Ethics 200

I have this patient. She weighs 900lbs. Her fat is killing her.

She was admitted to hospital about 7 months ago with a leg infection. She only weighed 700lbs then, was able to get around with a scooter, and was very very unhealthy, but still living relatively independently.

Since she has come to hospital, she has gained 200lbs. How? By ordering pizza. By asking the nurses to bring her T-Ho's "Iced capps" or get frappucinos (extra whip) for her. By snacking.

She is no longer able to turn herself. She is so heavy that she cannot roll from side to side. She has developed bedsores. They are infected. This week, we had a discussion with her and her family about the fact that, should she have a cardiac arrest, we will not be able to resuscitate her.

Why don't we stop her from eating?

Because, in Canada, individual rights trump common sense (or medical experience). She is a human who wants to eat herself to death. We must respect her right to do this.

I have issues with this:

1. People who refuse food (anorexics) are considered mentally ill. We force feed them. This woman is literally eating herself to death. She is aware that her food choices are killing her, but she cannot stop eating. However, as food addiction is considered a life-choice (like alcoholism or smoking) we must allow her to continue.

2. Suicidal patients have their human rights temporarily violated until can be treated for their intention to self-harm. This woman's in-hospital weight gain is an act of self-harm. As such, we should be able to temporarily restrict her caloric intake until she has undergone psychiatric assessment and treatment.

3. She is not capable of getting this food by herself. She only gets these extra/unnecessary calories when hospital staff bring them to her. Just as smokers are allowed to leave the hospital to smoke, we could allow her to snack as long as she gets the snacks herself. We are enabling her by providing her with toxic food.

4. She is currently costing the Canadian health care system 10,000 dollars a day. Our socialist system does not have an unlimited budget. She is currently scheduled to stay in hospital until she dies, because there is no other facility that can hold or treat her. Even if we argue that her individual rights should allow her to kill herself, surely the collective rights of the Canadian people outweigh this. She should be restricted to a sensible diet until she is mobile can be managed in a less expensive facility where she is not taking a hospital bed from someone else.

Alas, I am not in charge. She will stay until her wounds become too infected, her heart gives up or she chokes on her own fatty tissues. This could be tomorrow, it could be next year. So it goes.

I miss the Australian medical system; I remember my boss saying, "I'm the doctor, I'm responsible, why should I let this bloody idiot kill himself under my care?"

Canadian medicine is too precious for my taste. I'll take common sense over individual rights any day.

Existential Crisis

Everything is heightened when you don't sleep. I've been on call for 72 hours in the last 5 days. Last night my pager went off at 5am and I woke to run to a Code Blue. 45 seconds from waking to pushing down on a man's rib-cage so hard that his ribs scrunched. He died anyways. It was truly horrifying, but I didn't have time to process it during the night. Today, I had nightmares.

Of course, this highly emotional state leads to big questions; what am I doing with my life? Am I making the right choices? Should I cut off all my hair?

I don't think I'll ever get convincing answers. And I don't know if it's better to roll the dice, despite your doubts, or to hold off and wait until you're sure. I've been alive for 31 years, and the only thing I was sure of, medicine, is making me question everything else.

Blah blah blah. Deep thoughts have no place in a post-call brain. Forgive the maudlin crap, I will be back and bright tomorrow. With proper medical tales to tickle your brain and poke your gag reflex.

Why I hate people.

At 7pm tonight, I got a page from the post-partum nursing station.

"We've got a patient here; baby is 48 hours old, has a bilirubin of 185. GBS-, term baby, normal delivery, no risk factors. We were going to send them home, but Mum is really worried that the bilirubin is going up."

Me: Ok, I'll go talk to them.
Nurse: Um...they want to know what the plan is...
Me: Ok. I'll send them home tonight, but ask them to come back for a repeat blood test in the morning, just to make sure.
Nurse: So...you agree that they should go home?

That should have been my first red flag.

I discussed the case with my staff pediatrician. He agreed - the baby did not need treatment, but should return tomorrow for a repeat blood test.

I walked into the patient's room, pleasant and smiling, ready to tell them the good news.

Me; "Good news! Your baby is well. She doesn't need treatment. You can go home tonight!"

All hell broke loose.

In the room I had 2 sets of grandparents, a crazed post-partum mother and a small (apparently inconsequential) baby. All of them, except the baby, started yelling at me.

"We can't leave. It's 7 o'clock at night and we live in Scarborough!"
"This baby is sick, you said we had to come back tomorrow anyways, how can you make us leave?"
"What do you mean the baby is well? She is turning yellow!"

Ah, I thought. These people are worried about their baby. I will give them reassurance.

Me: Your baby is actually ok. It is very normal for babies to have some level of jaundice in the first days of life. Her level is not dangerous.

"How can that be true? She is turning yellow!"
"My daughter had jaundice too! I know what this is! She's sick"
"Even if she's fine, what if she's not fine tomorrow, you can't tell us to leave!"
"It'll take us 2 hours to pack up all our stuff and we didn't bring a car seat!"
" We were told we could stay until 11 am tomorrow!"

Ah, I thought. These people don't understand jaundice. I was about to start explaining when...

Grandfather: "It's snowing out. You want us to take this sick baby out in the snow, then put her in the car when you don't know what could happen to us on the road?"
Grandma 1: "I just want you to hear what I'm saying, we want to stay till tomorrow because it's going to be very annoying for us to go all the way home tonight and come all the way back tomorrow".
Grandma 2: "The baby has jaundice, the numbers have gone up. You said it yourself. You said the baby is sick."

Ah, I thought. These people are ignorant fucktards, and I would be doing the baby a favor if I gave her to a pack of wolves to be raised.

I kept trying to explain, but everything I said was ignored. Finally, I said, "This baby does not need treatment tonight. She is well. Her numbers are not in the dangerous range and so she is safe to go home."

Grandma 2: "I don't believe you. I want a second opinion and another doctor. A real doctor."

At this point I excused myself from the room. I took a deep breath.

When I came back in to tell them they could have what they want, I didn't expect gratitude. And my expectations were way too high:

"You know, you are the reason people complain about the human face of healthcare."
"It's not personal, we respect you as a doctor, but you have to know that we're right..."

This is the edited version. The actual event took about 2 hours. On the plus side, I made 8 dollars.

Lord.
Just 11 hours of this shit to go. (I wrote shift, but I believe my typo speaks the truth).

NPR

Neonatal resuscitation follows the same principles as adult resuscitation, right? Like, babies should be, like, breathing and stuff. They should totally have, like, heart beats. And oxygen. Oxygen is totes essential.

This was my approach to NRP (and not NPR, as I've been calling it). I thought that newborns were much like tiny tiny adults, and that you could simply open their mouths, grab their wrists for a pulse and treat them like grownups.

Wrong.

Scenario:
Baby is blue. What do you do?
Me: Um, intubate them and start CPAP.
NRP: Wrong. You popped the tiny lungs and now the baby is dead.
Me: !
Me: Um, ok. Just apply the mask and give CPAP.
NRP: Wrong. There was baby-poop in the baby's throat and now it's dead.
Me: !!
Me: Well, what if I just open the airway with this head position and bag and mask the baby until help arrives.
NRP: Wrong. You have the baby's head in the wrong position. And it is...
Me: Dead. Slippery little suckers, aren't they.
NRP: !!!

The correct choice? Don't answer your pager.

Clearly, everything I do to this baby is lethal or torturous or both. Might as well hide in the call room watching "Say Yes to the Dress" marathons and practicing my penmanship. Letters from inmates are all the rage these days.

Disclaimer: My NRP exam is tomorrow. I am only studying. I have not killed any babies yet. I do not intend to.

The babies may have other plans.
I'll keep you posted.

Happy Baby Posture

Remember medical school? Remember when all you wanted was to be around soft, squishy, wiggly babies all the time? Remember when you thought that nothing could be more delightful than baby-time, all the time?

Turns out you were right. I'm doing pediatrics right now, and baby-time is the BEST!

I start every morning with a round of the NICU, picking up babies that fit into my palm, poking their tummies, tickling their feet. Sometimes I cuddle them and get to feed them. Sometimes I stroke their soft spots until they calm.

Then, I go to clinic. All day, people bring their tiny adorable children to me. I sometimes get to watch them play (developmental clinic), sometimes get to help them eat (nutrition clinic) and sometimes get to wiggle their feet (well-baby checks).

So why am I 100% happy I'm going to be a family doctor, instead of a pediatrician?

Because sometimes your pager goes off at 1am for a "Code Pink".

Sometimes the baby is born early, at 33 weeks. And you have to run this tiny sack of skin down the hall and place it on a warming table. You have to bag & mask while your boss gets the tubes ready. You have to hold it still as a tube is forced down it's throat, then watch blood bubble up. You have to squeeze a chest the size of a toy, squeeze it with both hands until you feel it crunch flat. Keep squeezing at a rate of 100bpm. And then send the baby to Sick Kids, not knowing if what you've done caused harm or helped.

Sometimes there's a Code OB - emergency C sections for fetal distress. For these, you're doing the procedures in the OR and you can hear the Obstetricians behind you saying things like, "She's crashing!" and "Why are her O2 sats dropping?". And meanwhile, the baby is white as paper due to a lack of circulation.

Sure, not all pediatrics is so dramatic. But sometimes kids get sick cos of parental neglect. Sometimes they get sick cos they got into Gran's medicine. Sometimes they just get sick. And sick kids are the saddest thing in the world.

So, I am truly thrilled to be a Family Doctor. The kids I see have coughs, colds and rashes. They will pee on me while I try and find their testicles (harder than it sounds). They will puke on my lap and poop on my examining table. But 99% of them will go home with Mum, returning in 6 months for their annual shots.

And those are the babies I want to see. I'll send the rest on to the Pediatricians, and wish them all luck.

Master Class

I am a 30 year old professional woman.

I am a 15 year old girl.

I am home for this lengthy vacation because my program offers "conference leave". I blithely fudged a "Marriage Conference"; a master class in parenting, child psychiatry and general medical knowledge. Alas, karma is a bitch. I am now injured, highly parented and having a regressive episode. I am living the master class.

What have I learned so far?

- Physiotherapy is a real thing. I woke up walking like a 90 year old due to a mysterious back pain. After 30 minutes with the physio I was walking like a 70 year old. He snap, crackle & popped me into shape, all the while using vaguely familiar anatomical terms like "spine" and "joint". Voodoo.

- State dependant memory is a real thing. That is, the things you learn when drunk will escape you when sober, but come rushing back next time you have a drink. Alas, high school appears to be a state of mind as well. Sitting around the table with people who saw you go through puberty brings back some startling memories. Mostly involving nudity.

- Regression is a real thing. I am depressingly unable to care for myself when my parents are around. In TO I am on top of my game, baking, washing, working, studying and managing everything with aplomb. In Vancouver, I can't buy tylenol without supervision (who knew there were so many kinds?).

While I am basking in the family time, I am also looking forward to a time where I don't burst into tears at the thought of making a decision. When I get back, I'll be starting pediatrics; once my favourite rotation, now a source of great anxiety (eg: it's all fun & games till someone kills a baby). I am sure I'll look back fondly on this time of being wrapped in a fluffy cocoon of family. I am sure. Any minute now...

theme song

Sometimes we can take ourselves too seriously.

It's easy to get swept up. "I'm a Doctor. I'm doing BIG THINGS. Lives are in MY hands. Blah di blah di blah."

Especially at St Mike's, where we specialize in dealing with marginalized populations; "I work with HIV patients".
"Well, I work with homeless people".
"And I work with people who are both..."

It gets competitive.

It also gets a bit wearing. The responsibility feels too big. The decisions you make feel crucial AND pointless. You get burned out.

Luckily, there's Seaton House. Toronto's largest shelter for men. They let us come in three times a week and we try to do some work. Right now, there are 4 residents and rotating medical students. We residents are all female.

One of us (V) looks like Sophia Loren, wears designer clothing and hates every second that she spends in the infirmary.
One of us (A) has adopted a supercilious attitude (see above) and likes to talk to her patients in what we've come to call "the Mom voice".
One of us (M) is chronically late, loud, inappropriate and (obviously) all her patients adore her. And there's me (S). Deeply cynical, easily annoyed and struggling with my control issues.
We are caricatures.

It got to the point where one of the medical students suggested we write a sitcom about our experiences. "5 girls" was born from a theme song and a snide comment but it has taken on a life of it's own.

Upcoming episodes:
- the one where M realizes she's had glass in her foot for 3 weeks and S tries to take it out without her noticing.
- the one where S finds out her "HIV+" patient isn't
- the one with the cockroach (hilarity ensues)
- the one where V loses it and refuses to see any patients all week
- the one where our supervising doctor reveals that he lives in a commune and has bedbugs

Each episode is punctuated with sassy repartee and girlish gossip.

Plus! The patients! These gentleman alternate between amused and horrified with their treating doctors (fun with racism!). They sometimes disappear on crack binges and don't take their ARVs. They sometimes try to hit on their doctors.

A running gag features the girls trying to work without sitting on any of the chairs (this following "the one where the guy lets his penile discharge drain onto the chair").

Every episode closes with the girls at their favourite sandwich joint or coffee shop, laughing and bonding over their shared experience.

Now, when things get out of hand (when you see the bed bugs, when the rash flakes onto your jeans, when your patient tries to steal your watch) you just turn to the camera, give a cheery smile and sing....

"Fiiiive giiiirls, working at Seaton House!"