Run Away to Mars...

So, this guy came in, having cut an artery in his wrist. Not on purpose. He was intoxicated and punched a window. Then he tried to beat up the EMS team sent to help him. Then he tried to beat up the cops who came to help EMS.  He had already beaten his partner for calling 911...

They brought him to me.

He is mean and mad and spurting blood at high velocity. He is thrashing and trying to pull his arm out of my grasp, and every time he does, I lose my grip on the artery and get shot with a thick jet of blood. Two cops, two security officers and 3 nurses are all holding him down. 

"Sedate him..."

Already done. Five and two became ten-four. Add 100 of ketamine to the mix and he stops trying to bite me. Now we can see what we're dealing with. My colleague grips the artery above the gash, and I push gauze pads over the wound. Can we see the vessel?

"You bitch! I'm going to fucking kill you!"

Ah. He's awake.

"I'm going to sue you. You can't sedate me! I'll ruin your fucking life!"

He wrenches his arm back, pulling his chest up from the restraints on the bed and lunging at me with his head. Another jet of blood sprays me. I'm covered. Head to toe. My badge is dripping.

Another 100 of Ketamine. He's down again.

We isolate the artery. Gem pushes it flat, I run a suture over where I think the blood is coming from. Thread pulls taught, she lets go of the vessel. 

Nope. Blood floods the site, and I lose my view.

Try again. Push, gauze, stitch. Stitch again. Again.

This time, it worked. The flow has stopped. My colleague has plastic surgery on the phone to figure out how to do a definitive repair. The patient is out cold.

At this point, I am covered in blood from the top of my scrub cap to the top of my shoes. My mask. My stethoscope. My neck. 

The patient's friend, who has been in the room the whole time to help keep him calm, turns to me and says, "when is the doctor coming?"

Anyways. I'm taking a year off of work. 

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???

Unleash the Sharpei!

Sometimes, a man's foreskin gets stuck in the retracted position. The tight band of the inflexible foreskin acts as a barrier to return blood flow, causing the head of the penis to swell, become engorged, turn red, turn black and eventually (if left long enough) fall off.

This happens most commonly in little boys - kids who play with their foreskin and forget to replace it. It can sometimes happen in men with botched circumcisions, who have lots of scar tissue on their remaining foreskin. And sometimes, little old men with dementia wake up for a pee during the night and forget to put the turtle back in its shell before going back to bed. This was my patient.

The great news is that my patient, a gentleman of some advanced years, did not have any pain with his paraphimosis. Yes, his penis was red, swollen and tender to touch, but he was pleasantly unaffected by the pain. His adult daughter was beside herself, wanting to support her father during his ER visit, but also really really really not wanting to see her Dad's schlong. We did a dance, trading places every time I went in and out of the room.

The treatments for paraphimosis are varied and mostly case studies. It doesn't happen often enough for a large body of evidence to exist. Sometimes people drain the blood with needles. Sometimes people use force to drag the foreskin over the mushroom cap. And sometimes you simply slice through that foreskin with a scalpel, releasing the tension and sending a wave of stagnant blood back into the body.

I did not do this. I dipped a stretchy bandage into a 50% sugar solution. I wrapped the wet bandage around the swollen red tissue firmly, but not tightly. I walked away (do-si-do with the daughter) and came back in 5 minutes. Then, I gently but firmly eased the foreskin over the now-shrunken penis. The osmotic pressure from the dextrose solution pulls the fluid from the foreskin. The compression helps. It all moisturizes the tissue and boom! The pig is back in his blanket.

I was lucky. I don't know if I could slice a confused old man's penis with a blade. But medicine with a spoonful of sugar? Happy to provide.

Suddenly, everything is terrible...

I've started my new job. ER in a busy city hospital. The patients are less wealthy, less healthy and need more done for them.

The staff (my colleagues) are stereotypical ER docs - big egos, borderline offensive jokes, lots of back-slapping and ribbing on the scene.

Sample: "This is John. He's the less virile Smith brother - he only has 3 kids!"
John: "Says the guy who can't get it up at all!"
etc etc...

These guys are all about the numbers. Their sense of professional satisfaction is tied to how much meat they can move and they are not interested in being slowed down by a new doc who hasn't figured out the computer system or how to cherry-pick the rapid cases.

On my first shift, I got left with 5 (FIVE!) sick, elderly, demented patients who had been transferred from nursing homes. All of these patients needed admitting for various reasons. By the time I presented the third admission to the medicine doc, she was irate. She took my arm and marched me down to a more senior ER guy.

"Your colleagues have screwed over this girl",  she said. He looked vaguely annoyed and made excuses about the new pickup system.
"No!", she said. "She is getting screwed over because she doesn't know enough and your colleagues took advantage of her!"

While I do appreciate the support, this is not a good way to get introduced to your team. This guy took me aside later and suggested that I bring in some home baking "to help get people on your side".

In addition to this humiliation, I also got blindsided by a PA. A physician's assistant. These are people who have a 2 year undergrad degree and are supposed to see low acuity patients. This PA had taken on a complex patient and (hindsight being 20/20) totally ignored her diagnosis, while focusing on her chest pain. She was in ER for 12 hours with no pain relief and turned out to have a broken hip.

My 8 hour shift lasted 11 hours. The admitting medicine doc (correctly) thinks I'm an idiot. My new ER team think I'm a pushover. I am not meeting my targets for patients to be seen. I am not providing very good care. And I have committed to 5 years at this hospital.

Maybe I'll run away and live in the country. When I work at Smalltown Hospital, I have great patient interactions, I have great relationships with the admitting docs, the nurses and I get along and (most importantly) my numbers are GREAT!

One week down, 259 to go.

cordial

During my ICU rotation, we had a very sick patient. The traditional cocktail of medications and machines were doing nothing and we, as residents, were stumped. We appealed to the Big Boss - what were we missing? What secret twist or turn would bring this patient back?

He shrugged. "I guess we could try methylene blue?"

And so we hooked a bag of blue dye to the patient's vein. It looked like a melted popsicle was running through the IV. Over some days, the patient did get better.

My boss couldn't explain why or how it had worked, just that he sometimes tried it, "When I'm out of ideas".

This case keeps coming to mind as I run through cases and old exam questions. Yes, on paper, the patient has A, we give B and the outcome is C. It's formulaic and relies on pattern recognition and memorisation.

In the ER where I work, I have yet to see a formulaic patient. The 7 year old girl with seizures? Could have been heat stroke, could have been meningitis. The 70 year old with a stroke? Also had renal failure and a cardiac event. The guy who shot himself with a nail gun? Well, actually, he was pretty easy to manage (pliers and a strong counterforce).

It reassures me, as I shuffle piles of paper and sort through antibiotic classes. Even my senior bosses sometimes have no idea. My patients haven't read the textbook. My nurses "smell" the diagnosis before I've walked in the room. The cops tell me someone is "hot and crazy" and know what to do.

Now I just have to convince a panel of examiners that all this is true.
When in doubt, give methylene blue.

newbie

What did you see during your first week of work?

I saw a kid who had been out in the sun all day. Her core temperature was 40 degrees celsius and her brain was cooked like an egg. We cooled her down until the helicopter could come to transfer her to the children's hospital.

I saw a glass dildo sitting high in someone's tummy; I wanted to ask them, "If you're going to spend all that money to put things in your butt, shouldn't you make sure they're butt friendly?" I want to make pamphlets for the waiting room: All about that bass? Try a flared base!

I saw a toe that had been disconnected from it's owner (mostly) and reunited these lost friends.

I saw a nail through a thumb that somehow missed the bone. The owner was learning to be a roofer. It was his first hour on the job. I suggested alternative career options as we yanked it out.

I saw fractures and cuts and coughs and colds and sore tummies and hernias and one thousand vaginas and one swollen ball.

All in all, a good week, I think.

Heavy Metal

The median level of ferritin in women is 45. This means that roughly half of women (surveyed in an American study) are low in iron. The study also found that women who were iron-deficient perform worse on basic cognitive tests.

Extrapolating from this, half of women are not meeting their cognitive potential due to low iron levels.

This information was delivered to me by my emergency medicine podcast, as I drove home from my first staff shift. My immediate thought was, "Well obviously! The patriarchy keeps us malnourished to prevent us from reaching our potential!"

Hear me out...

Society pushes women to be thin and sweet and docile. This involves being gentle - not red meat eating carnivores, but salad grazing ladies. This means eating less; smaller portions proportional to our dietary needs. This means eating restrictive diets that prevent women from getting their required levels of iron, folate and thiamine; all required to maintain healthy hemoglobin levels.

I'm not saying the patriarchy is consciously forcing women to have a low-iron diet in the hopes of keeping them docile and dumb. I'm just saying it's a nice coincidence that the same societal mandates that keep us hungry and weak also work to keep us cognitively slow and cardiovascularly deplete.

I got a nice rage burn as I drove. I pulled a chicken bone out of someone's tonsil yesterday, no sedation required, so I'm pretty sure I'm at the top of my game. And my iron levels are spectacular. Fight the patriarchy! Eat a steak! Or take your ferrous gluconate regularly.

pants off dance off

Three things are happening.

1. I am studying for (yet another) exam. My pants are off, my hand is stained with chocolate chips, my eyes are sore and my mind is wandering.

2. I've been listening to the podcast, "Adults read things they wrote as kids". It is exactly what it sounds like, and the results are often hilarious and sometimes poignant reminders of what it was like to be writing stories and diaries and journals and (eep!) poems as a boy-crazy kid and angsty adolescent.

3. We're finishing unpacking our house, sorting through all our books and papers as we put them out on shelves. I found my old blog archive and have been reading through it.

These events are coming together to form a perfect storm.

I am having flashbacks to every exam I've studied for previously. Long days in the UBC library, curled over molecular biology texts. Sending mass email quizzes to all my friends so they would write back and divert my attention during study breaks (the world before facebook). Chugging diet pepsi and sitting at my little blue desk in my little blue bedroom at my parents house, playing CDs (CDs!) to mark the time I could start and stop working. Perspiring it out in Australia, experiencing my first page-curling palm sweat that rippled my notes. Googling boys and pictures of cute puppies and babies. Writing diary entries and blog posts and study haikus and...

Anyways. This is my last exam. Ever. I'm getting better at studying. More efficient. Enjoying my breaks more (baby cuddles are way better than pictures) and feeling less guilty about eating all the junk.

I do have a worrying urge to send out a mass email to all my 2001 friends. Answer the following questions and i'll send you my answers. I actually saved all their answers from back in the day, but alas, they're on discs. I'll keep thinking about what i want to know...

What book are you reading right now?
What song is MAKING your summer?
Who are you thinking about kissing? (Way more interesting before everyone got married...)
What's the weirdest thing you've ever done in the library?
What should I google right now?

All this, plus comforting manatees.

One last exam. ONE MORE TO GO.

googles, "how much is botox"...

When the patient's mother grabs me and says, "Are you the staff?" I am momentarily chuffed. 

I must look authoritative. Mature. Confident in my medical professionalism. 

"I'm not", I say. "But what can I help you with?"

"We want another doctor. Our doctor looks too young."

Sigh.

I am in that delightful stage where I look haggard enough to be staff, but am inexperienced enough to need someone supervising me. 

The fun part about working at the Children's Hospital is that I am not supposed to know how to manage kids, so people give me lots of help and training and double check my plans. 

(They also ask me for help with ER specific problems; last night I used ultrasound to place a hematoma block and reduce a Bennet's fracture, which is a bit of a rock star move. FYI.) 

The less fun part is that the junior residents look about 12 years old and I keep mixing them up with the patients.

Oh well. Wiggly butts, rashes, minions teeshirts and therapeutic popsicles. Pediatric ER is not all bad.

Routine

Elective time.

Drive a million miles, arrive at a musty-smelling home with sad motel furniture.

Claim a room, figure out which couch is comfiest.

How many channels do you get?

The wifi password is Isengard? How are you nerdy enough to have that password, but misspell Isengaard? How did I notice?

I think the hospital is walking distance to here, but where is the nearest LCBO?

Yelp "best delivery thai Ottawa".

Is this pad thai? The soup tastes like dirty bathwater.

Man, I wish this place had air conditioning, but at least it's clean.

Why can't I log into my schedule?

I think my first shift is tomorrow. Where are my scrubs? Did I forget to pack my scrubs?

I have done this every year, several times a year, for about 10 years. This is my last elective. Unusually, I have my family with me to help settle in, and also make things complicated (I know which couch is comfiest and I'm not currently on it.) Three weeks, then I'm done. Living in one place for more than a year at a time. Making a paycheque. Deciding what shifts I want to work and when...

Now all I need is a recommendation for good delivery food in Ottawa.

Killing it!

What happens if you take all the drugs, then all the pills, then decide to take a little sleep? ICU!

What happens when your stomach starts bleeding and we suction 2L of frank red blood out of your esophagus and end up needing a transfusion of 15 units? ICU.

What if your balls turn black and the skin starts flaking off them and you get a fever? ICU.

Emergency C-section for placental abruption due to cocaine use? ICU.

Morbid obesity preventing you from breathing? ICU.

Anorexia stopping your heart from beating? ICU.

Fall down go boom brain bleed? ICU.

It's been a good rotation so far. I'm tubing and lining and tapping everyone. The nurses have finally learned my name and let me sleep at least one hour per call shift (5-6am, holla!). I have supervised my juniors and taught them things and haven't bitch-slapped the one who suggested I'm dumb cos I have a baby (win!). They've offered me a job covering the weekends that will give me ludicrous amounts of money and lots of chances to learn.

Am I winning at ICU? I'm winning at ICU.
I want to call in sick for the next two weeks, stay home and play with my baby, but I'm winning to ICU.

24 hours

At three thirty on Tuesday afternoon, I sat in the library basement with my baby on my lap. We sang songs and passed toys around a circle of babies and carers. We clapped our hands, we stomped our feet, we shouted hurray! (We were happy and we knew it).

At three thirty Tuesday morning, I was doing chest compressions.

A young guy who worked at the hospital was chatting to his girlfriend on the phone. She said they were laughing and then suddenly he stopped.

She heard, "Oh my god, babe..." and then a horrible moaning sound. The phone dropped. The girlfriend also works at the hospital and called security to go find him. He was in an upper hallway, and by the time security got to him, he had been down for about 15 minutes. They called the code blue. We arrived and started doing all the things we do. Chest compressions. Intubation. Drilling into his bones so we could give IV fluids, drugs and electrolytes.

His girlfriend arrived and watched the whole process, sobbing and repeating, "He's ok. He's ok. He's fine..."

Blood started coming up the tube. We suctioned about a litre in the first 5 minutes. He still didn't have a pulse. More epinephrine. More bicarb. More compressions. Ten minutes passed. Twenty. Still no pulse. No shockable rhythms.

Finally, the code doc called it. After 30 minutes of no return of circulation, there's not going to be a heartbeat. We stopped working on him and started to pack up. Because it was a mysterious death, we weren't allowed to remove his tubes or wires. The coroner was called to assess the scene. The police were involved. The girlfriend lay across her partner's body and gently stroked his hair.

"We had such a nice conversation..." she said.

It was a bad night.

12 hours later, I held a chubby squirmy girl in my lap and nuzzled into the softness of her neck. I sang songs to her and tried not to think about having to do compressions on her. Or having to drill into her bones. Or having to put a tube in her throat.

99% of the time, my job is awesome. The other 1% gives me nightmares.

rich mouse, poor mouse

What's the difference between ER in O-town and ER in Big Smoke?

The approach to the drug seeking patient.

O-town is a wealthy area of the province. Most of the patients are well dressed, ask for the wifi password while they wait (so they can play on their i-pads) and have access to insurance that covers extended benefits.

It was a delight - I was treating back pain with physiotherapy referrals (best option!), giving the appropriate medication for the condition (even if not on ODB!) and talking to patients who really, truly believed that their health was a priority.

Contrast this to my previous work at Big Smoke ER, in the inner city. There, patients would be wearing soiled, thin clothing, ask if they could have a sandwich while they waited and let me know that while their health is important to them, they were not able to give it their full attention at this time.

The number one difference became apparent when I met a man who was asking for a refill of his oxyneo prescription. He told me he had dropped his pills in the sink and so he needed enough to get him through the weekend. He told me he was taking 80mg four times a day. He told me he had been taking this amount for years.

If this patient had walked into Big Smoke ER, we would have laughed him out the door. Patients with addictions are offered help to quit and directed to supportive chronic care, but they are NOT given massive doses of opiates cos they dropped theirs "down the sink". Honestly, the addicts downtown will know this and at least give a more creative story. They fake a serious injury. They say they've never had this pain before. And they don't ask for a dose that would level a hippopotamus.

I carefully documented this conversation and went to chat to my boss. "I'm going to offer him the number of addictions services, a family physician number and tell him not to come back to ER", I said.

The boss said, "Enh. We get these guys so rarely. Just give him a few days worth and send him home."

I prescribed enough oxyneo to kill several people and sent this (surprised but excited) young man out the door. This does not sit well with me.

I think I am not well suited to the easy, cut and dried, clean and wealthy medicine of O-town. I think I am supposed to be surrounded by chaos and serious pathology and patients with bed bugs. I think I am meant to have my new job. I'm excited, and ready, to say no to drugs.

Back in the Saddle

Butt bleeds. Peritonism. Dialysis patients with infected lines. Dudes who can't pee.

A four year old who was afraid to be examined until I gave her a smile. She turned and whispered something to her Mum, who said, "She DOES look like Doc McStuffins!" and then she let me poke her in the eye.

Asking the back dude if he had had any erections since his injury. When he hesitated, I prompted, "Not even morning wood? Or...a more professional way of saying that?" He and his girlfriend laughed and then it was a little less awkward when I tickled his anus with a Q-tip.

I am so so so rusty. I didn't give pantoprazole to the guy with the upper GI bleed! (Mr G shrugged when I said this, but it's the equivalent of not giving morphine to someone with appendicitis...)

I forgot to give morphine to my lady with appendicitis.

The thing is, everyone was really nice, the nurses are great, my staff doc was SO fun to work with and I got to do some bone crunching in a little old lady wearing fabulous sunglasses.

I was very happy to go home and watch my baby sleep on the monitor. And it was nice to have today off. But

I still love my job. Yay!