’ ‘growing up’
With haphazard scratch marks
Now-smudged pen marks
Crawling up the wall
But now we measure growing – how?
Trees bud new leaves..
Creatures shed shells..
We shed naïveté
Adding wrinkles instead of tree rings
Our hearts, too, wrinkle - shrink
Against the bitterness of the world
So now we measure loving – how?
Tongues tied and twisted round these statistics
Sadistic
Unfamiliar laugh lines
Learned back then,
Back when..
When age lines, length spines
Stood tall
Up the wall…
No rewinds.
No. Now we look round, down the hall,
Black hall
Blank walls
And measure going – how?
the worlds we fall in to
written February 2020
Melanie Reid is the author of The World I Fell Out Of, a narrative detailing how she became tetraplegic following a horse-riding accident at the age of 52, and her life afterwards.
“If we did dream, our dreams tormented us by putting us back on our feet again. Dreams so vivid that when we woke, it was especially desolate to rediscover reality. […] I remember one night I even said to myself in my subconscious, ‘Now don’t be fooled, this is a dream, you can’t really walk again,’ and then I dreamt that to test it, I had woken up, and it was true – I could actually walk again. Double-dip dreaming. A plot within a plot. But of course everything remained within the parameters of the dream. Waking that morning, for real, was particularly cruel.”
“Tetraplegics with some arm function had [their call buzzers] draped across their bedclothes, as in my case. Those who could move only their heads and shoulders had them beside their cheek, so they could turn their head and press them.” [pp. 76-77]
I am jolted back to his dark single room in ED late at night, the sliding glass doors bearing a white Infection Control sign. I donned a gown and gloves to greet this patient, a man returning from long-term care. Paralyzed from the neck down, an indwelling catheter was the reason for his repeat admissions with fever and infection. His gaunt chest, muscles wasted, revealed each rib behind taut skin as I listened to his heart and lungs. This man’s BP was starkly low, to my unaccustomed eyes, but he reassured me “it’s always like that.” Owing to spinal cord injury and impaired autonomic control, I inferred.
As I began to make my exit from his room, he asked “Can you pull the sheet all the way up?” I gently tugged the blanket up just past his chin. “Higher….higher…Ya.” Only his dark eyes peeked out, below the ridge of his toque; bright light from the monitor reflected off the half-exposed bridge of his nose. “I’ll see you tomorrow,” I said, making sure his call buzzer rested there upon the pillow, right beside his cheek.
~
Tomorrow – having seen that his mild confusion and fever were improving – I was preparing to exit when he asked plainly, “Do you wipe eyes?” I stopped, caught off guard by his question. “Oh… yes, of course, sure,” I fumbled. “Just here, with this towel,” – he nodded his chin toward the small white hospital towel lying across his chest.
I clutched a clean edge, and gently wiped across his closed lids, from medial out to the side. “Harder,” he said. I was hesitant, cautious not to hurt him, but he insisted. Satisfied, I repeated the motion, firmly, across his other eye. “Thank you,” he breathed.
I had somehow forgotten this immensely tender, jarring, vulnerable moment, until I read Reid’s passage. I remember leaving his hospital room – that night in ED, and even more so the next morning – with this intense, warm, weighty feeling; even now I can’t describe it. My own nervous system somehow fiercely at attention, breath caught in my throat, as I tried expertly to perform these two small tasks just so, just as he needed them. I wanted the blankets to rest precisely where he desired them. I wanted his eyes to be free from grit and sleep, comfortable to stretch open and survey his world; his world in which, for a measly moment, I was somehow blessed to feature.
Just Listen
written August 2019
He is nameless and ageless as I enter the room, pulling blue gloves tight down to my wrists. I interlock my fingers and place my arms straight down in front of me, to take up as little space as possible in the crowded single-bed room. There are at least ten people in the room, plus the unresponsive patient. Chest compressions are ongoing; there’s a flurry of activity around the gentleman lying, fully exposed, on the hospital bed. My eyes scan round rapidly, taking in sights and sounds, and come to land on the patient’s arm hanging down over the bed, gently bouncing and rocking with the force of each chest compression. A bone drill whirs to life as intraosseous access is obtained; a nurse calls out ‘two minutes’ signalling for a rhythm check; a resident calls to charge and deliver a shock.
Thirty minutes elapse. With seemingly no other options, the Cardiology Attending summarizes what has transpired thus far; he asks whether anyone has other ideas, or any objections to stopping this resuscitation. No one does. We cease chest compressions and take a half-step back.
This is my second call shift, my first Code Blue; my first death.
I feel deep sorrow for this man, who died amidst sterile chaos, without family by his side.
I don’t yet know how to say goodbye to patients – and I don’t just mean those who have passed away, like this gentleman, but even the inpatients under my team’s care when my elective would come to an end. Those faces I’ve smiled at for the past days or weeks; hearts I’ve heard; hands I’ve held. Countless patients’ illness experiences for which I may never know the outcome. Their faces and stories, sons and sisters, widows once wives – they stay with me.
I sat by the bed with a young man’s wife the day after they received devastating news. There were no further treatment options for his widespread disease. No feasible clinical trials. Malignancy tore away at his insides; he was pale and so, so tired. Profuse night sweats left him sleepless and dehydrated. The faces of these newlyweds will rest forever behind my eyes. They were perhaps the kindest couple I’ve met, in spite of it all; why does that always seem to be the case? Perhaps tragedy has a way of ‘right-sizing’ things. Priorities. Sometimes tragedy brings out overwhelming heartbreak, denial, or anger. Other times, it seems capable of bringing out a gentle calmness. It’s as if, amidst so much thick tragic air, some souls simply refuse to add any more hostility to the room, to the world. So they are kind, grateful, even smiling — these heart-wrenchingly tender, weary smiles.
When you’re acutely aware of the precious energy required for a patient to lean forward for deep breaths, you are gentle, and you listen hard with your stethoscope. When you know your fingers palpate a topographical metastatic map, you are quiet and thorough. When you know your ears hear a heartbeat that pumps blood to his tumours, but also to his mind and heart itself, you close your eyes and just, listen.
This is immeasurable privilege. This is Internal Medicine and Oncology. This was Electives summer.
CROSSROADS
written March 2019
On my commute last week, the bus passed a bridge that looks exactly like a bridge back home, and I couldn’t help thinking about the crossroads at which two worlds diverge.
Crossroads and diverging paths have been on my mind a lot lately. Path A, or Path Z? (not B, for they’re far too different). Opposite ends of a spectrum; opposite sides of the globe; worlds apart. Both at once Ambitious and Zigzagging. My mind-map to “deciding” has been truly as back and forth, tortuous and torturous, uncharted and unnerving, as a mAZe.
So I had to get some perspective.
~~~
We encounter crossroads and diverging paths so often in medicine, life, and self. Most notably, perhaps, in the tug-of-war between our Narrative self and our Experiential self. (Bear with me).
The Narrative self is who you tell yourself you should be; what you believe you should be doing; how you tell yourself you should spend your time. The ‘would be ideal’.
The Experiential self is the ‘in the moment’ real-life version of you; how you actually spend your time; how it makes you feel; what you can handle and what you do. How you experience your life.
Oftentimes these selves align and run in parallel – our experiences in the present match the narrative we’ve planned or imagined, and we are contented.
Other times, they diverge – sometimes of our own volition – the Narrative self says ‘we should study’ but the Experiential self scrolls relentlessly through Instagram – but often the divergence is wholly out of our control. You planned to go to medical school in Canada, your narrative unfolding in your mind the way you’d always imagined it, following that straight ideal path. But this narrative wasn’t in the cards, so every cell of your Experiential self ended up studying medicine and living life in Europe. And, turns out, this experience is a whole heck of a lot more enriching, adventurous, and full of growth and challenge than your little Narrative could have hoped for.
Crossroads were especially topical these past few weeks, as results of the Canadian and US Residency Match came out. Your Narrative self would match, of course, through CaRMS or ERAS, in the first round. And perhaps you did! Or perhaps you didn’t. Either outcome is a gift and an achievement. Your Experiential self will roll with the punches and take everything one day at a time, playing the hand it is dealt. Life has a funny, surprising, purposeful way of working out just the way it’s meant to, in ways you never expected.
So rest assured (as I am learning to) that with each passing day, and every accomplishment or perceived downfall, each hardship, decision, joy, or triumph, slowly but surely your experiential path becomes the new narrative. Just the way it should.
“THE HUMILITY SHIFT”
written January 2019
This has been a week of bereavement.
[I’m on a 6-week rotation in General Practice/Family Medicine]
First, we saw a 20 year-old patient whose mother passed away over Christmas, after a long battle with cancer.
Then, a father who buried his son on Christmas Eve. He was only in his forties.
Later, a grandmother whose teenage grandson was recently killed. She attended our clinic with her other grandson, who lost his brother.
I had a heavy heart.
~
Every day in medicine, I am reminded of one simple but vital truth – something I try to hold at the front of my mind, always.
You can never ever know (by simply looking or judging) what someone is going through. That person you just passed on the street, sat next to on the bus, queued behind at the store checkout – they could be having the worst day, week, or month of their life. They might have lost a loved one. Received a tragic diagnosis. Lost their job, or their home, or their spouse, or their child.
You never know, so you cannot and must not judge or assume.
Too often, we are hard on each other. Cold. Rushed. Insensitive. Impolite.
Too rarely are we compassionate, gentle, forgiving, or patient.
~
It’s such a simple thing – to assume ‘good’ in people, to smile, to be kind.
Honestly, being anything less requires more effort, and only hurts those around you.
I’ve been thinking about this a lot lately, and stumbled upon a 2015 New York Times article – “The Moral Bucket List” – that I first read a couple years ago. Re-reading it, the words were still so impactful and inspiring; a reminder, a wake-up call.
“It occurred to me that there were two sets of virtues, the résumé virtues and the eulogy virtues. The résumé virtues are the skills you bring to the marketplace. The eulogy virtues are the ones that are talked about at your funeral — whether you were kind, brave, honest or faithful. We all know that the eulogy virtues are more important than the résumé ones. But our culture and our educational systems spend more time teaching the skills and strategies you need for career success than the qualities you need to radiate that sort of inner light. Many of us are clearer on how to build an external career than on how to build inner character. […] It is easy to slip into a self-satisfied moral mediocrity. You grade yourself on a forgiving curve. You figure as long as you are not obviously hurting anybody and people seem to like you, you must be O.K. […] But all the people I’ve ever deeply admired are profoundly honest about their own weaknesses. […] They have achieved a profound humility, which has best been defined as an intense self-awareness from a position of other-centeredness. […] That kind of love decenters the self. It reminds you that your true riches are in another. Most of all, this love electrifies. It puts you in a state of need and makes it delightful to serve what you love.” – David Brooks (NYT)
~
In medicine, we recite and uphold the Hippocratic Oath. It states (to varying degree, depending on which version you read): ‘Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm. I will remember that there is art to medicine as well as science, necessitating warmth, sympathy, and understanding.’
As I go about my days, I challenge myself to keep these thoughts ‘present’. To not be clouded by judgement or conjecture. To offer strangers and colleagues and patients and friends the most understanding, kindest version of myself.
This takes constant reminders, pauses for reflection, and purposeful effort.
But it is rewarded in spades by a patient’s warm smile, honest tears, heavy shoulders, or sincere handshake, when they feel heard, respected, and valued.
* Here’s to a kind and compassionate 2019 *
OBGYN: 7 weeks, 6 b’s, 5 senses
One passion.
written December 2018
Post-natal history taking was one of the most fulfilling and heart-warming clinical experiences of my 7-week placement in Obstetrics & Gynaecology, over the past two months. The mothers are….warriors. Goddesses.
Myself and two close friends and classmates introduce ourselves as medical students with the OBGYN team, hoping to have a chat about how mum and baby are doing since delivery. Most cases are uncomplicated, as we work our way through the 6 B’s of post-partum (puerperium) health and care. We ask mum about:
Bleeding (lochia, post-partum haemorrhage)
Breasts (mastitis, engorgement)
Bladder (retention, UTI)
Bowels (constipation)
Blues (mum’s mood, post-partum depression)
Baby! (feeding, stooling, sleeping, being precious)
In medicine, as in any walk of life, we must address patients, people, by what they wish to be called. “Ms. X” or, “just Y is fine.” Of course, this also includes the newborn baby.
“Congratulations! Who’s this? Do we have a name yet?” I begin the post-natal history. Often, a name hasn’t been settled on just yet.
“We’re still deciding between two,” she admits. Her son is pink and perfect, swaddled and sleeping tucked against her. “Alex...or Max.”
My heart stops, and soars, a wide smile breaking unstoppably over my face. I say warmly, “Those are the names of two of my dearest friends in the world, so I promise, whichever you choose is perfect.”
The pure new-ness of these moments…it’s impossible to convey in words. Early morning hours on the post-natal ward, women of all beautiful, strong, gentle shapes, colours, ages, and cultures; first-timers and returning mums.
That all my senses got to bear witness to these monumental moments of near strangers’ lives during my obstetric rotation is…inexplicable. Remarkable. My eyes embracing warm tired smiles, and taking in clinical exam findings; my ears receiving the vulnerable, intimate, heart-wrenching details of patients’ lives and bodies; my hands measuring and mapping the unborn baby inside of you; the smells of labour, delivery, Caesarean sections, newborns, and more; the sound of your baby’s first breath and cry.
This is privilege. This is life, and love, and flesh, and heartache.
This is medicine.
This is why we do it.
IN MEMORIUM
written in First Year Medical School
Seated against the wall, I have a wide view of the pews; I scan the profiles of countless solemn faces, people of all ages, a few wiping quiet tears from their cheeks. But I cannot tear my eyes from one nearby woman, in her early fifties, brown tousled hair, a dark patterned shawl falling off her shoulders, her eyes wetter and sadder than the rest. She blows her nose many times, but remains stoic in her mourning.
It is the second semester of medical school, and today was a truly memorable one. We were invited to attend the college’s memorial service to honour those who have donated their bodies to medical science, to our Anatomy Room. Held at a small church just down the street from the school, the service welcomed the donors’ family members so that students, surgeons, anatomists, and staff could offer them our sincere gratitude for carrying out the final wishes of their loved ones. Collectively, we honoured the deceased, thanking them and their families for the immense sacrifices they have made so that students may study the intricacies of the human body in an invaluable, hands-on way.
In Irish culture, burial is a revered tradition of utmost importance in the grieving process. As a medical student in the cadaver lab, it can be all too easy to forget the tremendous sacrifice a donor’s family makes when allowing their body to be donated for medical study, too easy to forget the protracted pain and bereavement they endure so we may have the incredible opportunity to really learn, from the inside.
Today, all this and more was remembered. Imparted. Felt.
~
After the service, guests are invited for tea in the oldest building of our medical school, pock-marked with bullet holes from the 1916 Rising, symbolic relics of a century-old sacrifice; now, we gather to share stories and express gratitude for the sacrifices of today.
I approach a friendly older woman cradling a teacup, standing in a small group with an anatomy professor, and introduce myself. She is here with her husband, in memory of his uncle. I thank her wholeheartedly, though the words feel strange. We talk about the moving ceremony, the beautiful choir. She is eager to hear what I want to study, then even more eager to chat with my friend about her years of dancing prior to medical school, as her daughter is a dancer too.
Next, I meet Gary, a charming, chuckling, story-telling, kind-hearted man in his late seventies, who travelled hours from Galway to attend this service in honour of his brother, a donor. We speak for quite some time - of my interests, his career and a fond trip he took to Ottawa, of his son’s new job as a Judge, and, briefly, his brother’s life. He talks and laughs easily and endearingly. He clutches my hand and I thank him again; it was so special to meet you.
I gaze round the room, filled with students, doctors, and these family members - strangers thirty minutes ago now bonding over an indescribably intimate thing. I find two classmates, and we approach an elderly man sitting alone at the far edge of the room; his two daughters and grandchildren approach as we do. We introduce ourselves as first year medical students, and learn from his daughter that they are here to remember her mother, his late wife.
She passed away in her sleep, only five months ago. I am nearly at a loss for word. Here is this woman, herself a mother, bearing parts of her soul to three medical students on the day of her mother’s memorial service, five long (and short) months after her passing. Five months after she and her family carried out the totally unfamiliar, unusual act of donating her body.
“See that woman over there?” she gestures to the small group standing nearest us. “We were in a fitness class together, and her husband died rather suddenly. He had wanted to donate his body. So I came home and told my mother about it. And she said, ‘That’s it. That’s what I want to do.’ And, here we are.”
“So it’s your fault,” her sister chimes in, half smiling but only half joking it seems.
“Shoulda kept my mouth shut,” she chuckles with a sigh.
Sacrifice. Respect. Honour. I am in awe of this beautiful family, children rolling and running happily on the floor, her daughter grasping sweetly and curiously at the red flowers on my dress, and this kind, grey-haired widower standing tall and brave as I take in his dear wife’s story. It is heart-wrenchingly evident that these five months, and this eerily foreign process, have been tremendously difficult. They are eager to have their beloved mother’s body returned to them, in some form, for a proper memorial service. Closure. For now, there is comfort and solace only in the knowledge that they respected their loved one’s last wish.
There is so much I want to say to them; we try sincerely to convey the magnitude of our gratitude, the immortal and unparalleled value of her donation, but words hardly seem adequate.
~
Just an hour before, I had been in the anatomy lab, clouded in formaldehyde, studying the deep impressions left by the heart after a lifetime against the lungs. Now, I am suspended by stories and faces that illustrate the impressions these donors have left in the hearts of their families, and the impressions they will forever leave on us.
Palliative care
written January 2018
Today a stunning sun rose for me, for Dublin - but the sun also set on many lives.
It’s been a... hard-to-articulate two weeks, on clinical placement in Palliative Care at the St. Francis Hospice.
My mind is swimming, reeling, yet eerily calm (?emotionally exhausted) - but I’ll try to articulate a few learnings ? insights ? feelings…
Over the past number of days, I’ve learned more than I could have imagined about compassionate, holistic communication. To respond to a difficult question not with an immediate answer, but with a sensitive, inquisitive question to uncover the reason/worry/desire behind that question. “How will knowing the answer help you? What are you worried about?”
To address things from all angles, all perspectives, for both the patient and their loved ones.
Above all, to listen. Actively. To reassure. To place a comforting hand; to convey, I am here for you.
Love is an exceptional thing. An utterly painful, vulnerable thing. A beautiful one.
To love you means I will lose you, and I will be broken.
But without hesitation, I will stay with you - bring you a single red rose - feed you ice chips - sleep on this pullout couch, watching over you each night.
The singular thing nearly every patient was worried about? Their wife or husband. “I just love him so much.” “She is working too hard, taking care of me.”
Decades of love, memories, and devotion, neither one near ready to say goodbye.
Grief. It’s heavy. It weighs one down. Then bubbles over. Sometimes it is silent, staring. Other times, it wails.
It’s just...there. No one in this sphere is spared it - patients, spouses, children and parents, dear friends, humble nurses, quiet students. Physicians.
But, they go on. Through quiet closeness; prayer; remembering; listening in earnest; a gentle touch; love; tears.
We go on.
Remarking to the Consultant Physician on the impactful weeks, she replied, “Don’t go drowning yourself in alcohol, go for a run or something.”
I won’t hesitate to admit that I went for the former.
With more time and experience, better clinical and communication skills will come, that I hope might come close to the incredible, inspiring, commendable skills of those I’ve just worked with - and, with any luck, better coping mechanisms will come, too.
(but, at least I wrote this, so there’s that)
the beginning
written December 2018
Medical school changes everything.
Everything.
It’s nothing like you imagine.
And yet, it is entirely.
“Med school is hard,” they say.
So you think you’re prepared, you think you know.
But that’s like saying…
A sunset is beautiful, or
The universe is big.
It’s an understatement in every syllable.
I have so much I want to say that I can’t even begin.
Let’s see which words my fingers decide to type first.
—————
I paid the online subscription for this blog a year ago.
I made a promise to myself, during an inspiring conversation on a perfect date night with my man, that I would devote more time to ‘me,’ commit more time to things outside of medical school that bring me happiness, balance, and joy. Writing, for one. Sharing words on this blog.
That was in about February, near the end of my second year of med school in Dublin, halfway to Doctordome.
Almost a year later, flying home for Christmas mid-way through my third year, well, that goal kinda failed...
—————
The fog of it all always seems to lift on the airplane, flying home, stepping away.
Away from the unforgiving schedule, the sky-high pressure and demands, the high-speed train you cannot get off, so fast and relentless you can barely look out the window to enjoy what’s passing you by.
I’ll be a doctor in just over a year… but along the way, sometimes I worry I might have lost, or forgotten, bits of myself. Of course I’ve gained and learned so much, but this whole ride is a little..insane.
I want to tell you everything.
I’m not the kind of person who’s ever struggled much in school, nor with stress or anxiety. I’ve never really felt overwhelmed, nor failed a course. Sure I get stressed before exams, but not in a debilitating way. I work hard, study for countless hours, and I do well. Typical. Average.
But I think a lack of panic lulled me into this false sense of ‘okay’. And then, with Step 1, things sort of shattered. (As it does for many, I think).
14 hour days, for 7 weeks straight, between the end of 2nd year and the beginning of clinical years. The WEIGHT of such a monumental exam, where the one-shot score labels you forever… on some level, it’s inhumane.
Couple that with the fact that my doctor boyfriend, who’d practically lived with me for the last year, had just moved away to start his Internship (essentially first year Residency) – things were tough, I was far from home, no family, no summer, no days off. And I finally learned what intense overwhelm, insomnia, stress, and even depression feel like. I cried from exhaustion, overwhelm, loneliness… But always had to ‘woman up’ and get back to the books.
But I got through it (and so will you), with the help of a few incredible close friends, some weekend visits from boy, and a lot of sunny runs and popcorn and ice cream.
—————
Clerkship started up soon after. My 7 week Paediatric rotation was a bit of a blur. I loved it, being on the wards and engaging with young patients and families, seeing cases and illnesses I’d only read about. But my mind felt like it was a bit underwater. I wasn’t quite myself.
One or two friends related, and when we found time to meet for dinner or a quick drink, we’d just kinda laugh incredulously and sigh at the madness of it all. We couldn’t offer much advice or comfort, ‘cause we were in it together, and just had to hang on and keep going. Stay on the high-speed train, keep our hands and feet inside the hamster wheel.
Paeds became Obstetrics, and the high-speed train kept going. No breaks. More information and deadlines about summer electives and Canadian and US board exams, now right around the corner. So much planning. So much to study. Overwhelm.
And all of that is just, medicine. It’s just, what you have to do. And in all honesty, it’s only a fraction of the reason I was spinning underwater.
But, the other thing is just too big. Too wholly impossible. A decision I don’t even know where to start imagining making. — More on that later. Maybe.
—————
I happened to write this on the same day Humans of New York (HONY) published this photo and story, which rings so true it hurts. Within mere hours of it being posted, this HONY story was shared with me and around me by countless medical peers and friends on social media, which just speaks for itself.
“I just finished medical school. Now I’m heading to residency, which is supposed to be even tougher. I’ve been working sixteen-hour days. Then I’m expected to study every night when I get home. Some of my classmates only sleep three hours per night. I tried that for a few months during my surgery rotation, but I ended up getting really depressed. I felt completely depersonalized. Everything seemed like a dream. To make matters worse, a lot of the instructors are jerks. I think they went through hell when they were students, so they feel like they should put us through hell. On the first day of rotations, my attending physician told me: ‘I’m an asshole, but I’ll make you a better doctor.’ He made fun of me in front of other students. He put me down in front of patients. He’d threaten to kick me out every day. I guess they’re trying to weed people out and make strong doctors. But they’re just traumatizing people. They’re making us apathetic. I got into medicine because I really wanted to make a difference in people’s lives. But after going through hell, I just don’t care anymore.”
inspired.
Must reads
Your heart is the size of your fist – Martina Scholtens, MD
When breath becomes air – Paul Kalanithi
Being Mortal – Atul Gawande
Cutting for Stone – Abraham Verghese
The Poisonwood Bible – Barbara Kingsolver
Fall on your knees – Ann-Marie MacDonald
Extremely loud & incredibly close – Jonathan Safran Foer