Thursday, November 9, 2017

Of Stepping Up and Overcoming Fear

My first patient for the day complained of pain where there were scar tissues on his internal organs. He had ‘severe pain’ but looked very comfortable when he didn't realise I was watching him. Some investigating later and it turns out he had been a very frequent flyer in our ED as of last month and had also been 'doctor shopping' - getting restricted medications prescribed to him by various new doctors. It soon became clear that he was only after one thing - more drug prescriptions.

In emergency, it's a norm to present most, if not all cases to our consultant in charge. Depending on the consultant who's on, they may or may not decide to see the patient with you too.

The consultant who was on with me that shift was one I had worked with many times before in the past and who I got along with quite well.

I was hoping he would stand up to this patient for me, you know, what with him being older and tougher-looking than little pipsqueak me and all.. but, he didn't. He listened to my story, taught me how to approach the situation sternly while remaining professional, and sent me to do the deed on my own.

I was fearful no doubt, but I took a deep breath and faced him to sternly say no.

And just like that, his pain was 'miraculously all better' and he left without too much of a fuss, even thanking me for looking after him.

...

Later that shift, my 7-week-old chubby baby boy of a patient needed to have his bloods taken. I was advised to try a heel prick first and massage it out if possible, but two attempts proved futile. Taking bloods from young babies is something I am still not very confident about - nothing says pressure like crying parents and a screaming baby.

My consultant held this screaming baby's hand for me and guided me to go for a tiny vein in his hand. One attempt - unsuccessful.

"Try again with a smaller needle."

Second attempt - unsuccessful.

By this time, I am ready to give up and let him take over but he looks at me and instructs me - "there's a vein higher up here. Feel it, and try again."

Did I mention PRESSURE is directly proportional to length of time spent doing deed and number of  failed attempts?

I feel it, calm myself, and try again. I have to move the needle a bit, but eventually I see the flashback of blood going into my needle, and manage to draw up all the blood I needed.

"You did a good job Candice," came the reassurance from my teacher.
I smiled with relief, and thanked him for his patience with me.

...

Yet another elderly woman comes in later who needed a surgery to save her leg, and she required bloods and a cannula in. She and her daughter-in-law warned me that her veins were very difficult and that I might have trouble with them.

"I hope you're good," they laughed.

"Ooh.. well I don't usually like to brag until after the deed is done," I joked.

I set up my tray, got into a good position and inserted the cannula in within a matter of seconds with no trouble.

"You got it in first go?? Oh wow, you're really good! You can come take my blood any time!" She laughed heartily and gratefully.

Relieved, I reassure her that I've seen my fair share of failures before being able to do them as well as I do now.

...

There's a saying in medicine - "see one, do one, teach one."

In reality for me it's more like see ten before you do, and do fifty before you dare to teach one.

As I packed up to leave for the day after my shift, I reflected on the day that had just gone. I thought of how fear will always be a companion, but that I no longer have the luxury of succumbing to it. Preparing to become a registrar is an insanely scary thing - to have to take on more responsibilities and be confident in not just doing but teaching as well.

But I keep pressing forwards with a hope, and a faith.. that one day, I'll learn those things too. And I'm hopeful too that this time next year there will be a new set of challenges that scare me while the ones that used to in the past become but a polished skill to keep under my wing. 

Wednesday, October 11, 2017

Here Today And Gone Tomorrow

"It doesn't get easier, does it?"

He looked at me with warm, misty eyes.
He understood, and his heart was grieving for this loss as well.

"No. No it doesn't."

...

Mr P always had the kindest eyes, and such a gentle spirit about him.

Ever since I went to review him that first evening many weeks ago now, he's remembered who I was. I can still imagine vividly him lying on the bed, his stockings pulled up to his knees and his nasal prongs (for oxygen) half taped up because one nostril was always blocked. I often felt compelled to stop for a little chat every time I walked past bed 4, and watch his face light up as he saw his unexpected visitor. "Thank you doctor," he'd always say gratefully even though all I did was talk to him for a bit.

Mr P didn't have good lungs. They were horribly scarred and he had been slowly deteriorating over time, finding it more and more difficult to simply breathe.

And then I stopped going to see him, because I got caught up with other jobs, other patients, and other responsibilities.

He eventually went home.

I came back from work last week after my week off, and found out he was back again, and that this time we were certain it would be his last ever hospital admission.

I debated for days whether or not I should go and say hello, in part feeling guilty for not having spoken to him more in my free time and walking past bed 4 hurriedly, in part not wanting to overstep my professional boundaries, and in part, once more.. caught up with other things to do.

I knew I had limited time though, and that if I didn't say something then, I might never get the chance to anymore.

Then two days ago, he complained of a slight blocked nose. In a circle full of present doctors, I volunteered first to be the one to review him.

"Hello Mr P, I haven't seen you in a while."

And with his same kind eyes, "Oh hello dear. Yes it's been a while, and yes, I remember you."

...

I walked past his room this evening and looked inside - he lay asleep peacefully in bed softly snoring, settled with the help of morphine and midazolam, and kept comfortable with his half-taped nasal prongs delivering supplemental oxygen.

If I'm being honest.. I was hopeful that I wouldn't have to do it.
I was hopeful that I'd get to hand over and walk out the hospital tonight without having to call a time of death.

But, as fate would have it, I found myself back in that room once again later tonight.. this time blinking back tears while looking at a body without a soul - the remnants of a life well lived.

...

Sometimes I wonder if I'm cut out for this, if I'm strong enough.

Like my colleague put it ever so honestly, it doesn't get easier. It doesn't get easier to look at a pale corpse and remember what it was like to interact with them hours or days ago.

It's not that I am unable to accept reality or that I wished my patients would live forever.. but there's always that pang of sadness that hits when death comes and leaves its gaping loss.

Once more I grieve, letting the healing process slowly begin again. But tonight I am blessed to have not been alone, to have seen it in the tear-stained eyes of my patient's faithful nurse - we're only human, and I know how you feel. 

...

Goodbye, Mr P. 

Friday, July 28, 2017

Heartstring Tugs


"I told you so."

...

Just as a child running back into the arms of the One who loves her most, so have I been these past couple of days. Yesterday morning I awoke and out of nowhere thought to take a long drive back to one of my favourite places on earth - Fort Nepean. 

It was a Papa and dice trip I so desperately needed. From the moment I decided to get dressed and pack to go, I was allowing the quiet tugs at my heartstrings to guide me. 

"No not there.. not where you've always gone. This time, I want to show you something different."

"What an adventurer You are Papa."
"I know. I am."

I disregarded that little beckon at first, but the turned back, eager to see where He would lead me. It took a bit of an uphill climb.. but it led me right there to that breathtaking view.

"There will come times where you feel all alone on this journey you're on, but know, that I am always with you. And I will guide your heart and your feet, and I will always know how to lead you to where you need to go. 

Come up higher. View the world from a vantage point. See how I see things."

And oh the overwhelming peace and furious love that overtook my heart then. 

You'd think I know by now how quickly Papa can move, the way He soothes the raging seas and quiets my unsettled heart. It's signature. Over and over and over again in my lifetime, I have experienced in deeply personal ways how He would shadow me from the ache of life's uncertainties, patiently pep talk his fearful child and re-instil a courage - that my God is bigger still. 

My God is bigger still. 

...

"The Lord your God will fight for you. You need only to be still."
- Exodus 14:14

Friday, July 7, 2017

Glimpses of Love and Love Lost

I've encountered many elderly widows who were living at home alone throughout my short medical career. In the past two months in ED alone, I have had multiple memorable encounters that left me pondering life, thanking God for all that I have in the present as well as feeling very blessed to have had a kind stranger open up to me about something so close to their hearts.

...

"It's my wife's engagement ring," he said as he pointed to the ring he wore around his neck. 

"She asked me to take care of it when she couldn't anymore. We were married for over 50 years. She was a really good wife.. And now that I can't drive anymore, how will I go and see her? I like to go visit her, just to have a chat and all."

He broke out into heavy sobs.

"I loved her so much."

...

"I moved here from New York all those years ago when I was working as a model. Sold all my designer clothes and bought a plane ticket. And if I never did, I would never have met the handsome Australian man that was the love of my life.

Every morning I wake up and look at his photo and have a chat with him. "It's all your fault!," I'd say. "What did I do?" "Well you up and died and left me all alone, that's what you did!"

But, he was a good man, he really was. And I do miss him so."

...

With both her broken arms up in slings, she said to me, "I'd been married 57 years dear. Let me give you some advice dear. Never go to bed angry. What's it that they say? Never let the sun go down on your anger. Sure couples will disagree, but you need to always hug and make up. Promise me, you'll hug and make up. That is the secret to a happy marriage. 

When you meet the right person, you'll know."

I smiled at her and replied then, "I know." :)

...

She held on to my right hand tightly as tears streamed down her face.

"After he died, I started getting a lot of blood in my poo. The doctors put three clips in there and said it was a stress ulcer in my stomach, from all that grief.

He was a wonderful husband, and I've had 60 years of wonderful. I know that's more than many people get in their lifetime. Many couples nowadays break up, or stop loving each other, but I got to have him. 

Sometimes I wake up in the morning and I still feel him waking up next to me."

Saturday, June 24, 2017

Debrief: One Night in Emergency

My consultant spoke to me gently, "You know, in the grand scheme of things Candice, uraemia isn't such a bad way to die after all."

...

She had metastatic bowel cancer, and had come in for yet another episode of small bowel obstruction from the extent of her metastatic disease. This was further complicated by her worsening kidney function because both her kidneys were grossly swollen for the same reason.

I was surprised as I scanned through her previous medical notes to see that I had met her before last year when she was an inpatient - despite reading the medical summary I had written, I still could not put a face to the name. I had written then that her oncologist had advised her chemotherapy was failing and that further chemotherapy was unlikely to be beneficial.

But, she's a fighter, this woman. 

She insisted then that she wanted to press on with curative chemotherapy, and when I went to see her that night, insisted again that she wanted the kidney surgery it that's what it took to keep her going.

And when I brought up the issue of resuscitation with her, she repeatedly told me calmly - "I will leave it to the Lord. Let His will be done."

When I picked her up from the list of patients awaiting to be seen that night, I knew she was sick. She most certainly had a small bowel obstruction, and her bloods soon revealed that with her declining kidney function was a potassium level of 6.6mmol/L. This was a severe elevation that required immediate treatment, and further increases could well result in cardiac abnormalities and eventually a full blown cardiac arrest.

Her nurse and I got to work immediately. She needed an urgent ECG, intravenous insulin and dextrose to drop her potassium levels, oral contrast, an abdominal CT scan, intravenous albumin, intravenous pain relief, repeat urgent blood tests, a nasogastric tube, a chest XRay, discussion with her usual private specialists, cardiac monitoring, and a signed not-for-resuscitation form.

We managed to bring her potassium down to 5.5 mmol/L, but her blood sugar level came down with that as well to 3.3mmol/L. That needed to be treated with more dextrose, and then her potassium was noted to start climbing again - now 6.1mmol/L.

What we were doing then was simply putting band aid after band aid on an actively bleeding wound. She needed kidney surgery to improve her kidney function, and all the insulin and dextrose in the world was but a temporising measure to attempt to stabilise her. And at this stage, she was by no means a candidate for dialysis.

Her CT scan later revealed a large pelvic metastatic mass that was compressing on her bowels and her kidneys, causing her presentation today. I spoke to her usual private surgeon who accepted her for transfer across to a private hospital where she usually gets care from.

Still, I worried about sending her across to a private hospital late at night with such unstable potassium and sugar levels. So, at the advice of a colleague, I made the decision to call the covering ICU doctor in the private hospital who was aware of this patient being transferred across. I had the intention of updating her of present issues, but was informed instead that her usual team of doctors were planning to discuss withdrawal of treatment and end of life care with her come morning.

...

How do you tell a woman who has been fiercely fighting for so long, that this was going to be her last fight? 

...

Stepping back and looking at the whole picture, I knew as well that that was the best thing for her. Her disease had reached a stage where it was overwhelming and no amount of surgery or medicine could fix it. Palliative care was definitely a most rational decision, but after hours of fighting with her, the news came as a surprise.

A dire sense of inevitable helplessness washed over me as I considered her young age and how her time was about to run out. I felt deeply saddened for the fate of this woman and extremely defeated as a clinician.

I know that I am still so, so early in my career and will see many more cases like this in the future.
I know that I've known and treated her for a matter of just hours, whereas other doctors have been tirelesssly fighting with her for years and have gone to even greater measures to help her get just a bit more time.

And yet.. once more, the world simply continued to spin madly on. 

Sunday, June 18, 2017

As Simple As Kindness

She was a "frequent flyer" in our ED, known to often present intoxicated after an alcohol binge.

The term "frequent flyer" is often responded to with a flurry of groans from ED doctors, what more when infamously coupled with "substance abuse". In the midst of busy days and sick patients, these patients are often labelled and stigmatised from the very moment they are triaged.  

I'd like to write that I was a doctor who was above that sort of petty judgment, and that I was one who always saw the best in people right away.. but if I were to be honest, I too often struggle to see beyond those triage descriptions. 

But that evening, as she lay on a bed drowsy from what she had been drinking and smelling so strongly of alcohol, I watched my boss respond to the situation differently. 

I watched my boss respond with kindness.

I stood by the door quietly and watched as my boss got down to her knees to be face to face with this woman. 

She spoke to her gently, reassuring her that she would be safe in hospital that night and that we would let her concerned partner know she was here. 

See, there's politeness, and then there's genuine kindness.

As I watched this scene before me in the midst of all the activity going on in this emergency department, I could tell that this was a genuine encounter, and that my boss looked at her and saw a person instead of just a label. 

Completely humbled, I stood amazed. Here I was, just starting out in my career yet already disenchanted by patients who come in with substance abuse, and here she was, years and years of experience yet still carrying a soft heart for these people who were broken and hurting. 

This woman will almost certainly never remember that encounter, and more than likely represent again one day for the same thing. 

But I know.. that kindness is never wasted. 

I believe in my heart that kindness is extremely powerful, and that God uses it to inflict change and influence the atmosphere. I believe that it reflects the love that God has for His people, and that we are being "just like our Father" when we demonstrate genuine kindness.

There's just something about kindness.. it's vulnerable, selfless, incredibly brave, surprising, and even rebellious as it rejects responding to an unfavourable circumstance with an earthly, natural, every-man-for-himself-in-a-dog-eat-dog-world perspective. 

So teach me Papa I pray, show me how You do it. Teach my heart to love others as You do and to see beyond a label on a screen and the sum of their choices in life. Change my perspective of others and grant me the courage to be bold and rebellious as I do things your way, and not mine. Remind me of the soul before me that I am privileged to encounter, and am empowered to bless. 

...

"Then the righteous will answer Him, saying, " Lord when did we see You hungry and feed You, or thirsty and give You a drink? When did we see You a stranger and take You in, or naked and clothe You? Or when did we see You sick, or in prison, and come to You? And the King will answer and say to them, "Assuredly I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.""
- Matthew 25:37-40

"Do not forget to entertain strangers, for by doing so, some have unwittingly entertained angels."
- Hebrews 13:2

Monday, May 8, 2017

Soul Food

"Meanwhile, the moment we get tired in the waiting, God’s Spirit is right alongside helping us along. If we don’t know how or what to pray, it doesn’t matter. He does our praying in and for us, making prayer out of our wordless sighs, our aching groans. He knows us far better than we know ourselves, knows our pregnant condition, and keeps us present before God. That’s why we can be so sure that every detail in our lives of love for God is worked into something good."
- Romans 8:26-28 (MSG)

"Be still and know that I am God"
- Psalm 46:10