It Could Have Been Me

It’s not the first time I’ve felt overwhelmed by issues occurring just outside my sphere of practice. It’s definitely not the first time I’ve felt overwhelmed by issues occurring within my realm of clinical responsibility. And it’s certainly not the first time I’ve had a panic attack. It is, however, the first time that I have had to spend a good hour of a morning reminding myself how to breathe, because someone else has made a mistake. And if you don’t follow the news in the UK, I’m referring directly to the Bawa Garba case. And anyone practicing medicine in Ireland should review this case, study it, know it. Because frankly, it could have been any one of us.

I have been lucky. I am an introspective person by nature, and constantly reflect on my practice as a clinician. Difficult cases that I have seen, in which I have participated in the management are brought home, diagnoses studied, decisions all open to circumspect. I challenge myself to learn. And I know that there have been moments, events, split-second decisions that managed to pull a patient through by the skin of my teeth. Be it a result of something I knew, something a colleague offered, the senior on the other end of a phone said, the time of day, the waxing or waning of the moon; by chance, there was a positive outcome. That time an entire department was short 3 SHOs, because the posts were never filled. That time 2 colleagues phoned in sick and I was cross-covering for the daytime shift. The rotation where I did call as a registrar when I was only 12 months into my BST. All the new registrars, pulled early out of their SHO years for staffing reasons. The nights where the volume of patients outstripped the beds, the staff, the chairs in the waiting room, turning Dublin into something akin to a warzone. There are just so many of these moments that could have gone horribly awry, that it is overwhelming to think about them. Any moment could have gone differently. And they didn’t. And I am still here, listening, learning, keeping a critical eye on myself and my practice. And now I shudder to think that any of this reflective practice put in writing, perhaps even as far back as medical school, might be used against me when I finally find myself coming up short. When I am not enough for a patient. Because eventually, I will not be enough. And as of last week, if Ireland is to follow the UK as it is wont to do, when that happens, I could go to jail. I could be struck from the medical register. I could be blamed, publicly named and shamed, over one of the many things we, as a medical community, work tirelessly to prevent. Theoretically, this concept always existed. There is nothing theoretical about it now.

Let us be crystal clear in this: the systems in which we practice are insufficient. Since I have qualified, I believe I was EWTD compliant in one 3-month job. Since the Irish NCHDs went on strike to prevent shifts longer than 24 hours, I continue to be in hospital for stretches of 27 hours and longer. I have seen IT systems fail; new staff or locum staff arrive to work graveyard shifts without access to basic tests and radiology (let alone knowledge of where the loo is); I have stayed late, arrived early, worked doubles, covered for two or three colleagues, faced verbally and physically abusive patients and family; I have witnessed loss; I have grieved; and I am exhausted. All of this, and I work in a field, a discipline and hospital that are some of the best supported and most supervised across the health service. I know I’m well minded. And yet…

We as NCHDs are still growing and learning. We are apprentices in a system designed to education through exposure, supervision, and mentorship. And we are now facing a system whose neighbor and mirror has suddenly deprived a single member of supervision, support, staff, supplies, and mentorship and subsequently blamed them when they weren’t enough. It is simultaneously outrageous and horrifying. It could have been any one of us. Frontline staff is crippled by systemic shortcomings, bone-weary, occasionally suicidal, and now scapegoated. Forget discussing reflective learning and work-life balance, where is the compassion?

This brings up another concern, issue, bugbear, ill-comparison that must be stopped. The medical system is not like the airline industry. Can we please all accept this? “You wouldn’t take off in a plane without a co-pilot…” No. No you wouldn’t. But at what point is an ED in take off mode? The ethical dilemma when staffing is short is never, “should I refuse to work in this environment,” it’s, “how do I help the most patients when we’re this short.” We aren’t doing takeoff and landing safety checks. We are in the air. Constantly. Non-stop. Refueling mid-flight. Slowly running out of supplies and rested crew. We are not an elective, consumer based industry. Health is not a business. Patients are not consumers. These are people trying to help people through the scariest and worst moments of their lives (occasionally the scariest and best moments of their lives). Perhaps instead, we are much more like the military (I know, I know… delicate subject to raise in a neutral country). But we are in a situation where we must function 24/7, no break, no gaps in the functionality. People are at risk of dying; we are working to prevent that. It’s an old, hierarchical system, full of tradition and excess and out-dated equipment and algorithms that are near impossible to improve at any speed. And bottom line is the single, exhausted, junior crew-member standing lookout at three in the morning can be, often is, the one thing guiding the ship between success and death. Consider again the frontline staff and how they are treated…

We are haemorrhaging medical staff. Doctors and nurses leaving the country, leaving the continent, leaving the industry all together, because it is no longer worth the toll to stay in their vocations. Burnout is soft word for PTSD. The system is broken and now the blame game has begun. No one person can possibly bear the burden of an entire health service and no one person should. I’ve been lucky. It could have been any one of us. I’m sure it’s already been me.

On Small Mercies

I was recently asked to give a reflection at our monthly ACE Advocate meeting. I've done these before, and they have often shown up here on my blog. Following the reflection, I was asked if I'd be happy for it to be published (quietly, I'm not one out for much publication) and I agreed. Having been MIA here the past year, it might be time to get back into the habit of writing, so I'm going to start off with the reflection and see how we go from there... So here is my reflection, the Year of Mercy, from the perspective of a medical doctor - Feb 2016.

 

Forgive me, I am going to unburden myself. And in a very un-teacher like way, I’m going to do so by plagiarizing people much smarter than me. I suspect it’s a good thing, though, that Motorhead didn’t have many songs about mercy, or we’d be listening to some music.

I feel like this is an appropriate day for me to give the reflection, based on the reading. But I also think I might be coming at this from a very different direction than I have in the past. The past few months, for me, have been plagued with indecision, uncertainty, blind-siding misery, and upheaval. Some of you may remember that the last reflection I gave was Jan 2014. I talked about change. And New Year’s revolutions. I am sorry to say that I am not entering 2016 with the same optimism. So I suppose it’s good that I’m not here to talk about optimism; I’m here to talk about mercy.

I found it apt that Pope Francis declared a Holy Year of Mercy, speaking of his thoughts on the Church’s mission to be a witness to mercy. He has, in my opinion, shed light on the need for forgiveness, on the human need for comfort, by simple and humble means. But mercy, like any of God’s gifts, is something that the harder I think about it, the less concrete it becomes. So where Francis says, “A little bit of mercy makes the world less cold and more just.” Chesterton would say, “Children are innocent and love justice, while most of us are wicked and naturally prefer mercy.” So what is it? What is mercy? And where do I find it? Because I’ll tell you, right now, it feels like I need it.

There is no easy way to say this. Mercy, in my line of work, comes out in what we tend to code as, “Small Blessings” or “Small Mercies.” It’s our round about way of saying that something is horrible, but it probably could have been worse. That I know the names and faces of the clergy and lay ministers that serve the hospitals I work in – small mercy; that of all the doctors and nurses that pass through the doors, they tend to know me – that’s a bit of a pity. I remember one horrible night, I was up and down the halls as much as our priest. And the fourth time I went flying past him, he called out, “Are we winning?” I looked at him like he had five heads and told him he’d seen too much of me for it to be winning. He smiled and said, “Ah, but at least I’ve seen you. Thank God for small mercies.”

I’ve had a bad run at work. The past half dozen shifts I’ve done saw the handful of things you only tend to see once or twice in a career. I’ve found myself saying and hearing the word mercy without knowing if it’s a real thing. The boy that crossed in front of the bus and was knocked down by a taxi – small blessing the cab wasn’t accelerating. That he only suffered a broken leg – small mercy. He’ll walk with a limp for the rest of his life, and only after the 5th surgery to correct the damage. But it could have been worse, couldn’t it?

The baby that was brought in at midnight, CPR from the ambulance crew for 30 minutes before reaching us. She had no pulse. In fact, she hadn’t had a pulse for at least an hour. It was 10 minutes before we were allowed to withhold resuscitation and declare death. That we didn’t recover a pulse in that 10 minutes – Small mercy. That I was 3 hours late leaving the department that night – shame, because, as HR told me, it was my own fault for not leaving on time.

Two days before Christmas, the little boy that mum knew just wasn’t quite right, she was right. Cancer. Mets to the liver. Mets to the lungs. Mets to the lymph nodes. There is no clemency there. No possible condolence to make right what had to be said. That I finished my shift two hours later, saw another four patients, stood as a shoulder for my colleague, for the nurses, for the mum and the grandmother, and managed to get into my car before crying – that was a small mercy.

That one patient, the one that everyone knew, because she was always so sick. Sick with her inborn problems, sick with complications, sick with the flu. Her charts stacked higher than her head, because she’d struggled with life from first breath. We all knew her. We’d all treated her. And she was in again. And when she died, we thought, “Good for her.” Death - small mercy.

I lost my cousin last May. He was 35; married; 3 young girls. It was cancer. A rare, nearly unheard of type of cancer at his age. No one knew how to treat it, but the survival rates were not promising. Months not years. It was aggressive. Weeks not months. And it metastasized. Days not weeks. And I had the first proper row with my mother in years, when she demanded that I be optimistic and stop being a doctor about it. But that’s what I do. It’s who I am. And when it was quick, I told my family that it was a small mercy and they nodded in agreement.

And with all these small mercies building up around me, above me, in me, I sometimes feel like I will break from them. It is too much to carry. All this mercy. Is it though? I can’t go on…

… I’ll go on (Thomas Beckett).

If you believe the old poets, Mercy… has a human heart (William Blake). And suffering is a gift – in it is hidden mercy (Rumi). Forgiveness when we don’t seek it. Compassion when we don’t deserve it. And somehow, it seems, that at the end of the day, the limitlessness of God’s mercy is only fathomed by the inability to accept it. It seems impossible. Get up and walk.

And this is where mercy becomes real for me. Many that live deserve death. And some that die deserve life. Can you give it to them? (JRR Tolkien) I can’t. But. The very contradictions in my life are in some ways signs of God’s mercy to me. (Thomas Merton).

2016 has, thus far, been peppered with loss on many different levels for many different people. And we’ve discussed showing mercy to others. So my question for reflection tonight is this: Where do you let God’s Mercy into your life? How do you let it in? How are you merciful with yourself?

The publication can be found online here: Reality - April 2016

Thoughts and Response to the Leadership Lecture Series: Thank you Dearbhail for starting this conversation.

            I’m not going to recap the talk from last night. So my apologies to those not in attendance, particularly where my references don’t make sense. It was fantastic, and I needed to write this.

When I RSVP’d to attend this month’s Leadership Lecture Series, I was middle of the road about it. I get CPD points. It’s free because of my employer. And having attended a good number over the past two years, they tended to blow a bit hot and cold; fascinating people sometimes gave rather dull talks, or lesser-known people really sparking up a good chat. I knew Dearbhail McDonald was going to be giving the talk—“Lessons in Leadership”—and the blurb was, well, bland. But, in spite of the weather, I left work and made my way down to the college, sat in a packed out Albert Lecture Theater with only a few familiar faces and one actual friend, and wondered which way the evening was going to go. I am so glad I went.

Forgoing the traditional powerpoint lecture slides, Dearbhail gave a room of men and women, clinician and administrators, people across the political and age spectrums a concise and personal, contextualized history of the 8^th Amendment to the Irish Constitution. It was impassioned and thought-provoking without being politically ostracizing. It was accurate without being filled with jargon, and as a clinician, I didn’t feel it was dumbed down either. It was a call to arms. It was brave. It was powerful. It was the longest post-talk Q&A of the Lecture Series (that I’ve attended). And I feel, after having slept on it, it deserves a response.

I in no way disagree with anything Dearbhail said. Aside from the accurate and understandable breakdown of the fumbling legal course of the 8^th Ammendment and 40.3.3, she was not there to convince anyone that their opinions on abortion are right or wrong. I want to respond to the thoughts that bounced around my head during and after her talk, that stemmed from the Q&A, that burrowed into my brain overnight. So Dearbhail, thank you for kicking this conversation into motion. It needs to be had.

First, let me just qualify my position, my allegiances, my biases, my privilege. I’m an American ex-pat; the product of Irish-American parents, displaced from Yankeedom to the Midwest, both of whom were horrendously supportive of my brothers and myself; and I’ve lived in Ireland long enough that Dublin has been “home” for nearly a decade. My education is a hodge-podge of Montessori, public (that’s the American version of ‘public,’ not the British) & private, Episcopalian & Anglican, and Catholic, and taken from three different countries.

At the age of eighteen, one of my friends had an abortion. She did it on her own and it was kept secret. At the age of twenty, studying abroad for a semester, I was assaulted and it was kept a secret. And we all left home for college. At the age of twenty-two, teaching in South Texas, I was asked if I was married. When I answered, “No,” the response was, “Oh, no. I’m so sorry.” When I was twenty-six, I was asked how I thought I’d find a husband if all I did was study. When I was twenty-eight, I wore skirts to clinic, because I was told that female clinicians needed to look “appropriately” professional. When I moved to my next job, I wore heels, because the sound of my shoes on the floors and the way I walked commanded more respect than a decade of post-secondary study. When I was thirty, I worked with a nurse in the A&E that called me “Doc.” It was the gentlest way I’ve ever seen to keep the patients from mistaking me for the nurses, because apparently being petit, female, and younger looking equates to being a nurse. Regardless of how you introduce yourself. When I was thirty-one, I was asked if I’d completely given up on having children of my own. And when I was thirty-two, I sat in the Dublin airport, waiting to board my flight home for the holidays, and watched two politicians debate whether or not a dead body was allowed to be treated as an incubator.

Ok. Thought point number one: clinical uncertainty and ethics. I could not, if given all the time in the world, recount the number of ethical landmines I’ve stumbled across in my field. I am a paediatrician. I have worked in the maternity hospitals here in Ireland, and do I have stories. I have worked in the paediatric hospitals, more stories. And I currently teach. Our curriculum recently added ethics as taught by the ethics department, specific to our subspecialty. It is apparent that there are no hard and fast rules. I used to enjoy the intellectual stimulation of debating these points in med school; I don’t anymore. Take, for example, the rules of consent for children. Under the age of sixteen, the parent is the person to consent for the child; this is, of course, ignoring the Gillick Competence that remains untested in Ireland. Simple enough? A father can consent for their child only if they were married to the mother at the time of delivery or he legally adopted the child subsequently. Foster parents are often not legal guardians and children remain wards of the state, or the birth parents retain consenting rights in spite of multiple years of fostering. Sometimes we have to send the Garda out to find parents of children brought into A&E via ambulance before we can treat them; sometimes we have to treat them before we can gain consent, because it’s considered a medical emergency. But at half-four in the morning, with a drunk child that has a laceration, and no one can find the parents, and the kid is refusing to give a blood sample, and you have your consultant on the phone telling you what you ‘might’ be able to do… Yes, I can absolutely see how three doctors ended up in a room debating the 8^th Ammendment.

We walk a fine line as doctors. We base our decisions, our clinical judgment, on evidence, statistics, and research, as well as past experience. I’ve looked at a child and known, instantly, what’s wrong with them; I’ll never be able to explain how I came to that conclusion. No, that’s not fair. I can explain it, but I’ll give you a rational and logical outline of something that happened in my head, at a speed that I didn’t even follow at the time. It’s intuitive. And it won’t stand up in court. Percentages, numbers, clinical guidelines, those stand up in court. Those are what we are expected to write in our charts. But at the end of the day, there-in lies the conflict of patient advocacy. If the numbers suggest that path A is the safest and most likely, yet experience or gut-feeling suggests path B is what’s happening… Regardless of which path is chosen, if it’s incorrect (and I have been wrong in both directions), it can leave you with feelings of self-doubt at best, and land you in a coroners court at the far end of the spectrum. In training, we are taught to expect uncertainty, but I don’t think we’re always given the tools to manage it. Particularly when the consequences of being wrong can (and rarely, but do) result in death. The fear of litigation shouldn’t be the deciding factor in medical treatment, but I know it can be. You can’t treat experience and you can’t teach judgment. [Brief side rant about the lack of training due to understaffing and overworking of NCHDs, NCHDs being pulled out of training early to fill jobs that they may or may not be yet qualified for, consultants working with more junior and less numbered NCHDs and expecting too much of them. The system is broken and it will fail the population in many ways, more than just overcrowding, and uncomfortable ethical debates.]

Thought number two: (as posed by the current Master of the National Maternity Hospital) Why aren’t we hearing more from our women about this [the ambiguity of the 8^th amendment and the necessity of “traveling”]? The number of women that travel from Ireland to the UK in order to obtain legal and safe terminations is shocking and desperate. And the immediate response was, “It’s time to start listening to our women.” It is. It is well past time. And I think the way we talk about it is part of the problem.

First, “Traveling.” Why do we have a gentle term for the horrifying practice of exporting abortion to another country? Let’s call a spade a spade, shall we? If Ireland wants to believe that there is, “a clear blue line” for safe and legal abortion in the country, then where is it? Fatal fetal anomalies are terminated in the UK for us. Anomalies that are not compatible with sustained life are terminated in the UK for us. As far as I can tell, the only non-exported terminations are those confronted in maternal life-or-death emergencies (and some are not handled well, I’m talking about Savita), and in threats to maternal health (and some are handled extremely poorly, I’m talking about the C case and the Y case). We cannot continue to export our shame. And we cannot continue to hide the truth of this practice in euphemism and evasive statistics. As Dearbhail said, “If we’re not letters, we’re numbers.”

Second, “Shame.” And this circles round to the suggestion that deference in Ireland has shifted from the Catholic Church to Law, though incompletely and perhaps in error. Why are these things secrets? Why do we have this intrinsic sense of shame in the discontinuation of pregnancy? Why do I have friends that dread returning to work after miscarriage, because they don’t have a baby to show for their time off? Why is the ability to produce a child still the pinnacle of what women are here for? It’s not a law reason. It’s not a logical one. It’s a historical one. If a woman is told that her baby will not live once it is born, why does she then have to decide whether to continue to grow the never-to-be-born-alive fetus until her uterus expels it (and take on all the possible risks and adverse outcomes of that path) or to leave her country and enter into another health service to terminate the pregnancy? Where is the logic? It’s certainly not cheaper. Where is the compassion? This is violent. And where is the objection to medical intervention coming from?

Third, “Time and Cost.” And this is something I often wonder about. Is the lack of court cases, the lack of publicity a result of the time-sensitive nature of termination? If you have less than a month to come to such a heart-breaking decision and make arrangements, is court really something that is in the forefront of someone’s mind? Cost is a huge problem. As was questioned, who is going to pay the legal fees from the case over Christmas? There didn’t seem to be any opposition, so how did it get to that point? And from a purely pragmatic standpoint, babies that are born with anomalies that are incompatible with life are very expensive for the health service. There is financial cost, time cost, emotional cost, and facing all of these, sticking your head up and making waves seems like one of the last things a person would be looking to do.

Thought number three: Why did I sit there and think that this talk was so very brave? I think everyone can admit that discussions around termination are a challenge. From the difficulty in seeking balanced representation in the media, to getting accurate clinical information and keeping the discussion on the current and relevant topic, this is the minefield. Dearbhail is right, this topic tends to bring out the worst in people (on both sides). And sticking your neck out tends to result in swift and ugly responses. I have been told I’m a bad Catholic for my views, I’ve been told I’m a poor excuse for a woman, I’ve been told I lack compassion, I’ve been told I’m not allowed an opinion because I’m not Irish, and I’ve been told I’m going to hell. But let me be clear, my religion and spirituality steady my ability to face life and death on a regular basis; my gender will never be irrelevant, but only gives me more space for empathy; my compassion keeps me up at night, has me staying late to treat patients (not for overtime pay), guides my rational and treatment of patient, parents, and families; we live in an ever expanding global community, don’t dismiss my thoughts for the sake of nearly extinct mental homogeneousness; and if I’m going to hell for those things, then I’m not sure I want that version of heaven. I know that this post will probably get trolls. I’m not out to debate abortion right now.

What I do want to discuss is the reticence to properly legislate termination. This is not something that can continue to be brushed off, keep your head down and keep on keeping on because it’s not been a problem yet. It is a problem. It’s a problem so severe that doctors are afraid to listen to their own clinical judgment and evidence. It’s a problem that had three doctors sitting in a room, hoping to get guidance that was never forthcoming, hoping to avoid a jail sentence longer than rapists, hoping to do what was right, but seemed counter to a Constitutional Amendment. I want to discuss the fact that the debate, the legal discussion, the court case, the entire situation was grotesquely absurd, and I thought (very privately) also horrifyingly necessary. This case, ultimately, came out as rather clear-cut, but it won’t be the last. There will be another that is murkier and gut wrenching, that tests the legal shades of grey, that pits the mother’s life against the unborn.

Pinch of prevention for a pound of cure. Just because the situation hasn’t presented itself, doesn’t mean we can ignore it. Quite simply, lack of preparation invites catastrophe. I’m not saying we need to board up the windows and doors at the first signs of wind and rain, but maybe we should at least put on a raincoat and pack an umbrella.

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.

On airborn emergencies...

So... My flight took an eventful and unexpected turn... And I'm going to put some things here for really one reason only. Please remember, it is far more important that you are safe and healthy than on time this holiday season.

I was flying trans-atlantic on a 767 with a major airline. I was sitting in coach (near the back) because long gone are the days that doctors can afford to fly 1st class (if you think I'm kidding, I will explain a thing). Prior to take off, a gentleman had (what seems like) a pre-syncopal episode. He was attended by a doctor sitting across the aisle, and seemed ok for flight. 30 minutes into the air, he got worse. The doctor who had attended him previously asked for another set of hands. That's when I stood up to help.

Aside: standing up on a flight to say that you can help is terrifying. I don't like to do it. It's scary. You have very little to no equipment (none of which you're particularly familiar with) or help. And, to put it bluntly, adults of any kind are not my specialty.

Now, that gentleman was ok... He probably (and his family probably) should have had the sense to not fly before we pushed back from the gate. But if the person says they're ok, a doctor cannot really force them off the flight. And, in defense of the first doctor (a chiropractor), I didn't see him at the first event. I may have made the same decision. Now... he was fairly easily managed. And I was comfortable not turning back to Dublin. I treated him, and returned to my seat with the thought that I'd check on him every hour (much to the dismay of my poor seat neighbor who really wanted to sleep - I am so sorry! I should have suggested you take the window...).

2.5 hours later... Things changed. Another passenger had what looked to be a seizure and collapse. Now, my college (God bless them) trained us well. I worked in adult medicine as part of my qualifications and intern. To make a call over the ocean with a manual sphig, a stethoscope, and your own clinical judgement is not easy or a happy matter. But I have to say, I know a clinical stroke when I see one. And that's when I had to make a decision, as the only qualified doctor, on a 767, over the atlantic, whether or not to divert the plane. And yes, I did.

The 2 hour delay plus repeat customs and passport control when we landed was a horrible inconvenience for both the passengers and the airline. For that, I am sorry. When they build isolation CT suites on all 767s with interventional capabilities, I will never have to do that again. For the passengers that missed connections, that had to reschedule events, that had to stay in NYC overnight, I am sorry. No one wants to start their holiday that way. It's crap. I've had it happen myself. And I particularly apologise to those of you with small children. They were so good! And you were so patient. To the flight attendants that took the flack for the delay before we touched ground, I am sorry. You too are front line staff. I know that pain. But you were all so calm and composed, and for that, I am eternally grateful. I was also grateful for the business class seat for the last 3 hours of the flight to NYC, not for the leg room particularly (I'm kinda short), but it gave me a quiet space to freak out in private. [Yes, freak out. As I mentioned before, I don't treat adults... I'm a paediatrician... I haven't had an adult patient in 4 years. But I did work in geriatrics for 3 months (I know that sounds short, but I have working experience in a number of small subspecialties) and my focus is emergency medicine.]

But let me be clear. I am not sorry for diverting the plane. That passenger needed hospital care on a time limited basis. I would do it again. And I would do it for another passenger if necessary. And I'm sure the airlines support this practice, because you cannot get repeat business if your passengers die (That's blunt and tasteless and they care about their passengers beyond revenue, but it's also kinda true). Furthermore, I have one thing to say to the "super important business man" who complained for the remainder of the flight and through customs and through passport control and through rebooking your flight and who suggested that "we" (I use the royal we to encompass all of the people looking out for the well being of the passenger) made the wrong decision--whatever it is that you do for your living... you are alive. And I doubt your career calls on you to perform outside of your expertise, in front of terrified and captive people, when you are supposed to be on holiday! (Yes... that's right... when's the last time you had a business emergency on a flight where they came over the PA and asked for a CEO volunteer?) If it had been you... If you were unconscious on the ground, seizing, vomiting... I would have diverted that plane for you... And you'd (hopefully) still be alive as well.
Now... I'm going to try to put this 25hrs of travel behind me... Sleep (since I am now essentially post-call)... And spend some quality time with my family.

Regarding the NCHD Strike - October 8th...

Dear Friends,
As most of you know the NCHD doctors in Ireland will be going on strike tomorrow. As my contract this year is through RCSI, I am not an employee of the HSE. As such, legally I cannot join the picket lines. As a clinical tutor, in solidarity with my colleagues, I will not be bringing any of the students into the clinical areas tomorrow. It is with a heavy heart that I admit the necessity of this industrial action. 24 hour shifts are in violation of the decade old EWTD law. Numerous times the HSE has been found at fault in various legal proceedings. It is not the 24 hour shift against which we strike; 24 hours is a compromise on our part. Instead, we strike against 30, 36, 48, 72 hour shifts. We strike against the exhaustion that threatens our health and the safety of the patients for whom we are responsible.

We are not looking for more money, as the HSE would like to the public to believe. In fact, we will make less money with less hours worked. In response to Minister Reilly who suggested we are causing pain to patients, I would like to address our fallen colleagues, those whom the system failed, those who are no longer with us, because dedication to patients cost them their lives. To our colleagues in foreign countries, who have left this system for greener pastures, seeking a place they can practice and thrive as humans. Not one of us has inflicted pain on patients. Their safety is central to this strike. Their continued well-being and our ability to care for them is why we ask for a limit to shifts at 24 hours. Airplane pilots are not allowed to fly a plane for 24 hours straight, truck drivers are not allowed to drive that long; these rules implemented for safety, yours and mine.

I cannot do these hours anymore. I have slaved through 36 hours straight. I have battled fatigue and my conscience in order to complete menial tasks. I have cried in fear for my patients and myself. I have worked above my pay-grade and out of my depth, because we are spread too thin on the front lines. I have borrowed money from a senior colleague to take a taxi home after 32 hours on my feet without sleep, without food, without a bathroom break. I have worked 80 hour weeks and come home to study for required exams in my "free time." I have collected my partner from work when he has been on his feet, scrubbed in theatre for nearly 40 hours in a row. I have watched my friends leave. I have been asked what I'm thinking remaining here. These hours are putting lives at risk; patients and doctors alike.

I ask you to consider this. Consider what happens at 3am when you are frightened, sick, in pain, and need a doctor... We care. We are there for you. We want to be better doctors for you. We want to sleep so we can make better, faster, smarter decisions for your care, for your parents, for your children. We ask for your support with the industrial action. It is not convenient. But after a decade of our work, our energy, our study, our skill, our compassion and our trust being squandered by the HSE, we can no long stand by, keep our heads down and plow ahead, ignore the imminent collapse of the over-stretched system and have "faith" that the HSE will fix it. We take this action with health, healing, and care in mind. Enough is Enough. You deserve better.

9 ways to piss off your paediatrician: A disgruntled A&E Manifesto

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Most people think that paediatricians are all fluffy bunnies and stickers. Well, we are… sort of… I find that as a group of doctors, we are generally nice. We tolerate a lot of things that the other subspecialties don’t see, at least, not en mass: Screaming patients, patients trying to kick us or bite us, patients vomiting on us, patients peeing on us, patients who stick things up their noses, patients that can’t/won’t talk to us, parents/families controlling the care (I know Psych and Med El know some of these feels). That being said, it is possible to upset your paediatrician. If that’s what you’re looking to do, look no further; I’ve compiled a list of ways to make your paediatrician cringe… Consider it something of a manifesto.

9 things that parents say in the ED that are likely to piss off the Paediatrician… (or at least, they really grind my gears) and the reasons why I stand my ground:

1.     I thought we were going to see a doctor.

Not to eschew gender stereotypes, but in spite of my size (yeah, I’m less than 5 and a half feet tall), and my gender (I am female), and my apparent age (I’m actually older than I look), I am, in fact, a doctor. I’m a paediatrician; I’m not going to pull out my diplomas to prove it. Let’s get past the fact that I’ve introduced myself as a doctor. I have worked my butt off to get to this point in my career.

I have, more than once, been asked if a patient could be seen by, “that nice male doctor.” Short answer: no. Long answer: more than likely, there is no male doctor working this fine day in the A&E. Furthermore, if you want to shop around for a doctor, go to your GP (or find some new GPs for every time your child gets the sniffles). An emergency department doesn’t work like that.

While this is one of the things that makes my blood boil, let me just say something small here. I have been a customer of many different A&Es (I was a bit injury prone). I’ve found a lovely group of doctors in each one. And to the kind, albeit nervous, ED doc that did my LP when I was SO sick, I feel your pain now. And you were fantastic.

2.     What do you think is wrong with him?

Now, I do understand this question. I actually don’t mind it (if you’re going to listen to what I say). But please don’t plop your kid down on the examining table and sweep your hand in a fed up gesture and demand an answer. I am not a psychic. I need to ask you some questions. I generally start off a history with, “What’s the story? What’s going on with ?” I don’t find it amusing or appropriate to respond with, “That.” Or, “See for yourself.”

Further, what I express as an answer to this question is my medical opinion. You can take it or leave it. But it is based upon my (or the other physician’s) clinical opinion as to how your child is medically managed. We studied hard and work harder (I’m not going to go into the hours and pay thing) to get to our place in this profession. We treat each patient individually. Yes, we occasionally make mistakes. But, not pulling rank here, we are the doctors. To the parents that respond with a roll of the eyes and, “That’s what my GP said too.” … I think there’s a special place in hell for you.

3.     I want my child scanned.

Generally, these are the first words out of the parent’s mouth. I find that they are often accompanied by a chronic (6 months or longer) complaint for which they are already seeing a general paediatrician. And frequently, it’s Saturday or Sunday at 8pm. Shockingly, most of the complaints are not ones that can or should be investigated by a scan.  Also, I don’t care if your GP suggested you come in to us for a scan [Dear GPs, don’t do that, cheers.].

CT scans carry a very high burden of radiation. This is why every child in the door isn’t passed through one on the way to triage. There is research that demonstrates lifelong increased cancer risk and mortality is linked to childhood CTs, and leukaemia and brain tumours are similarly linked (triple the risk!!!). Down the road, I may have to stand up in court and explain why I requested (nay required) a CT scan knowing this risk. Saying the parents bullied me into it won’t stand in court, nor would it stand in my conscience.

X-rays carry a small burden of radiation; that is why the nurses and techs that hold your child for an x-ray wear protective lead shields. I realize that it is a quick test, but it is not without risk. I don’t x-ray children without indication. And x-rays are crap for diagnosing bowel problems…

MRIs are really pretty. I love them. They’re great for certain soft tissue windows. They make nice brain pictures. They’re time consuming. Your child needs to sit, unmoving, in a loud banging tube for thirty minutes to an hour… So, at times (such as in the A&E) I find them a little unpractical.

4.     I need an antibiotic.

No, that’s not a typo. “I” need an antibiotic. My brain instantly responds with, well then why are you here, clearly you need an adult physician, you’re far too old to be treated by a paediatrician. And yes, I know what they mean… They mean that they think their child needs an antibiotic. These too are often the first words out of the parent’s mouth, prior to the history, prior to the exam, often accompanied by the phrase, “The D-doc said it was viral, but I know my child and they’ll only get better with an antibiotic.”

Small news flash: If your child has vomiting and/or diarrhea, there is an incredibly slim chance that an antibiotic is the right answer and an even slimmer chance that the antibiotic will do anything but make the vomiting and/or diarrhea worse.

We are no longer living in a time where it is acceptable to give an antibiotic without a source. If a child has a UTI, there needs to be a culture and sensitivities. If it’s a bacterial tonsillitis, a swab should be taken. If it’s OM… don’t get me started. People are all up in arms about super bugs and MRSA, yet won’t bat an eye to demand an unnecessary antibiotic from the GP or Paediatrician. Yes, my responsibility is to look out for children, so I’m doing my best not to breed super bugs. You tell me that every time your child gets a head cold, it becomes a bacterial pneumonia, fine. I’ll give you an antibiotic when there’s a pneumonia. It sounds harsh, but trust me, you’d rather the standard penicillin actually treat tonsillitis than just give your kid the trots.

That being said, I do, on occasion, prescribe antibiotics. Which brings us to the next point…

5.     My child won’t take that medicine.

I assume you mean that you’re not willing to make your child take that medicine? Let me be frank for a moment. You have brought your child to an emergency department. They have been diagnosed with something that requires medicine. Now you’re telling me that they will be dying of overwhelming sepsis, because you don’t know how to give them medicine?! Ok, that was a bit over the top. But think about it. What wouldn’t you do for your child? Apparently force them to take medicine…

I’m not trying to be glib. I know it isn’t easy to be a parent. I know it isn’t easy to do things that your child disagrees with. But you HAVE to do them every day. If it’s not medicine, it’s brushing their teeth, eating their vegetables, going to bed at night, NOT PLAYING IN TRAFFIC! As a parent, you are going to have to do things your child does not like. And no… I don’t think it’s appropriate for me to stab your child, break the skin and introduce a foreign body into their vascular system, and give them IV antibiotics so that you can be the good guy… That does not make you the good guy… Nor does that make you a parent. Stop trying to be their friend, be an adult.

On occasion, the objection to a medication is one of allergy… That I do understand. But just going back to my previous point, vomiting and/or diarrhea is not an allergy, that’s a normal side effect of antibiotics. Swelling up so you can’t breathe or breaking out in a rash and having your skin peel off… Now that’s an allergy.

6.     But… We’re going on holiday tomorrow…

Look, I know how much we treasure our holidays. I’m happy that you are one of the few families that can afford flights and sun based holidays. I know how expensive they are. Do you know how expensive life long impairment is? I’m sorry that you wanted to swim with the dolphins. But your child has a) a serious infection requiring hospitalization or b) broken their arm/leg/head and require treatment.

I am not unsympathetic to the need to change holiday plans. However, looking at me with puppy-dog eyes will not make this problem go away, nor will it change the way the system works. For example, we do not put full fiberglass casts on in the A&E, because there is a good chance that a fresh fracture will continue to swell. You end up with one of two outcomes; either the cast is too tight and it cuts off circulation to the extremity, or the swelling recedes and the cast is too loose and the fracture is not stabilized. There is a reason we do things this way.

More aggravating to me, is the idea that some amount of negotiating is going to make me laugh and say, “Just kidding, there’s nothing wrong. Your child was screaming for no reason and that massive deformity in their forearm is just a joke.”

7.     This wait is too long. I’m leaving.

Sometimes, there are no words. Sometimes, there is only an expression of exasperation. Let me be clear on this: the reason there is a wait time in the emergency department is because there are a lot of sick children; and if you’re waiting, it’s because the other children are sicker than yours. I don’t like the days when the wait times brush 4 hours. I think it’s terrible. But frankly, if your child is sick, and you’ve been concerned enough to come to the A&E, you should be concerned enough to wait. Leaving before being seen by a doctor is normally a sign that you didn’t need to be there in the first place.

One of the reasons the A&Es are overrun is that we don’t have the space, the equipment, the staffing numbers that are needed. Another reason is that people just don’t go to the GP… Most of the kids (and shamefully, I’m going to estimate about 50% of them) don’t need to be in the A&E… There is neither an accident nor an emergency in some of the attendances. And yes, it’s summer, kids are out doing silly things, there are a lot of injuries. This means that certain things get pushed back on the timeline. Wounds that need suturing in the ED, sometimes we have to leave them until we can sit down and give them the appropriate attention. This isn’t because we don’t care; this is because we have to work as efficiently and effectively as possible. And not all lacerations need sutures, and not all lacerations that need sutures need to be seen by a plastic surgeon.

8.     We have a safety net on the trampoline; it just wasn’t closed…

I file statements like this under the same category as, “My child doesn’t like wearing helmets,” “I always let them swim by themselves,” and “My child’s friends drink, but they don’t.” … And I know, there are some kids who can have that peer group that drinks when they themselves don’t partake (I was one of them). There are some things you cannot prevent. Kids will fall down (or off of things). Kids will push boundaries and challenge you. Kids will strive for independence. But there should be a safety net where possible. Don’t buy a safety device that you don’t plan to use. Don’t let your kids swim in a pool/ocean/river/pond without supervision. Don’t leave your kids to fend for themselves without preparing them for the pressures they will face.

Also, trampolines and bouncy castles should be banned… Or you should be required to sign a waiver before letting a kid on it, accepting all consequences, including broken bones.

9.     I don’t believe in vaccination.

To me, that’s like saying, “I don’t believe in gravity,” or “I don’t believe in the moon.” It not only makes you sound foolish, it makes you sound dangerous. I’ve talked to many parents that don’t wish to vaccinate their children. I’ve also listened to them plead for a solution when their child is ill with measles.

We see some pretty horrible things in paediatrics. One of the worst is something preventable. I don’t like watching children suffer. Measles is horrible. But worse than measles is slowly dying of encephalitis years later. I have, thankfully, only seen one such case. I’ve seen epiglottitis, where a child struggles to breathe as the airway swells. I’ve seen little babies cough so hard they cannot catch a breath due to pertussis. I’ve seen a child need multiple infusions to prevent infection following a dog bite. And that horrible discomfort you see with chickenpox… Yeah, that too is preventable (though not on the national immunization scheme). There was an 8 month measles outbreak in Wales that was just declared over which saw more than 1200 notifications, 88 hospitalizations, and one death (you can read more about it here).

My largest concern is that opting not to vaccinate your child puts other children (even the ones that are vaccinated) at risk. I’m going to be super controversial here and say that not vaccinating is like drunk driving: you put more than yourself at risk (single story here). There are buckets of research in favour of vaccination. There’s only anecdotal stories to the contrary. A couple in New Zealand went through a horrible experience as their son nearly died of tetanus; they’ve been telling their story (here) in hopes of keeping others from suffering the same. Maybe only 4 out of 5 dentists recommend a certain tooth paste, but 95% of paediatricians are all for vaccines (and of the remaining 5%, there are some objections to the schedule, not the vaccinations). In the US, paediatricians now have the right to “fire” patients whose parents are vaccine refusers. Still have doubts, this is one of best responses to arguments against vaccination I’ve read (here).