scrub-chafe

Moments I will cherish from the Peterborough ER (in 2013) -

1. Man with epistaxis (massive nosebleed) requires packing to stop the flow. "Which side did it start on?" "The left." I then proceed to meticulously and painfully pack his right nostril. After some time he clears his throat and asked, "Are you going to do the other one now?" Oops. And yes.

2. Older man brought in by paramedics. Found in bathroom with no pulse, no vital signs. They had done CPR for an hour before he arrived with us. He was, in short, very unofficially dead. I, being team leader, have to run the code. I intubate him and then immediately declare him officially dead. My staff asks me "why tube?" Answer: Um...cos he was there??

3. Stab wound to L chest causing pneumothorax. Inserting chest tube, hearing that beautiful rush of air and hearing the patient say, "Oh...that's better".

Moments I will not cherish from Peterborough the town (in 2013) -

1. Discovering that when they say, "Let your car warm up before you drive it", they mean it. Did you know your brake pedal can freeze in place?

2. Trying to find one of 30 recommended breakfast joints in P'bo's famous "cafe district". They all close between Christmas and New Years. The only open cafe stopped serving breakfast "Oh...just....now." (watching the clock tick over to 11am). They deigned to serve me their leftover oatmeal. Plain. No milk. No sugar. Tepid.

3. Coming home starving from said breakfast debacle and desperately looking for food in the apartment. Other residents have lefts bits and pieces behind. Finding a tin of "fish-bites" - herring fillets in hot sauce. Eating said herring fillets. Spilling the hot sauce on my pants and the floor. Coming home to an apartment that smells entirely of herring.

Roses and thorns, really.

I'm working NYE until 1am. Am planning to scout out a party hat and some snacks for the shift.

Would really like to come home and chug champagne, but fear that that will somehow lead to further herring-related incidents.

Worse. Could eat the pop-tarts. They expired Jan 2013, but how bad could they be?

Maturity

What makes a "bad" call shift?

When I was a first year resident, I would lie awake in my narrow bunk, praying that nobody would page me. Any night that I didn't make a decision was a good one.

Last night, I got called twice between midnight and 7am. This is unprecedented, especially for ICU call. The calls I got involved simple medication changes (labetolol, I love you) and clarification of nursing orders. I never got out of bed. At one point I thought, "This is weird. Maybe I should get up and check if everything's ok". But then I reassured myself that my phone and pager were both on and working, and pulled the covers tighter.

As it turns out, I was right to be suspicious. The junior resident HAD received a call, a consultation from ER. He had seen the patient, made some decisions about treatment and done admission orders. All of this would be fine, but he had done it without making a diagnosis. He approached the patient with a shotgun of drugs, all for different causes of respiratory failure, and gave them all.

I went over his decision making with him this morning.

Me: So. You had very sick patient, the ER gave you a terrible handover and didn't tell you why they had intubated him, you were unsure of the diagnosis and you didn't call me. Why?
R1: I wanted to manage the patient on my own.
Me: But you were worried about them and didn't know what to do. In that case, you are supposed to call for help. If not me, then the staff.
R1: But I want to manage patients on my own.
Me: (murder eyes burning through his skull) But. You. Are. Not. Qualified. For. That. You are a junior resident who is supposed to be operating as part of a team, in a teaching hospital that spells out clear rules for when to seek help.
R1: I wanted to manage him on my own. And...I thought you might want to sleep???

Now that I am a senior resident, I want to be making decisions. I want the R1's to call me and tell me what they're thinking. I am comfortable making choices at 3am that affect patient outcomes. I am happier to be sleep deprived and thinking all night than sleeping in the call room.

I guess this is growing up?

As a side note, I also did a kick-ass thoracentesis and took a litre of fluid off an old dude's chest, allowing him to breathe without oxygen for the first time in weeks. It wasn't a totally terrible night.

Humbug.

Once again, my profession is stepping up to try and ruin Christmas. Manitoba Christmas, to be more precise.

I'm sitting in a toasty living room while snow falls softly outside. My hot chocolate is Irish, my niece & nephew are napping and I don't have to shovel the walk again for at least 6 hours. Bliss, yes?

Weeeeell...

This morning we went to the Polar Bear zoo. As we walked around the "Churchill South" enclosure I was reminded of a story my boss told me.

A family med resident had gone up north with her new husband to celebrate their graduation from medicine. They canoed for 4 days, then were attacked by a bear. The girl was mauled until her husband fought the bear off with a pen-knife. He then carried his wife back through the wilderness for 3 days, trying to get help. She died on the way.

I told my in-laws this tale as we watched Hudson the Bear tearing apart a tire.

When I watch Mr G play with the kids, my first thought is, "That's how you break an arm", "That's how head injuries happen", "That kid is gonna aspirate that pen-cap"... He's big, they're small, he doesn't know the meaning of the word "aspirate".

I was hoping to let go and not think of work while we were in Manitoba, but it is not to be. Instead, I'm leaning in; when the kids nap, I'll read about mechanical ventilation. While my in-laws curl, I'll look up head-injury guidelines. As my father-in-law pounds litres of coke, I'll think about managing SVT in older adults.

Not very festive, but very G.

The Why & the How

I am on vacation this week, which means sleeping in, drinking expensive lattes and walking the dog as far as her paws can carry her. It also means a chance to catch up on my reading.

I started with "Pre-oxygenation in patients destined for Endotracheal Intubation".

It turns out that there are many things we do in the ER, that I do without thinking, that have a scientific basis I didn't know.

Why do we try and get a patient's oxygen saturation up to 100%?
Because when they drop below 90%, they lose the partial pressure of oxygen required to maintain saturation, de-saturate rapidly, develop cardiac arrythmias and die.

Why do we continue to oxygenate a patient after we have paralyzed them, effectively stopping their breathing?
Because oxygen behaves like a liquid, pooling in the back of the throat and diffusing into the lungs, even without the driving force of breath to guide it.

I know. These seem like things a kid could tell you.

Why do we breathe? Cos if you don't breathe, you die.

Still, it's nice to know that the things I do have science behind them. And I forgot how lovely academic reading can be. Coffee in hand, Pickle at my feet, knowledge washing over me in gentle waves. Almost distracts me from my imminent trip to Winnipeg. In November. Almost.

shift.

I got home from work at 2:45 am this morning. My boss of the night was very disorganized and likes to touch every patient before letting them leave the hospital. "I like to lay eyes on them, so I know you're telling me the truth..." As a result, instead of finishing at 1, I left at 2:30.

At home, the dog had eaten some chocolate chips, so I got to hear the tale of how Mr G had attempted to make her vomit (hydrogen peroxide in yoghurt, fingers in dog-mouth) and was now wracked by guilt and fear. Settling them both back to sleep (in the guest room; chocolate makes dogs poop) and I was asleep by 3:30.

I woke at 11:30 today. Washed myself, ate some food, and now it's time to go back to work. Days like this are a write-off (unless you consider burning through Netflix an achievement) and then I go, buy more coffee and go back to work. I have worn my sweat suit for the last 3 days straight. No point in changing, I've got scrubs to put on in an hour.

I know this is my dream job and technically, I'm getting all the perks of random hours. I can go to yoga in the middle of the day! No lineups at the bank! Brunch on a Wednesday morning!

I just wish it didn't take me 12 years of post-secondary education to finally start living like a teenager.

Unrelated

Technically, this is a blog about my experiences with medical training. The focus is intended to be purely professional (ha!) and limited to "things that happen at work".

However.

We got a dog. Sort of.

Pickle is a 6 year old beagle/mutt cross that we saw on the SPCA website. She was happy and smiley in her pictures, and was described as "a quiet, gentle lap dog" who just needed a place to nap in the sun. We like to nap in the sun. Mr Gargantuana works from home, so is available for walks, pats, feeding and other dog sundries. I was not actively afraid of this dog. It seemed like a perfect fit.

We applied.

"There are a few other applicants", the SPCA lady said. "We'll let you know..."

My competitive instinct blanketed out my common sense. The voices is my head were saying, "But you don't like dogs. Pets gross you out. You're really bad with messiness and uncontrollable situations." I ignored them. No one was going to beat me at dog ownership! I wrote an email to the SPCA explaining that we were the perfect parents for Pickle.

We got her.

It turns out I don't like dogs. I don't handle poopy messes well. I get angry when she barks, when she pees on the carpet, when she tries to get into bed. I don't like the fact that, as we were walking out the SPCA door with her, we were told that she was in heat and that she had lungworm.

Do you know what lungworms look like?
Do you know that heat = dog period?
Do you know how bad dog farts can be?

It's been a week and a half. Mr G and I have a deal; every day that she's here, we renegotiate. She can stay for another week as long as I don't have to scoop her poop. If I don't have to walk her.  If she stays off the furniture. If she doesn't pee on the rug. If we move to BC.

She's still here.

Mr G is away for a day. Pickle is lying beside me on the sofa (she will NOT be allowed on furniture) and snoring like an 86 year old with emphysema. I will take her for a walk. I will clean her pee off the rug. I will feed her treats and try not to panic when she claws at our bedroom door in the middle of the night. We are still living in Ontario.

I am losing at dog ownership.

perk!

I got to ride in an ambulance with all the sirens going!!

That's all.

Happy Thanksgiving.

Show, don't tell...

Last night, a kid came into ER. He had sand in his eye. His eye was irritated, red and leaking thick tears. He was not a happy chappy.

Part of our standard eye exam is to put drops into the eyes to make them numb. They also dye the eye yellow, so we can see any scratches in the surface of the eye. They (allegedly) sting a bit, but most people tolerate them fine.

This kid had already had his parents squirting water in his eye and the teachers at school trying to flush him out, so he was understandably nervous about the drops.

I decided to try and make him feel comfortable.

"Look!" I said. "I can put the drops in my eye to show you it doesn't hurt!"

I stood up, tilted my head back and opened my eyes wide. A single drop of yellow dye hit the surface of my cornea with a splash.

"FUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU*K", I thought.
"Oh holy sh*t this burns with an unholy fire!", I thought.
"Owowowowowow", I thought.

I stood totally still. Rigid, even. I couldn't move a muscle or the kid would know how bad it hurt.
"See?" I said. My face with a rictus smile. "Not so bad!"

The kid looked at me with total suspicion, but submitted to his drops. He bounced up after they were placed. "That was fine!"

As for me, I had yellow snotty-looking dye leaking from my eye for the rest of the night. Every patient I saw leaned away from me during exams and one little girl burst into tears when I walked into the room.

Good with kids? You bet.

Coasting

The Pitch:

Welcome to the Community! In this Emergency Department, you will see a wide variety of cases under the supervision of an experienced physician. You will have the opportunity to practice resource management, while providing excellent care for the people of your town. Friendly nursing staff and a safe, engaging place to build your skills!

Yay.

The Reality:

Welcome to the Community. In this ER, you will see little old ladies who have sprained their ankles (plus one who broke her foot and walked around on it until it turned black!), old farmers who have cow-bite-related infections and lots of lovely babies with coughs, colds and rashes. So far, so good.

The usual lacerations, back pain and UTI's will cycle through the department. The nursing staff will alternate between feeding you and making fun of you (this is ok). Your (one) staff doctor will let you see patients and manage them as you see best, while keeping an eye on sicker people to make sure you're doing the right thing.

Then, the ambulance phone will ring.
A VSA arrest is coming in. Vital Signs Absent. The ambos gave 3 shocks and some epinephrine, and this guy now has a heartbeat. Your boss, knowing you need this practice, will ask you to run the code. You will think over your training and stand at the door, gloves on, pits sweating. When you see the lights coming towards the driveway, you feel sick.

They roll in with the guy on the stretcher. His heart is beating, his pulse is strong, but his pupils are not reacting to light and he is totally limp. He doesn't fight when you put drips in, when you shift him onto the stretcher, when you pull his teeth out and stick a tube down his throat. You can't remember what order the drugs are supposed to go in; should you give the amiodarone now? Does he need the full dose, or can he have less cos he has a heartbeat? Do you need to paralyze him before putting the tube in? Or is his total non-resistance an indication that he's braindead and you're just temporizing? The one staff doc is watching you through this whole process and nodding, so you keep going, but then it's 5pm and shift change and she has to go home and pick up her kid so you're suddenly alone in the trauma bay, trying to remember what the next step is and...

Anyways. Community ER. It's like that whole "Air Traffic Controllers" joke; mind-numbing boredom 90% of the time, pant-wetting terror 10% of the time. This is my future.

I am trying to remember why I picked this job.
Anyone? ... Anyone?

ER is the Worst.

Young women are the worst.
They come into the ER shrieking about their pain being "the worst of my life", they cry when you examine them and they snap at you when you tell them the test results will take an hour to come back. "But we have dinner reservations for seven!"

Middle-aged women are the worst.
They talk down to you for being a young woman, bitch about how their kids are waiting at home for them, then tell you they've had this pain for at least a year and "can you hurry up and fix it so I can go for a smoke?"

Young men are the worst.
They're drunk. They cup your ass when you're stitching up their faces. They throw up when you put freezing into their cuts, and yell at you for hurting them, when they've been in a bar fight that resulted in 7 new ER customers. They hit on you as they leave the ER, despite behaving like jackasses all night.

Old men are the worst.
They tell you they have no pain, that they feel just fine and would like to go home. They don't acknowledge that their chest is filling up with blood and that they're having trouble breathing. They decline pain meds for a chest-tube insertion, then cry silent tears as you jam a finger through their rib-cage.

Old women are the worst.
They pat your hand and call you dear. They say how lovely it is to see a young doctor these days. When you tell them their cancer has metastasized and there is nothing more we can do, they smile and tell you it's ok. They thank you for your help, when you did nothing.

Babies are the best.
They are fat and smiley.

Off to Napanee ER for a month of hard-core community medicine. No CT scanner? No problem!

flow...

As a third year ER resident, you have three objectives:

The first is obvious; you need to increase your medical knowledge to the point where you can manage most crisis situations without having to rely on books/looking things up/phoning a friend.

The second is important as well; you need to learn to interact with multiple health care providers, the general public, hospital staff, police, ambos and miscellaneous drunk people, all while maintaining a professional demeanour.

The third is the hardest; you have to learn "flow". Alas, this is not a yoga term describing the transfer of healing energy. It is getting as many patients through the department as quickly as possible.

A few weeks back, we had a lecture from an ER doc who works in a town between TO and K-town. He told us that new ER grads are "ruining emergency departments" across Ontario. "35 patients per shift" he said. "That should be your target, your minimum."

If you don't see that many, you leave a snarled and tangled mess for the doc coming on after you.

I have kept this in mind over the past weeks. I have increased my multi-tasking.

"Ok, I'll leave the ultrasound machine to warm up in room 5 so I can see if she's having a miscarriage and while that happens I'll give this kid some freezing so I can reset his cast and in the meantime check this guy's ECG to make sure he's not infarcting and order bloodwork from the nurses..."

In theory, it's great.

In practice, sometimes the kid needs you to be calm and reassuring while you jam a needle into his hand, so you have to sit and play and build rapport.

Then, the young woman is indeed halfway through a miscarriage and you have to go in and yank the dead tissue out of her cervix so she doesn't bleed out, and then, by the time you go see the chest pain dude, he's left the department cos he really wanted a smoke and couldn't be bothered waiting for his test results, which are positive. So you chase him around outside trying to convince him he's having a heart attack, all the while keeping an eye out for the drug addict you had escorted from the ER for threatening to kill you and boom! Suddenly your shift is over.

This was last night. I saw 25 patients.

I think I am learning to cover the bases. I may not be a medical expert yet, but my interactions and flow are coming along...Right?

My vicious brain.

Yesterday was exciting. At 9am, I sat down in our teaching simulation centre. Every Thursday during the Summer, we are given a topic to research, then locked in a room with a bleeding mannequin and told to "fix it".

Yesterday's topic was Procedural Sedation; that is, giving people drugs in ER to make them drowsy so you can hurt them with minimal distress. I had not done the reading. I stayed up late watching a documentary on Netflix called "Babies", instead.

"Sam, you be the team leader." said my friend/senior Jen.
"This is a 200kg woman who has popped her prosthetic hip out of alignment. It's the third time this happened and she is in a lot of pain. The orthopaedics team is here to do the relocation, what drugs would you like to give?"

I could feel the stress flush creeping up my neck. I couldn't remember any drug names, doses, side effects, nothing... The mannequin started moaning and crying. My team looked at me expectantly. My peers, watching on the other side of the 2-way mirror, tunneled through the glass with their eyes. My armpits steamed up.

I gave propofol and ketamine. Not enough initially, too much eventually. The woman, once her hip was back in place, stopped breathing on her own due to my drugs. We had to help her breathe until they wore off. And my peers, while supportive, judged me with their eyes.

After this intense humiliation, I walked across the street and began my 8 hour ER shift. During this shift, 2 traumas rolled in. A young guy having some sort of seizure and a man who had been pinned under his tractor for many hours. I successfully intubated the young guy, giving the right drugs at the right dose. I scanned the tractor guy's belly using our portable ultrasound and identified some internal bleeding, teeing him up for surgical exploration. I also poked 3 year old with broken clavicles, old men with tummy pain and young women with bleeding in early pregnancy.

It was a good day. I happened to also be on call for the Trauma Team last night, so my pager was by my bedside, waiting to go off all night. When I turned it off at 8am this morning, I fell into a deep sleep.

A woman named Laura (I don't know any Lauras!) with dark hair and an acerbic attitude, was walking with me through the snow. She had talked to all my ex-boyfriends, and took me through all the stupid and humiliating things I've done in previous relationships. "You shouldn't have bothered with the surprise birthday, I'm just saying..." She told me that my enjoyment of my work was a sign that there was something wrong with me. "Sadistic, though?". Mentioned that most people thought I was a loser and breaking up with me was the best thing they ever did. I woke up shaking.

I don't know if my brain was just waiting to remind me of my Sim Lab failures, or if 20 hours of work/stimulation/emotion is too much. I do know I am never going to sleep again.

Fear-Based Medicine

Things come in threes. I hesitate to say "good" or "bad" things, but you certainly start to see patterns in the people who walk through the ER doors.

Last week I had 3 people with small bowel obstructions.

The first one I handled delicately, pressing and probing gently on their swollen belly. They got blood tests, lots of xrays and a CT scan before I felt confident about the diagnosis. The second woman got a thoughtful exam, a directed xray and a call to Gen Surg. The third? Slap on the belly and straight to OR.

My latest trend is anaphylaxis.

The first, a week ago, took place at the Urgent Care Centre (eg: not the full ER) and was a bit of a shambles. The nurses didn't realise they should give the epinephrine (epi-pen to y'all) in a muscle, not through a vein. They spent at least 20 minutes looking for a vein in a woman who's throat was closing rapidly. I quickly ordered the epi IM and then spent the next 4 hours shaking with terror at what had almost happened.

The second came in during my night shift. I was stitching up a drunk teenager (one of three!) when I heard my voice being called over the speakers. I ran to the cubicle to find the Staff calmly dispensing orders and monitoring the situation. Epi in the arm, back up drugs through the drip, monitor for 4 hours.

The third was wheeled in on an ambulance stretcher, gasping and flailing her arms. The ambos called "looks like anaphylaxis"! and I grabbed the nearest nurse. "Give her 0.5mg of epi IM stat, please!" It was done.

Then I actually assessed the patient. She did NOT have tongue swelling. She did not have a rash. Her blood pressure was stable. Her heart rate was acceptably fast. She was, not, in fact, anaphylactic.

I spent the next 8 hours watching her, waiting for the effects of the epinephrine to wear off. She was jittery and crazed all night. She settled as the sun came up. I did not.

The rule of threes may apply, but I haven't seen my third anaphylaxis yet. Because I was expecting one, I went ahead and dosed a woman with a drug that can cause cardiac arrest.

I am retreating to cold wine, a soft couch and a documentary about babies.

Casting Call

I like it when people break bones.

Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.

However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.

Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.

Folds in the stocking. Folds in the padding. Wrong.

Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.

The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.

My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??

Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.

And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.

Nope.

This is the stupidest day of my life.

Yesterday, I got up extra early to be in the cardiac cath lab for 7:45. There, I was scheduled to insert a large-bore femoral line into a man's groin. This is done in order to prepare me for emergency situations where urgent IV access is needed. I arrived, put on my new blue scrubs and introduced myself to the patient, the techs, the fellows et al. I helped set up the equipment. The head cardiologist arrived.

"Ehm, this patient is anticoagulated, so it might be a bit messy. Why don't you just watch this one?"

I smiled, nodded. It made sense. If the patient's blood is thinned (anticoagulated), there is greater risk for bruising and hematomas. I watched the fellow insert the lines, taking note of the smooth and gentle technique.

They were supposed to call me in the afternoon so I could insert the lines in a less complicated patient. They called me at 2:00pm.

"Um, the surgeon is scrubbed and they're starting the procedure. Did you still want to come watch?"

No.

Today, I was optimistic. Today, I would practice a valuable skill! Scrubs on, smile in place, I arrived bright and early.

"Today's patient is a bit complicated, perhaps you could watch the morning case and..."

I gritted my teeth, smiled.

I watched today's Fellow attempt the insertion. His technique was not unlike a jackhammer. He wiggled the needle back and forth in what could be best described as "vein-shredding fashion". I watched blood bubble out of the groin and bruises form in the patient's crotch.

The Cardiologist patted me on the shoulder. "Why don't you come back for this afternoon's case?"

I had to decline.

This afternoon, from 2-5, I was scheduled for Eye Enucleation training. That's where you remove the eyeballs from corpses so they can be used for transplant. I explained this to the cardiologist, who said, "Well, if we start early, we'll give you a call..."

No call.

I arrived, full of nervous anticipation (I am a regular anatomy-lab fainter), at 2pm. Then I checked the schedule. The class actually started at 3pm. I could have tried for another femoral line. I was annoyed, but consoled myself that at least I was missing one skill to learn another.

But. The cadavers were over-preserved. The Doc tried to pry the eyelids open and they just peeled off in her hands. We attempted to gently cut around the ligaments and little bits of stuff kept flying up like formaldehyde-scented confetti. The afternoon was a write-off.

The last 48 hours have been a useless mess. I feel like a useless, hot mess. I am going to drink a bottle of wine and get a sunburn, and celebrate my birthday in style.

Taking the long way...

This morning, I helped the team insert five thick wires into a man's groin. Well, his femoral artery. He was awake, and I kept patting his shoulder and saying, "It's alright Mr X, it's supposed to sting a little". Then his arterial blood sprayed me.

Then I watched a video to prepare for tomorrow's lab session. In the film, a cadaver has it's eyelids cut away in preparation for corneal harvesting. Our job, as ER docs, is to cut the ligaments that hold the eye in place, then pop out the eyeball and put it in the esky (cooler, to you Canadians).

Then, I opened up my schedule for August. ER involves shift work at all times of day. I will be working for about 10 days in a row, between chunks of time off. Most of my shifts will be at night or in the evenings. I will not see much of my partner, who moved to Kingston in order to spend time with me.

This afternoon, another groin, more wires.

I am staring over the precipice of the "What have I done?" spiral.

I could be working Monday to Thursday, nine to five, with weekends and holidays, living in Toronto surrounded by friends. Instead, I picked the worst possible option for a newly married family doctor about to take on a huge amount of debt. Blerg, blerg, blerg.

flipflop

I still don't know about Kingston.

It's incredibly beautiful and offers everything I've missed about Vancouver. I ran along the waterfront this morning before attending a free Yoga in the Park. I hit up farmers markets and sat in green spaces and I can stare out across a large body of water.

Now I'm missing the ease of interaction that I had in Toronto.

It's not all bad. On Friday night, I ran into a group of ER folks on their way to the bar. They grabbed me, bought me beer & chicken and told me good things about my program.

However, Saturday night, I met another group of ER folks for dinner. One girl gave monologue about viral cultures. One guy appeared to be sleeping, but would occasionally mention how much he liked hot sauce before lapsing into silence. I found myself calculating how many minutes of Netflix I was giving up to be there.

I tried to make a joke about cocaine zombies at dinner and got a round of blank stares (when coke is cut with levimasole then they call it "zombie crack" cos it makes bits of your face fall off). The average age in my program is 25, and these bright shining kids just don't get drug humor, I guess.

At least this week I'm learning ophthalmology. I will spend my mornings ramming into people's foreheads with the slit-lamp, poking them with q-tips and trying to figure out if their red eye is serious, or just allergies. I will practice cutting out an eyeball from a cadaver so that I can harvest corneas for transplant. (I will also see World War Z, so expect nightmares).

Right now, I'll watch the sunset from my window and hope I made the right choice. 2 weeks down, 50 to go.

First/Last

I am in my pajamas, on my couch in Toronto. Despite this, I am counting today as the first day of my ER fellowship. I have been watching videos of rapid diagnostic ultrasound all morning, preparing for our crash course next week. I have been letting the first flickers of excitement sneak past my wall of apprehensions.

Now that Family Medicine is over, (passed, attained, whatever) I do feel some regret about moving on. There were patients that cried when I told them I was leaving. Colleagues who I will miss. A lifestyle of 9-5, Monday to Friday that I got comfortable with. ER will be more challenging, with no room for error, terrible hours and less flexibility. I know this, but I am still getting excited.

I am hoping that the ER fellowship will give me lots to write about; the people who choose to work ER tend to have strong personalities, and the patients are generally bat-shit crazy. I will also be teaching residents and medical students, which has great potential for hilarity. (First win: I will be supervising my grade 9 ex-boyfriend, the most misogynistic man on the planet. I will be his boss during August. I will carry the memory of his realization face through the rest of my life.) I will also be working weird hours, alone a lot of the time, and attempting to study huge amounts of material in a small amount of time. There is a strong possibility that my husband will leave me.

All this is just to say; I will be blogging more in the future. I look forward to it.

Finally, whenever I am leaving a city, ending a program or just making a life change, I always seem to get nostalgic for the past. If you have any desire to sit down and hash out the when, why and how of the past, now's the time to do it. I've got lots of room on the couch.

Kokomo...

Late at night, lying in a single bed and listening to frogs chirping outside your window, you might start to relax. You can feel your sunburn radiating into the cool cotton sheets. Aching muscles remind you that you chased a pack, or flock, or rumble?... of goslings around the lake in the canoe. You stretch out, settling into a deep and untroubled sleep. Big picture happiness.

Medicine is a permanent hierarchy. Regardless of how far you've come, you will always be looking up to someone, looking down on someone else.

Friends of mine have mocked my choices; Australia, family medicine, the non-academic path. These same friends come to me now with sunken eyes and pale complexions. They need to know that their sacrifice is worth it, so they try to convince me they're having more fun than me. They talk about the work they're doing; seeing interesting cases, learning interesting medicine.

Their girlfriends ask me, "How can I get him to do what you're doing? I never see him". The answer is easy, but very hard for those who need the hierarchy to maintain their sense of self.

In family medicine, the work is not glamorous. You see the same patients. You say the same things over and over again.
- It's a virus, you don't need antibiotics.
- It's gonorrhea, you need antibiotics.
- You have got to start eating right and exercising.
- You have got to lose some weight.

Your patients will tell you you're stupid. They will counter your every suggestion with WebMD printouts. They will book an appointment to have you fill out their tax exemption forms, then shout at you when their application is denied. They will threaten to sue you whenever they're unhappy, and ignore you when you do things right. You have to be able to let go of your ego and try to see the big picture.

My big picture involves working reasonable hours for reasonable money. I need to feel that I've made a positive difference in at least one person's life every day. I need time to exercise, to cook (a political action now, according to Michael Pollan) and to wrap myself around my giant man. I need time to read for pleasure. I need time for Pender.

Family Medicine gives you big picture happiness. Emergency medicine will be icing (or gravy) on top. I used to feel defensive when I talked to my Internal Medicine colleagues. Now I look at them with sympathy and say, "When you're ready to let go, come find me".

Palliation

I have been having panic attacks.

There are a few all-consuming things going on in life right now; licensing/certification exams, life-long commitments, fellowships, new homes & cities. In short, it is totally reasonable that I have been waking up at 3am with the taste of fear in my mouth. My couch and I have developed a meaningful relationship; watching the sun come up together can do that.

However, I am lucky to be working on a Palliative Care unit this month. I am looking after people in the last days of their lives and this is giving me some much-needed perspective.

First, let me say that, yes - the cliches are true. In Palliative Care, you get way more out of it than the patients do. There is the scientific aspect; learning to manage pain, dyspnea, agitation & end-of-life delerium. There is the compassionate aspect; you provide counselling and reassurance to people at a vulnerable time in their lives. There is the immediate reward of working shorter hours with fewer patients and less paperwork. Plus, every day is cake day on the PCU.

The darker side is the sense of relief I feel. At the end of the day, I can walk out the doors of the hospital and go home. I am not dying. I am young and strong and I have made choices that have lead me to a really happy time in my life.

So, frankly, I benefit a lot more than the patients.

I'm still glad I'm going to do ER training, but I could definitely see including palliative care into my practice. After all, the cake is delicious & moist and makes you glad to be alive.

Calling

I knew I was going to be a doctor from childhood.
I had the cheesy moments of "yes" - being 14 at summer camp and cleaning up another camper's shredded foot while my counsellor dry-heaved behind me. The prickle of excitement when learning the layers of anatomy. The internal laser-focus and external calm when faced with a crisis.

There was a lot of opposition from the universe. I was rejected from Canadian medical schools coast to coast, told to reapply "once I had my Masters", told to consider nursing, midwifery, to go back to Starbucks.

I moved to Australia and struggled through physical homesickness, depression and a boyfriend who told me "Doctors are the worst people - they're just scientists who want to make money..."

I still wanted to do it. Rather, I didn't want to do it, but felt compelled.

Medical school was a constant flood of deferred gratification and unnatural behaviours. I kept saying I wanted to quit, but I knew I had to finish.

I graduated from medical school in 2009. At graduation, I walked across the stage after hearing my name impressively mispronounced. I spotted my family in the audience, waving, and I grinned like an idiot. I had finally done what I needed to do.

I write this as I am about to hurl myself into another year of delayed happiness and self-selected turmoil. I am moving to Kingston to finish the training required of ER physicians. It's already affecting my relationship and my life choices for the worse. I am, once again, choosing my job over family, friends, love and happy life. I feel that I have to.

When I start a shift in ER, everything else goes away. I don't remember the fight with my partner, my Mum in hospital or my empty stomach. For better or worse, my focus is total. I can only think about the job in front of me. At the end of the shift, it all floods back and I become human again, but during the shift, I am the job. A vessel in scrubs.

If I had a choice, I think I would stop this July, be a family doctor and go about the quiet business of a comfortable life. But I can't. I'm so close, but I'm not where I need to be yet, so I keep going.

Maybe my ex was right; my Doctor life choices make me the worst kind of person, putting the job before all else. I can't stop though, so I might as well keep going.

Just keep swimming.