A Study in Death

It's been a while since my last post and I've been stewing over a few things, so it feels the right time for another. There seems to be another upsurge in discussion of doctors’ health, more specifically mental health, in the past few weeks. It’s an important topic, partially because it’s often overlooked, more so because it’s not discussed. Doctors are people. We all carry our own experiences, our own strengths and weaknesses, our own scars and banners. There are those of us that manage complete detachment and those of us with so much empathy that it’s overwhelming. And we will each deal with adversity in our own way. But unlike the population at large, we see and are involved with far more death. I’m not saying we’re the only profession that does, far from it. But pronouncing death, as much as sustaining life, is an integral part of being a doctor.

No one will argue that death is an emotionally charged moment. It is moving in so many different ways and affects people sometimes unexpectedly, sometimes predictably. I don’t want to talk about the reasons for death here, I don’t want to talk about the specific cases or the hospitals; I want to talk about death and it’s involvement in my career. I’ve learned that there are episodes, single points in time that will stick with me, that I carry with me, that are learned scars on my heart that I hope, somehow, make me a better doctor. Some of these vignettes are not easy to read; they certainly are not easy to write. But if someone were to ask me about death, this is what I remember.

I started to get the sense that I wanted to be a doctor when I was in high school. I loved science (and I was good at it). I had done intensive research, competed in science fairs, but I knew I wasn’t a lab person. If I had been, I probably would have become a Scientist (capital ‘S’). I have friends that are Scientists. Their intelligence astounds me. I didn’t have the attention span for it. And it was in the middle of this development that I lost someone dear to me. It was not the first death in my family, but it was the first time I’d been so close to it. My grandmother had become unwell about 4 years prior and subsequently, she had a rapid onset of Parkinson’s and was wheelchair bound. We, as a family, went through various stages of care, but ultimately, my grandmother was in a nursing home only a few minutes from our house and my high school. Final cause of death: Pneumonia. Not uncommon, and it was, thankfully, a very quick end. I remember the night my dad picked me up from practice after school and told me where we were going. I remember saying goodbye. I remember the stages of grief my mother, my aunt, my uncle went through. I remember the next day was Halloween. I remember the funeral was on the East Coast, because it was autumn and the leaves were changing. I remember thinking that this was how you were supposed to do it, the whole death thing.

When I was in medical school, we were relatively insulated against death. I think there was the feeling that death isn’t what we were in med school to learn; we were there to learn about saving lives. Right? We had communications courses or practice, but the difficult scenario was more along the lines of telling someone that their procedure was cancelled or something had gone wrong. Learn how to say the word cancer without cringing. Learn how to have someone yell at you without crying. Tough spine, stiff upper lip, thick skin. Perhaps my focus on surgery at the time put me in the mindset. It was still very ‘old boys club.’ And we knew that as females we were in for an uphill battle. No room for tears. No room for weakness. And yet, one of the most profound rotations for me was in a peripheral hospital on the palliative care team, aka ‘pain team.’ (Not because what they did was painful, but because they were the pain management team… seemingly). We did dry rounds on Monday, Wednesday, Friday. We didn’t have many patients, so we all knew them very well. And on my third week, we lost a patient. It was mentioned at the end of the dry round. I will never forget the heavy sigh from out consultant, the careful nod, and heartfelt murmur of, “Good for him.” I will never forget using the same line myself.

Another thing that isn’t necessarily taught in med school is pronouncing death. Breaking bad news is one thing; declaring a body inert is, in fact, a procedure with legal ramifications that must be learned. As an intern, I remember hoping not to be the first one bleeped to do it. What if you do it wrong? In honor of the first intern to have that duty, I salute you, sir. I memory of your timid entrance into the room, your nervous smile to the family, and your skill at blessing the patient with the sign of the cross and saying, “I pronounce you,” I will be eternally grateful. (If you’re not aware, that is not what you are legally required to do). And God bless the CNM that caught you by your ear and threw you back into the room to do it properly. Someone had to do it. And we all learned from you. It’s something that I became relatively good at over the course of the year. I remember having to do it 5 times in one night. I remember running into the priest in the middle of the night, and he looked at me with a tired smile and asked, “Are we winning?” I think I told him I’d seen him too much that night to call it winning; I’m pretty sure he agreed.

I remember the time I was called to an arrest for a patient that was NFR. The family was in the room and looked at all of us, crash cart in hand, and demanded to know what we thought we were doing. The nurse that called the arrest didn’t know the patient was NFR and she was behind us demanding to know what we thought we were doing when we started away from the room. I remember the time a patient was brought in by ambulance from a place an hour away, and the paramedics had been doing an hour of CPR with no success, and I knew the poor man was dead, but because the senior doctor didn’t want to stop until the family arrived, we continued compressing the dead man’s chest for another 20 minutes. I remember the time a family screamed at me, told me I might be an ok doctor but I was a terrible human being, because the doctor’s place was at the patient’s bedside when they passed. That patient was NFR as well, and I had been at an arrest on the other side of the hospital. They filed a complaint against me. It was the forth patient that had died that shift. I went home in tears.

I was working in a maternity hospital the night we lost a mother. My senior took me aside and told me that I had to support the new father. I bluntly asked her how to do that. Give your condolences, but remind him of his beautiful new son. His son was beautiful. And I’m sure he was and is very well loved. But at four in the morning, grief was more powerful, and I watched a man sob over his son. And I felt powerless. Four weeks later, and two weeks after I’d filed my report for the coroner’s inquest, I got a call from the occupational health office, just checking in, making sure I was “Ok” after that night on call… I’d already been on call ten more times, and we’d lost three babies in the NICU. I told them I was fine. We were having a normal day until paramedics pounded on the door to our NICU (how they got there, I’ve no idea), carrying a 25-week gestation baby, born in the ambulance on the way to the hospital. They’d hadn’t the equipment in their ambulance for a baby so small, but it was five minutes old and had the faintest and slowest heart beat. There was a resuscitation so that the mother could at least arrive (she was downstairs having the placenta delivered). When we managed an adequate heart beat through rather rigorous resuscitation efforts, I&V, drugs, I remember my consultant whispering, “Damn.” Later that day, I was privy to the conversation about outcomes for that baby, brain starved of oxygen for too long. The parents decided to let nature take its course. They were holding their baby when it passed away.

One week into a new job, and the entire team was in a handover meeting. An arrest call went out and there was some confusion as the bleeps hadn’t fully changed hands, the time of handover hadn’t been reached, a hodgepodge of people were called and arrived. I knew this baby, I’d been looking after it, it had become unwell overnight and apparently more so than expected. It was a one-hour resuscitation, and it was unsuccessful. But we had a debriefing one-week later. It was the first time in my career I’d actually had time or been asked to sit in on one. I ended up presenting a case study about that baby. I do not regret anything that was done in that resus. It was the first time I didn’t question an outcome. I don’t lose sleep over this one.

A child, two-years old, was brought into the A&E by ambulance at four in the morning. The ambulance crew has been attempting CPR; they’re not allowed to declare death, they have no other course of action. The child is DOA, full rigor mortis has set in. The consultant is phoned, and we are given permission to withhold resuscitation and declare death. I ask what it is I’m supposed to do. I’m told to inform the parents, get consent for the PM, and get as many of the PM samples as I’m able. I had never done any of those before. I’d never sat in on one of the bosses breaking the news to parents that their child was dead. It was four in the morning. I got on with it. I walked out of the room where I’d left the parents and was intercepted by another parent who wanted to inform me that their child had vomited again. I told them I’d be with them shortly, and started collecting samples for the PM. I saw eleven more patients before I ended my shift at eight in the morning. I couldn’t sleep all day.

One of the patients we all knew, a small child with charts that stacked higher than their head, a child whom had struggled with life from first breath, was in hospital with pneumonia. This time it was like so many other times. The parents knew the routine, the child knew the routine, and we all knew the story. I remember coming in to handover three days later and the on-call team informed us that the patient had passed away. I remember whispering, “Good for him.”

A Victim's Impact Statement

One year ago, a woman whom I deeply respect for many reasons, underwent a life changing event. And while I have many feelings, many thoughts, many reactions to what happened and what continues to happen, I am going to let her statement stand alone. This is her victim's impact statement. She read it in court. She has shared it with friends. She has made public her pain and her strength. And she gave permission for it to be shared further (minus a name). But frankly, she speaks with a voice that could be so many people, and gives so many women a voice where they may have none. So here is a victim's impact statement:

For me, crimes like this come down to one singular word- choice. Due to the choices made by my assailants, my life has been permanently changed. I was not given the choice to not have my life threatened and my body used as a plaything. I was not given the choice to not worry that I was going to wind up dead with no way for my family to find and identify me. I was not allowed to choose whether I wanted these men to penetrate me repeatedly and simultaneously in the back seat of a stolen car for an hour while they attempted to steal my money. I could not choose to not be thrown from a moving car. My choices were taken from me the moment that these men chose to enact this vicious, thoughtless, and demeaning crime upon me.

I am still dealing with the consequences of their choices. I involuntarily have nightmares about my ordeal. Despite my desire to be able to feel the freedom to be out in public with strangers, I often cannot manage simple tasks such as getting gas or groceries on my own without experiencing debilitating panic attacks. The financial burden on my partner and I was certainly not something we would have chosen. Both of us would very much like to have been able to continue work, but that is not what happens when your choices are taken from you. Instead, I spent months not working and am still only working on a part-time basis. My partner has taken time off to help me, as well as deal with the trauma this has caused him, which has caused him to be on the verge of being let go from his job. I spend my time in a constant state of concern and fear. My family and friends spend their time in a constant state of concern. I doubt that anyone would choose to feel this way. My current existence is entirely based on reactions to other peoples’ desires, rather than action towards my own.

Eventually, I will regain my choices. While the defendant’s choices will inform the course of my life forever, I will not let them permanently define the type of life I choose to lead. They chose poorly when they chose to rape me; I refuse to let their choices take away the endless possibilities that stand before me. While the defendant took my feelings of safety, of security, and of home from me, he cannot take my determination to not let his choices limit mine.

With all of that said, your choices have impact that far exceeds my personal struggles. Crimes such as this add to the lack of choices that women everywhere feel. Women are inhibited by the very concept that they do not have the freedom to choose to live their lives however they please without concern of being attacked. Women live in a constant state of vigilance, fueled by tales told to them about violence perpetrated against women. Women are raised to not trust, not walk alone, never go on a date without calling a friend before and after, and never leave a drink alone at a table. Women are taught to live in a world of nots, don’ts, can’ts, and shouldn’ts because of people like the defendant, who feel that their choices supersede the rights of the women they assault. At a time where women are trying desperately to hold on to the progress they have made to choose the course of their own lives, it is unconscionable that young men such as the defendant continue to plague our society with a continued commitment to violence against women. Today, I am the one making the choices. I am choosing to stand here and make my voice and my story heard in the hope that it can be a small step towards making a difference.

New Year's Reflection - ACE

Some of you may know that I go to a monthly mass + dinner with friends who have graduated from, or support, or participate in the ACE group here in Dublin. One of the things we do during the evening is have a post-communion reflection and questions for discussion after dinner. This has been a part of the evenings since we started up in Dublin, and one that I love. I've given the reflections in the past (once at Christmas, once in November), but it's been probably 2 years. I gave the reflection last night and it went really well. So, as I have done in the past, I've posted it here.

Enjoy :)

It’s been a while since I’ve given a reflection here. And if you’ll forgive me, indulge me a little, condone the excess of a captive audience without the pressures of my normal work environment bearing down, and excuse the quotes peppered throughout, as there are people so much more eloquent than I am. So herein lie words of wisdom that I need to give myself. A diatribe to me. Things I need to hear, and perhaps, will bring some thought to you as well.

Let me begin by wishing everyone a very happy new year. Welcome to 2014. Welcome back. Welcome forward. Welcome new and old. And we can start with the traditional question: what are your new year’s resolutions? Diligently, every year, I sit down and write a letter to myself on new years day. I read the letter from the previous year. I take stock. I make my resolutions, and, regrettably, tend to break them by February. I was late this year. I had quite a bit of jetlag on the 1^st and one of the worst travel adventures in the eight year I’ve been commuting transatlantically. But that is a story for another day. Funny thing, the new year though… We get this feeling of opportunity, a clean slate, a fresh start, a ground swell of new pressures, of growth, of personal commitments, and of change.

Ah. Change.

Those of you who know me well, would know that I am a creature of habit. I’m good at organizing. I’m fantastic at planning. I can table a day down to the minute so every second is productive. And when on a routine, I am most efficient, most effective, and possibly happiest. So maybe then, it will come as no surprise that I do not like change. I suspect I’m not alone. Many people dread it. Change is intimidating, daunting, frightening, inevitable… Necessary. “All changes, even the most longed for, have their melancholy; for what we leave behind us is a part of ourselves; we must die to one life before we can enter another.” (Anatole France).

I am certainly not new to change. I am an ex-pat, living in my third country of residence, in my sixth city, on my second career, and in my eleventh “job” since graduation from medical school. Like death and taxes, it follows everywhere. Some change has always been regrettable: the death someone we love, irreparable transitions in relationships, forced job change, moving house, moving country, immigration, catastrophe… Change as loss. Wherein we feel the victim, through injury or sacrifice, change is thrust upon us by outside force. I’ve somehow always been better at facing this type of change. Bracing against the elements, following the protocol, an algorithm of survival to come out, weather weary, perhaps only slightly worse for the wear on the other side. Easy.

There are the changes that are festive though. A new life, a new relationship, an unexpected surprise. Change as gain. Change as a present that gifts our lives with something new. Deserving or not, we welcome, always, the pleasant changes that bring us joy. How could we not? I have the most beautiful new niece. Through nothing of my work or device, the most blessed change. Lucy is a tiny bundle of joy that changes everyone who meets her. I met her at 3 days old. I’ve already watched my brother become a father with his first son, but I’ve seen another change now. One that’s hard to describe, but beautiful. And so happy.

And then there are the changes that come from plans. The ones we anticipate, perhaps with anxiety, often of our own making. It’s slightly more challenging to run the course when we’ve set out the plans ahead of ourselves rather than have them thrust upon us. These changes are the ones I resist. The ones I dread. The ones I dig in my heels and stubbornly refuse to acknowledge until there is no other choice. If you’ll forgive my language, the change that comes as a kick up the arse that I need to move on, to move forward, to do what is necessary, because I’ve become stagnant, because I have forgotten what I can do, what is possible, what I should do, what I’m called to do. And I hate it, because I should know better. I should have more faith in my ability to be changed and bring change. “Never believe that a few caring people can’t change the world. For indeed, that’s all who ever had.” (Margaret Mead)

So then, in the almost unnatural calm that follows the Christmas season. That follows the waiting and anticipation, the chaos of tasks of joy that flow into the dead of winter, we find our ebb. Our sparkling, clean new year. Our moment of pause before we crash forth into January, into work, and weather. And in this moment we make resolutions. Resolutions to do differently, to do more, to new habits, to breaking poor routines, to fix, to mend, to repair, to arrange, to secure, to better, to change. And perhaps, this is where my failings lie. These things, these resolutions are plans. Plans of change, perhaps promises of change. And we all know how great I am at planning and terrible at change. The juxtaposition of my strength and weakness side-by-side. Staring me down.

So I’m going to take a risk here and throw out my resolutions. Forget the forward planning and do. Be bold. Be tenacious. Don’t make resolutions, make revolutions. Rebel against the things that I would fear and dive in.  Jump first, “and build your wings on the way down.” (Ray Bradbury). Do not wait to be changed. Be change and be changed now. Unashamedly, shed that which we wish to change, leave it behind, and by the grace be now what we know we can be.

“It may be hard for an egg to turn into a bird: it would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad.” (C.S. Lewis)

So my question is this: what are our plans for 2014, little eggs? What are our New Year’s Revolutions?

2014 - Well... It can't get worse, so...

Ok. I have many many thoughts on 2013, and few of them are family friendly... I'm glad that year is over, I'm glad we're moving on to a clean slate. And it's time to put up the 2014 New Year's Music! [aka: Tom is going to hate on all my music so bring it on - post]

New Year's Music 2014:

1. End of the World - Deap Vally
   [I'm down with angry chick rock. This is some of the best I've heard recently. I loved it from the first time I heard it, and I think I fixed on it, because there's nothing else out there like it right now.]
   
2. Cannonball - The Breeders
   [Moving swiftly on to a more classic version of women rocking it, The Breeders. I forget why this popped up, where it popped up, who played it... Doesn't matter. This has been heavy in the playlist since last February.]
3. You've Got Time - Regina Spektor
   [Straight shout to "Orange is the New Black." I love this song for its use in the opening credits, and for the sound of it. I like that it builds to something loud and then fades into a softer female vocal, then bam, right back into a fast beat. I also love her voice. I think it's so interesting. So here since March...]
4. I Sat By the Ocean - Queens of the Stone Age
   [I'm a dead sucker for the 90s comebacks. Queens released a new album this year and I gladly, happily attended their show here in Dublin. Best rock concert I've seen since Pearl Jam (and that's including Soundgarden... Sorry Chris, but this was brilliant)! Off of their new album, which I think has a great mix of new and retro, this is my favorite song... And live... whoooo...]
5. Can't Hold Us - Macklemore & Ryan Lewis[I tried... I tried... I can't keep this song out of my head. I love the rhythm and speed. It's just fun... Plus, I went for a run listening to this and holy frick I was running fast! I also recommend this for cleaning the house... It makes me smile, and I can't hear it without wanting to dance. It's so infectious, hence the popularity, but come on! The ceiling can't hold us!]
6. Galvanize - The Chemical Brothers
   [Also finding its way onto the list from a workout perspective, I love this. It's a different kind of rhythm than the previous, but it's synthed up and has a solid beat. I can't sit still with this one either. It gets me pumped up! Judge me if you'd like, it's not the worst on this list.]
7. Radioactive - Imagine Dragons
   [Imagine Imagine Dragons imagining dragons listening to Imagine Dragons... Kill me now. I can't stop listening to Imagine Dragons. I think I first saw this song attached to a fanvid of STiD and I was sold. As it's been said, try to listen to this and not picture yourself in a post-apocalyptic wasteland, walking like a badass. Welcome to the new age...]
8. Infallible - Pearl Jam
   [Lightening Bolt; Pearl Jam's new album. I love it. I love so many things about it. Mind Your Manners is so perfectly 90s Pearl Jam. Sirens is just a bit softer. Then there's Infallible... It reminds me of a few other bands (bit of Goo Goo Dolls, Incubus, Switchfoot, Lifehouse) but then you've Eddie singing. I like the odd background sound. It's not the hard rock Pearl Jam is famous for, but I really dig it.]
9. Keep Yourself Warm - Frightened Rabbit
   [I'm bringing this one back. Who doesn't love the organ in the background of falsetto cussing? I think I'm on a 'retro' kick... I think the music doesn't quite have the brutal edge that the lyrics deserve, but I like the flats, minor harmony that sounds like Biffy Clyro. It takes more than f*cking someone to keep yourself warm...]
10. Closer to You - The Coronas
    [I went to the pre-Christmas Dublin Olympia concert this year. It worked out better than the last attempt where the power failed and they had to cancel... I dig the Coronas, and they're brilliant in small venue concerts. They know how to design power lighting for their shows, and I'm a big fan of the Olympia in general. But this is their last bout of shows before seclusion to finish their next album... Which I'm excited about.]
11. The End Is Nigh - Bell X1
    [This has been on the list since the release. I like the crescendo that builds to drums with piano as the power instrument. Again, upbeat major key for a melancholic song. It's the first BellX1 that's really caught me since Velcro, but I can't stop listening.]
12. Love Like This - Kodaline
    [There are a few really up and coming Dublin bands, and Kodaline just released another album... They are strong, with lovely lyrics, and walking a fine line between pop, alt, trad. They don't go full trad like Mumford, but they rock the harmonica. It's a great sound.]
13. Beautiful - Ben Rector
    [This is really a guy and his guitar. He can sing. It's not particularly unique, it could easily be from the Script (except it's happy...) And it's just a pop song that has a nice soft sound. Sue me, I like it.]
14. A Thousand Years - Boyce Avenue
    [This is acoustic session stuff. This sounds like a giant confession. It's a love song... I've filed it under the list of songs I'd love for someone to sing to me (and mean it). It's fluff... I know. But we know I love this sh*t.]
15. I See Fire - Ed Sheeran
    [Two reasons: 1 - The Hobbit DoS. 2 - Ed Sheeran. I think he's just lovely. I like a lot of what he's done, but this song has that same haunting tone that you hear in LotR. It's something that I'd like to learn how to sing and play. It's all minor key and harmony and it gives me goosebumps.]
16. Coming Home - Diddy, Dirty Money, Skylar Grey
    [I've heard a few versions of this... But I like it. This is like MIA and old Hip-hop. But it just sticks with me. I like it. There's nothing else to it.]
17. Get Lucky - Daft Punk
    [You cannot have thought you'd get out of 2013 without this song... It's the disco awesome summer song. I heard it and liked it, then it was played so much that I wanted to rip the radio out when I heard it. But I still love it. It is a summer song. I can only picture that silly cabbie dancing with a tourist... Give it a nod and it's due. It earned a spot here.]
18. Long Hard Times to Come - Gangstagrass
    [100% here for Justified. If you don't watch that show... You should. I also love that this is a weird country/rap mix... It's kinda fun... You'll have it stuck in your head.]
19. I Am the Doctor - Dubstep Remix "the (Un)Official Tumblr Soundtrack"
    [You better believe I put this in here. You've got the Doctor Who theme, technoed and blended into some Dubstep. I'm not a massive Dubstep fan, but there's something about this one. It's kinda intense. Plus... it's been a year for Who. It's been a helluva year. "F*ckity Hi!"] 

So there you go... Music for the new year... Use with caution and all that...

2014 started for me with exhaustion after 30+ hours of travel (yes, I've had bad luck with travel recently). I have raging jet-lag that is still persisting... Then the Irish Government (I'm really just going to hold everyone in the government responsible for this... no exceptions) has now decided that all non-EEA doctors require work permits (to the tune of 500E/6months or 1000E for a year). GNIB cards will cost 150E and will not be issued for any duration longer than one year... I'm sorry, HSE, I thought 1) you were desperately SHORT on doctors... oh wait, you are! and 2) you just promised to go to 24 hr max shift (something not yet possible in a lot of hospitals due to the doctor shortage) with penalties to follow, and an aim to be EWTD compliant by 2015... Have you forgotten that your NCHDs all went on STRIKE! This is your answer?! Make it more difficult for those of us here to stay? ... This close, HSE... I'm this close. I've said kind and moderated words here before... I'm no longer capable of that. So here we go, me, starting 2014 off angrily... I'm gonna blame Amit.