heavy bleeding

"You know, I'm not religious, but I can't help thinking that this is God's work..."

So said my nurse colleague as I entered blood work results for a patient. The patient was a woman in her early 40's, bleeding heavily from the vagina. She was undergoing fertility treatment and it wasn't working.

The nurse then proceeded to list cases she had seen that confirmed her theory. People who'd had abortions early in life, then failed to get pregnant later. People who had given up children, only to regret later infertility. She said, blithely confident, "if you waste your chances, God will make sure you regret it later..."

I've been watching The Handmaid's Tale over the past two weeks. It has been scaring me. It's too real - under the surface of our seemingly progressive society, people are harbouring judgements about who deserves to suffer, who deserves happiness. I have been reassuring myself that, in Canada, we have entrenched abortion rights. We have guarded "universal" health care. We have the right to access birth control and fertility treatments and we support same-sex parents and...

It all rings a little hollow when your colleague, whom you like and respect, spits out the wrath of God at an unsuspecting patient.

I know, I know, we all bitch about our foolish patients and the choices they make (smoking! drinking! washing the blender while it's still plugged in!) but this seemed particularly vicious and unkind.

It makes me worry what she's thinking about me - one child, older than 35 and trying...What she's thinking about our other RN - one child, unable to have a second for medical reasons...What she's saying to the patients she triages - "This is your fault. You did this to yourself. You deserve this."

I hope that her professionalism is better with patients than it is with me. I hope this was a sign of a bad day, and not a burning dissatisfaction that leads to extremism. And what I really hope is that she is one of a kind, and not a harbinger of changing attitudes to come. The US is too close to ignore, but I hope we can oppose the attitudes creeping across the borders. For me and my patients.

The (not-quite) Grub Street Diet

Because it's hard to write the same things over and over again; A nod to my favourite Friday morning read. I don't expect the same level of scathing comments, but I can hope!

Wednesday April 20th

We are in Austin, Texas for a week of sun and swimming and tacos. Or at least that was the plan, when we booked the cheap tickets back in February. Today, Austin has other ideas. I am woken from a mild hangover by the sound of torrential rain on the corrugated tin roof of our AirBnB. Luckily, Mr G is also woke, so starts making coffee. He brings both coffee (something organic provided by our host) and baby Zozo to me in bed. I am doubly spoiled - breakfast in bed, and hungover from seeing a show last night - Liz Phair and Smashing Pumpkins. My 14 year old self could not have imagined such splendour.

We venture out in the rain and find Tacodeli - breakfast tacos served by tattoos and beards with alarmingly good cheer. Our server recommends his own concoction; egg, chorizo, bacon and mashed potato. I also get spinach and cheese, beef tips and eat most of Mr G's Al Pastor. And some of Zozo's scrambled egg. Still not satisfied, we venture next door to Houndstooth for flat whites and a chance to be sneered at by attractive youths. They do not disappoint.

In the afternoon we drive the 40 minutes to Salt Lick barbecue. On the way there, kilometres of highway are marked "sponsored by Salt Lick", so we can assume this is a successful institution. When we arrive, we think we've made a mistake. This enormous farm, with surrounding vineyards, and industrial-sized smoke pits, must be the Salt Lick factory? But no, it's a restaurant. Texan-sized. We order family style and Vickie, our server, keeps slinging meats at us until we're sweating. Brisket, ribs and sausage, plus sides of beans, slaw, potato salad and the most divine, sugary white bread. MrG and I debate tucking some bread in our bag, but then Vickie comes by to ask if we want this round "wrapped up to go". Of course we do. With extra bread and sweet tea for the road.

Thursday April 21st

Rain again, with no sign of letting up. Organic coffee, cereal and fruit. We don rainwear and head to the Thinkery, a huge interactive children's museum where Zozo delights in destroying everything she can touch. The wet room is the biggest hit and she comes out soaked.

To dry off, we head to Torchy's tacos; this is another Austin recommendation, and we try to order widely. The special of the month is the "Washingtonian" which has pork, avocado, a spicy salsa and extra cheese. MrG tries the deep-fried avocado and I eat the "Trailer Trash" -  served extra dirty.

Travelling with bub means being home for a nap at noon. We drink more beer in the sun and read the trashy magazines you can't justify buying at home. Esquire's money issue is stressing me out.

That night, a treat - a friend has arranged a sitter for us so we can go to Uchi, apparently the best restaurant in Austin. We arrive early for our reservation and have cocktails on the patio - champagne, ginger and mint for me, apple and bourbon for Mr. We ask the server to tell us about the omakase. She is so sweet and enthusiastic that we have to try it. Cauliflower, sashimi, wagyu beef rolls, thinly sliced mushrooms, a green curry sorbet with coconut pannacotta...Top it off with two glasses of sparkling rose and life is incredibly beautiful. Everything is sparkling and wonderful. Mr G has to drive.

Friday April 22nd

Travel day. We eat the contents of the fridge (cereal, milk, fruit) then head to Jo's Coffee for...breakfast tacos (we are not wildly imaginative). Zozo chases the aggressive pigeons on the patio, much to the delight of the other patrons, and we fill her up with scrambled eggs, salsa and black beans.

Our flight isn't until the evening, but Zozo needs a nap. We solve this problem by driving out of town to Lake Travis. Once you leave Austin, you start noticing signs of the "real Texas" - gun racks, cowboy hats and really big trucks with anti-abortion bumper stickers. We get lost and end up driving around a private lake-side community with the most enormous, over-the-top mansions I have ever seen. Every driveway has cameras and security gates. I have to pee, but I envision being filmed and pepper sprayed if we stop. Instead, we find the sketchiest gas station on earth and purchase the use of the facilities with beer salt and a packet of HoHos. This is America.

The rest of the day is full of unpleasantness; rental car drop off, security lines and a cranky baby in a small plane. Also, we probably shouldn't have fed a toddler a bunch of beans before putting her in a metal tube that lowers the atmospheric pressure, expanding all the gases inside her. Just saying.

Saturday April 23rd

Home! Zozo and I stumble down to the local for flat whites (for me) and a cheddar bacon muffin (for...her? She gets at least half). The day is spent enjoying the features of home. Our own beds! Our back yard! Our crappy Canadian Netflix!

We are scheduled to meet some friends for dinner that night, so the day eating is light. Our friends are new parents and want to stay close to home so they suggest AAA Bar. It is a great little bar that specialises in Texas-style barbecue. The irony is not lost. This is the first time I'm not driving after a meal, so I get a margarita on the rocks (bliss!) and a huge basket of brisket. The friends arrive and tell us they've already eaten as they thought this would be a snack night. I try to make them eat the brisket. They decline. There is still no brisket left at the end of the night. I am very full and very tipsy after two Canadian-strength beers.


Sunday April 24th

 Gloom! I have to go back to work today. But not until 4:30pm, so we try to cram a little more luxury and bacon into our lives.

Evergreen Brickworks is teeming with hipster families, but my hangover is so poisonous and palpable that people avoid us. We get a table on a patio and nobody sits near us. Perfect. We get scrambled eggs on buttermilk biscuits with vegan garlic aioli and the pain starts to ebb. Zozo and MrG choose plants for our spring garden. I wear my sunglasses indoors and burp brisket smells into the wholesome crowd. We head home and I sleep for two hours.

I'm alive! And off to work. They're implementing a new triage system at this site of my hospital and today it is not going well. The nurse in charge is not on board with the changes, so we go from periods of having nobody waiting to suddenly having "17 to see you and they're getting irritable". I end up staying till 2 in the morning to deal with the backlog. At the end of the night my summary says that I saw 40 patients. This is a new record for me. It seems unsafe, but hey, gotta move the meat, right? On the way home, I eat a protein bar and drink water for the first time in 10 hours.

Monday April 25th

Going to work on a Monday seems bizarre to me. I am startled by the presence of other cars on the road, of people lining up for coffee ahead of me. Give me weekends any day - I like my off-peak lifestyle.

Alas, Monday is another shift from hell. My first patient of the day is a 23 day old who has "funny breathing". I assess him, determine that he is stable and refer to the paediatrician. She grabs me later; "Thank God you sent him to me - he turned blue and we had to get ENT to intubate and they couldn't so anaesthesia was called and they couldn't and now he's being airlifted to Sick Kids!"...The day progresses much in this vein with lots of sick people. I end up seeing only about 25 patients for the day, which seems like an achievement given how chaotic the department is. During the shift I eat...uh...nothing. And I ate my protein bar yesterday, so tonight I stop at MacDonald's on the way home.

The guys manning the drive thru seem to be having a similarly chaotic night. "Uh, just hold on Miss...We're sorry for the wait...We'll get to everyone eventually..." The panic in his voice is reminiscent of my charge nurse. I sit back, crank the music and fantasise about my imminent fries.

Tuesday April 26th

Work again.

My internal medicine colleague brings me a Death By Chocolate donut that I shove, whole, into my mouth. It is the greatest thing that has ever happened to me at work. Thankfully, Tuesday is a cold, rainy day, so people stay home. (Most of the people who show up to ER are not actually sick, and if there's any inconvenience involved in getting there, they don't come).

We are training a new PA, so I get to show him lots of fun technical skills - incising an abscess, glueing a forehead closed and stitching a finger back on. When it's not so busy, I actually get to talk to my colleagues. Since I'm the most junior, I usually end up running cases by them, silently praying that they'll say, "Oh, that's what I would have done!". So far, I'm about 50-50.

By the time I get home, I'm done. I have no strength. No zazz. No pep. All I want is to drink beer in my pajamas and eat greasy food. Thank god for UberEats. Our local Hakka food joint sends us crispy beef, spicy eggplant and noodles soaked in MSG. I manage to drink a whole Labatt Blue (it was in the fridge, what can I say) and then pass out while watching the final episodes of The Hundred. This show started out as "sexy teens sent to Earth to start a new civilization" and has now become "progressive politics plus violence plus strapping leather-clad muscle bound"...Anyways. It's shot in Vancouver, which I really enjoy.

I crawl into my soft, white, fluffy bed and sigh. No work tomorrow and a whole day of cuddles and Peppa Pig and goldfish crackers. Life is sweet.

work

I come home at the end of a busy day and Mr G asks, "How was work?"...

"Busy. Nothing special..."

I saw a young woman who had been assaulted over the weekend. She met a guy at a bar, and after drinking and partying together, invited him back to her place. After a while, she asked him to leave and he got angry and beat her until she was unconscious.

I assessed her for skull fractures. She had a perforated eardrum. Her eyes were swollen shut by bruising. The rest of her injuries are too specific to mention, but they were extensive.

I documented everything carefully, and offered to give her copies of the documents for the police.

"Oh, I'm not going to report it. I know how it looks. I was drinking, I invited him home."

I said to her, "You know, inviting someone to your home doesn't mean they are allowed to beat you or hit you or physically harm you..."

But I didn't push. I didn't insist on calling the cops.

Because she's right. I couldn't say to her, "The police will help you. The police will be on your side. You will get the justice you deserve."

I know she's right. I know how it looks. She will be told that because she invited him in, she brought this upon herself. She was drunk. She was high. She didn't call the cops immediately. She waited 24 hours to come in to hospital. She is a woman who was assaulted by a man she knew.

It's infuriating, but the only thing I can do is be a good clinician. I offered her social work, I offered her pain medication. I treated her wounds and got her some clean clothes. We made arrangements for her follow up. And I repeated to her that her records would be on file, if she ever decided she wanted to report this.

As she left, she thanked me and said, "Usually the doctors aren't so nice..."

But, alas, when Mr G asks me, "How was work?" I would still say, "Busy. Nothing special." Because this is a totally normal experience in Canada in 2016.

I am so angry. All the time.

Consequences...

A 13 year old was brought to ER by his mother with flu symptoms. I assessed him, determined that there were no signs of bacterial infection and gave them my spiel about rest, fluids and over the counter analgesia. Mother seemed happy. Son seemed fine.

As I turned to leave the consult room, the mother stopped me.

"Doctor, I have another question. Just a quick one. When should my son's foreskin fully pull back?"

I paused.

Trying not to look at his mother at all, I asked him the key questions; can he pee without foreskin ballooning? Has he had any infections under the foreskin? Does it ever get stuck in the retracted position?

He stared firmly over my shoulder. Yes. No. No.

"But what we can do about it? Does he have to have a surgery?"

"Well, ma'am. As long as there are no side effects, it can be normal for the foreskin to remain tight until even as old as age 17. The recommended way to "loosen" it is to continually retract and replace it, which most young guys end up doing a lot during adolescence."

I am now looking firmly at the mother, but I can FEEL the blush running up this kid's body. She says, "What can I do to help?"

"Well, a good quality moisturiser could help with the friction..."

This poor kid. His mother and a lady doctor discussing optimal masturbation technique. I bet he ends up deeply scarred and only able to ejaculate while eating an orange out of a paper Whole Foods bag.

I was only trying to help.

Too Good Not to Share

A 28 year old woman walks into the cubicle.

Her: "My tooth has been really hurting for a few days now. I took some (branded strong painkillers) that I had at home but they didn't work and now I feel all sleepy and nauseated and weird."
Me: "Why did you have those strong painkillers at home?"
Her: "Well, they're actually for my dog..."
...
Me: "Why does your dog take these painkillers?"
Her: "Oh, he had surgery recently."

Not only did she take DOG MEDICINE, but she overdosed on it.
Not only did she overdose on painkillers, but she stole those painkillers from a WOUNDED DOG.

I didn't know what to do, so I laughed at her for a while, then sorted out a dental appointment and sent her home.

My job can be delightful sometimes.

2 easy pieces...

I'm chatting to a lovely man as I pull the bandage from the back of his head. He is charming the nurses, calling me "bellissima" and thanking us all for his care. The bandage is heavy and thick with blood. When I peel it away, I notice a pulse, a spurt of red from his lower scalp. I slam the gauze back in place and ask the nurse to apply pressure, then run to get the stapler.

12 staples, 5 sutures, 3 deep silk ties and a second doctor later, the bleeding has been contained down to a slow ooze. I'd asked the nurses to grab a second doc after I put the fifth suture in and the wound continued to spurt blood AROUND the closed tissue. I estimate that this poor man lost about a litre of blood between his fall (a simple trip) and getting his scalp closed.

As I wrote my notes, the sweat dried on my body and I thought, "Phew. First night back, pretty exciting..."

And then the PA called me to come see another patient.

PA's (physicians assistants) are a new thing in Canada. They have a 2 year diploma from a college and are employed to do the minor scut work in ER - placing simple sutures, casting, examining sore throats and ear infections, diagnosing UTI's. Some PA's are highly experienced, having worked in military medicine or been medical professionals outside of Canada.

Some are...not. This particular PA is about 19, has exactly 2 years of post-secondary education, and believes that she knows more than anyone in the department.

She grabbed me and said, "I think this patient is sick". I thought, "Uh oh". I walked into the room to see a person curled in the fetal position, shaking and pale. Temperature? 39 degrees. Heart rate? 110. Her voice was noticably muffled, as though her mouth was full of cotton wool. Or, say, a hot potato. Alarm bells began ringing all over my brain, and then the PA said, "I couldn't get a good look at the back of her throat, but I really tried!"

Kids, what is the most concerning diagnosis in this case?
If you said epiglottitis, you'd be right!
And kids, what is the NUMBER ONE rule of epiglottitis? A rule so fundamental that every medical student can recite it in their sleep? A rule so important that it is a pass/fail question on medical exams?
DO NOT EXAMINE THE THROAT OF A PATIENT WITH SUSPECTED EPIGLOTTITIS.

You are supposed to get the ENT team, the anaesthetists and a surgical OR ready before you even ask the patient to open their mouth wide. This is because an epiglottis can swell so quickly and completely obstruct the airway that even asking a patient to say, "Ahh" can be fatal.

Anyway, the PA got huffy when (after calling in ENT, pediatrics, anaesthetics and the OR team and seeing the patient safely shipped off) I suggested that next time she should not examine a patient's throat.  "Well, I didn't think it was epiglottitis, so I needed to look!" she said.

First day back. I am ready for another vacation.

grades???

I miss residency.

Alas, I am not joking. I don't miss the mandatory shift hours, the scut work or having to run every decision by someone subjectively senior to you.

What I miss is the feedback.

After every shift, I want someone to go through my list of patients and say, "You know, you could have done this better, but overall, you did a good job tonight"...

I realised this at the end of my second solo night shift. (Yep, just me, in charge of the whole ER, through a long and hectic night).

As I was leaving, a nurse grabbed me.
"Doctor, you've written a prescription for the kid in room 3?"
"Yes!" I cheerily replied.
"Yeah, you've written it on the chart for room 6..."

I groaned, tore up the script and made a joke about how I wouldn't be safe to drive home, as my brain was all goopy. The nurse smiled politely, but then, as I was leaving said, "You're doing a good job".
I stopped, frozen in place. "Sorry?"
"You're doing a good job! Have a good sleep."

The words were like pure chocolate, a rush of warmth and sugar and support and validation and...
And that's when I realised. I miss residency. I need external validation, which grownups don't get. So yes, maybe I'll go back to school. That critical care fellowship looks appealing. Just another 5 years of school???