Saturday, 24 June 2017
Around 11am, my cockatoo basically crashed. He'd been looking a bit worse for wear the last few days so we'd made a vet appointment, but he became acutely worse. My husband rushed him to the vet, but I had to be at work so I couldn't go.
He died in the vet's hands while I was at work.
I was speaking with my very upset husband on the phone while he held our beloved pink fluffy cockatoo minutes after his last breath. Our pets are very dearly loved and we go to the ends of the earth for these creatures we choose to share our lives with, and we have fought so hard for so long to keep Gallifrey going, but his body finally couldn't hold out any longer. He went downhill so fast, there was no saving him.
When I have lost pets in the past, I've had an extremely hard time in the immediate aftermath. Hearing my big, strong husband that upset - he is as close to our pets as I am - is also really hard. Thinking about the devastation my kids would feel is hard.
But today, I shut it down. I shed a couple of tears and then told myself to shelve it, I had work to do. So I put it out of my mind and went back into the pit and kept going.
I smiled and laughed and joked with my patients, and chatted with my colleagues, and I learned and worked, and followed up and figured out where things go. I sutured and lanced and interpreted x-rays and labs and I think performed very strongly as a medical student today.
And now as I sit to write this, and I think about the fact that I'm not going to see that little beast trying to steal my supper anymore or sneaking up behind me to 'preen' (pull out) my hair, I'm finally letting the tears fall, because now I can. Now I'm me, not the doctor-in-training, and I have space to let myself feel the grief for the loss of my feathered friend.
Today I realized that I finally can pull down that barrier when I need to, far more effectively than I have in the past. I can shut it down and shelve my personal life and get the job done, and when I leave I can still feel, I can still process. I can hit pause on the processing I need to do, and I think that's a very important skill to have developed.
But now it's time for bed, and then in the morning I'll wake up to a slightly quieter and less colourful house.
Wednesday, 14 June 2017
Monday, 29 May 2017
I forgot I was at home earlier, and went to reach for my call room key in my purse.
It's been a long few days and I'm really tired.
Right now Im trying to get a ton of paperwork stuff done because that's life.
My husband is going to be returning to work part time next month when his parental leave is up, and then full time in July. Our older two kids are going to be going to spend much of the summer with their grandparents, so conveniently we'll actually be down to just one kid for all of July, then we're back home for two weeks (vacation for my family, elective for me.)
We've decided to do this as a means of limiting our overall debt. Our original projections took into account that I'd be applying to the sponsorship program and while it was obviously never a guarantee that I would be accepted for it, I'm pretty sure at this point I won't be applying to it because I still very much want to go for OB/Gyn.
I find on post-call days, particularly when I haven't had any sleep, I lean pretty heavily towards just going for family med because it's a specialty that allows for much more sleep and a better lifestyle, and at the moment, that is incredibly appealing.
But it's kind of like that whole "don't shop hungry" idea. Don't make career-modifying decisions whilst exhausted.
Family med has a lot of customization, it really does. You can tailor your practice in many ways, but it is still primarily a medical specialty with some occasional procedures and maybe, maaaaybe some surgical assisting.
I want more than that, and I know that if I'm going to have the stronger emphasis on procedures and surgery, I need to go for OB.
But ugh, sleep. Sleep is nice. Being home for supper with my family is also nice.
There's the rub, and that's why I've been going around and around and around.
Which is making me even more tired, so I'm going to go to bed now and stop thinking about it until tomorrow.
Unrelated to anything: my cat looks like he has a side quest for me.
Tuesday, 23 May 2017
The title of this post is a medical phenomenon. Patients with dementia or delirium sometimes go through something called "sundowning." Towards the end of the day, they begin to get more confused, more agitated. Sometimes combattive. It's quite the challenging phenomenon to deal with, and it is hard for the patients.
Years ago, I started making a habit of going outside at the break of dawn with a cup of tea, sometimes a cat, and breathing in the fresh, clean morning air.
I don't think that's likely in this city, but as I wrote the bulk of this post last night, I made plans to find a quiet corner high in the hospital to enjoy a coffee and watch the sun rise over the city. That didn't happen, as I slept through my alarm and was late to handover, but I intended to find my way to the hall outside the teaching room, where large windows look east. That meant first getting through the night.
Overnight, the hospital halls are hushed and still in a way that is so at odds with how people usually see them. I remember from the parts of my childhood spent in the hospital that it reminded me of an empty church. It still does. My father is a minister and so growing up I spent a lot of time in empty chapels; walking between the pews, hearing my footsteps echo off the angled ceiling. I was allowed places parishioners often were not. After the service, I'd get to drink the leftover communion grape juice from tiny glasses. I'd play with the organ. Knowing the church in emptiness felt like being in on a grand secret.
Most churchgoers only ever see the chapel at its height, teeming with life or celebration or clouded by tears and grief. Most patients experience much the same of the hospital; they have visited sick family members, they have grieved in the halls, they have perhaps celebrated new life in the one ward for functioning organs. But they have not known it in the stillness, even when they have stayed. Like the chapels of my youth, walking quiet corridors deep in the night feels like a privilege; a trip down the fairy way into a different world.
There is a certain smell and a particular acoustic quality to many churches. These are branded in my memory as markers of peace. While I left the faith in my teens, I do have pleasant memories of hours spent sitting on the carpeted dais and hiding in the secret places parishioners don't go.
The difference, of course, is that the hospital at night is far more populated than those chapels I explored. There are nurses walking as quietly as possible to and fro, people paging, monitors beeping, nighttime medications to give or vitals to take. The hospital is never still. It is never fully at rest. But like the churches I knew, is a place where families change and death and new life are both addressed plainly. It is a place of transition.
The room I spent last night in smells like an old church, which is what brought this all to mind. As I walked the corridor towards my nominally locked door, the soft thump of my footsteps echoed in just that right way to remind me of my father's steps down the annexe hall. I lay in bed in my call room, unable to sleep, but listening to the creak and grumble of unwilling pipes that were old when I was born. Like evenings spent in the sanctuary as my father fixed something or set up some new system, or as the women toiled at some project intended to help the world or the community, I rested without sleeping. As I child I would sleep anywhere, but my curiosity often kept me awake. That's still a problem. But as with then, I seek out the quiet places where my mind can settle.
I watched the sunset from the eighth floor windows yesterday. As I looked east, the sun behind me, I saw the broad brush of orange light paint this industrial city vibrant for a short time as houses nestled in the shadow of the hospital stared back at me with undressed windows.
For a short time, I found some peace, and I stopped to enjoy it. The hospital is both a cage and an endless world of new experiences for us. Life under the microscope of constant evaluation, constant assessment and reassessment of how well you are adhering to the plan for how things should go; whether as a learner or staff, it is challenging. But I found a moment yesterday, I stopped and for a time felt peaceful, and I thought about how hard I have worked to get to that eighth floor hallway, in my scrubs, my stethoscope heavy around my neck, the weight of responsibility in between the pages of the chart in my hand.
The sound of a siren in the distance reminded me I had a job to do. The papers in my hand, a dictation waiting. It came easier this time. It will keep getting easier, they all tell me.
When that was done, I made the pilgrimage back to my room, and listened to the silence, in search of peace, awaiting sunrise.
The juniors residence is visible in this photo. As is Miss M, who made my morning much brighter.
Sunday, 21 May 2017
There's actually a physical reason for this - going through workup, but basically right now I'd be a great OSCE station and the labs and imaging are more to confirm what's already pretty obvious - so I know I'll be doing a whole lot better once I get that side of things worked out. It's actually probably why I've been so flat out exhausted for months. But that doesn't make it any easier to cope with the fatigue and brain fog in the meantime.
This is all very difficult because I normally have extremely high retention for what I study and I've never had to brute force study like this, but my mind is so foggy right now that I'm actually having a hard time with basic day to day tasks. This is much worse than the third trimester 'baby brain' and I felt like an idiot with that.
It also doesn't help that while I'm dealing with absolutely soul-crushing fatigue, I'm about to start a 26 day stretch of work (three weekends in a row) with 7 call shifts in there, so I kind of want to curl up and cry. Post-call days are still work days. I don't leave until 10am post-call, which means I've worked ten hours on that day. So yeah, I still count post-call days as work days. My next day off is June 17th - the second last day of this rotation - and I've spent this entire weekend studying so I basically haven't had it 'off.'
Honestly I'm having a hard time finding any time for self-care. Okay, I'm not just having a hard time, I have had precisely no self-care time at all. I've barely seen my kids this rotation so I feel like if I'm not studying I should be with them, or taking some of the load off my husband, but I'm minimally functional right now right now and am saving all the energy I can for work.
I'm sure it's pretty evident by my posts lately that my mood is in my boots. I've basically spent all of today holed up in my office trying to study and failing miserably because I can't remember anything, so I've spent the last two hours starting at this stupid SIMPLE (online training) case feeling like the biggest idiot in the world because I just can't remember anything. And I'll feel like more of an idiot when I can't answer at the drop of a hat what the mechanism is for whatever drug that I read about six months ago and have never seen used clinically.
I've tried to write a post about this a few times, and have failed. I'm not even sure I'm going to post this one because I've been doing a lot of complaining lately, and this is what I signed up for so I really shouldn't.
I'd be lying if I said the thought of just leaving med school hasn't crossed my mind. I wouldn't, I never will, but damn it's tempting right now to just say 'screw it' and walk away from this and not feel stupid anymore and have to work 10-16 hours a day for a almost a month straight.
I'm trying to be positive. It's only four more weeks. It's only four more weeks. I will come out the other side of this with much better essential skills and knowledge. This is a critically important formative experience for my future as a physician.
This will make me stronger. I know it will. I just have to get through it. A month is nothing in the long run.
But it's a long month, looking at it from this end.
Sunday, 14 May 2017
Friday, 12 May 2017
Well, there's no 'probably' about it.
Basically, my anxiety got the best of me and I froze up at every possible opportunity to demonstrate any sort of skill. I stammered a lot. My presentations were awful.
I just, overall, completely sucked as a clerk and basically made more work for everyone.
The way the CTU schedule is, we really have about 3-5 hours a day of clinical time. The rest is spent in teaching or meeting with our team (new patient rounds in the morning, running the list throughout the day, or handover.)
I lose about an hour of that because I need to pump. My pumping room (a call room) is in the juniors residence which is on the first floor in a different wing, far away from where I'm usually working. I'm down to two pumping sessions a day, but still, adding in time to get there and back, plus pumping time, plus time to wash my stuff, and I lose over an hour of that clinical time, and I can't run off during other activities.
So between my absurd level of sleep deprivation, my sky-high anxiety about doing poorly on this rotation, and the fact that the issue I've been trying to see my doctor for since February is getting worse, I'm basically a stressball at the moment. I'm that harried, slightly crazed-looking med student who is muttering to herself and stumbling over words while presenting.
In short, an absolute mess.
This is burnout. I'm actually a very strong student with a very solid knowledgebase. There is absolutely no reason my reflex should be to say "I don't know" about things I'm 95% sure of, but I still do that because my anxiety gets the best of me.
I'm also in too much pain to bother putting in the effort some days. Looking up the ridiculous name of an obscure trial so that I know the answer to some trivia question the next morning is really not high on my priority list. Absolutely I need to keep up on medical research and I need to be critical of evidence and stay on top of guidelines and why they are the way they are... but that's supplementary to, not in place of, what I need to work on right now. Preclerkship helped me build the foundations of my medical knowledge. Clerkship is building the walls. Residency is deciding on all the fiddly bits and doing the decorating.
I'm coming out of my first week of internal feeling very defeated and exceedingly stupid. No one was unkind to me at all; in fact all the staff and other learners have been very kind so far.
Tuesday, 9 May 2017
I need a ton of study time because I basically need to review the entirety of the last nearly two years because I feel like nothing at all has stuck in my mind.
Study time is one thing I don't have.
We got our tutorial topics for tomorrow at nearly 8pm. I've been studying, but just do not feel like I've even begun to appropriately cover anything adequately for tomorrow, and I'm on call tomorrow.
Time management has always been my forte. I'm good at getting stuff done, at prioritizing, but I have no idea how I'm going to make enough study time on this rotation.
When I'm there during the day, I don't have time for anything. I've already cut down my pumping to 2 sessions a day, but that still means I'm losing about 45 minutes in that 9 hour day where I could be doing clinical stuff, so I have to get the same amount of work done in less time (3-4 hours of that 9 is meeting/running the list/teaching) which means I need to be even more efficient than my peers.
I'm finding it rather hard to be optimistic about the next six weeks. This is an absolutely critical rotation to my development as a future physician. Much of the information I already know, I just have to work on my confidence in putting together a plan. It's not that I have massive knowledge deficits - not as huge as I feel like they are anyway - but it's just a matter of putting things together in a coherent and structured manner, and learning the ins and outs of how this unit works.
Sunday, 7 May 2017
Then on Friday I was in the OR all day and realized one very important thing: I really like the OR. I got my first inkling of this last year with my IR elective when I learned I like procedures a lot more than I thought I would and my enjoyment has been confirmed repeatedly since.
Friday was my last OR day until late August and that made me very sad. My next rotation is internal medicine, then emerg, then I have family and emerg electives before my surgery core (4 weeks general, 2 weeks gynae onc.)
For my next core, I have to dress up every day. No scrubs. No sneakers. No silly hats and victory laps down the OR racetrack towards PACU.
May eleventh is exactly 1 year from the final day of our program. Graduation will be a couple weeks later, but I really finish med school 1 year from Thursday.
In that final year, I have 3 weeks off for CaRMS interviews, 2 weeks winter break, and six weeks of concept integration. It doesn't feel like very much at all, but it's even less when I consider that I've really got six months to decide what I'm going to do for sure because CaRMS is rushing towards us at lightning speed. This year's somewhat depressing match statistics - 77 OB spots for 113 applicants listing it as first choice - have been released and that's it. Next year, one of those data points will be me.
The 2017s are done clerkship; we're not seeing them around the hospital anymore because they're doing concept integration. Well, they were. I think they are done now, and just finishing their preparation to write their LMCCs.
Friday, 5 May 2017
So from my accumulated wisdom from the last four months of clerkship, I've learned a handful of things I wish to share.
1. Carry at least two (functioning!) pens and a piece of scrap paper at all times.
2. Watch what your staff does so you can learn how they do things - ESPECIALLY surgeons. You may get looked at like you have two heads for doing something the way you were taught by another staff. Don't take it personally.
3. Don't take anything personally.
4. If someone 'corrects' you, even though you are doing something exactly the way you were instructed to do it 24h before, just go with it. Don't argue. Related: if you're told you contaminated yourself and you're 100% positive you didn't, still don't argue. Get a sleeve/new glove/new gown anyway.
5. Thank people for teaching you. Not everyone will try.
6. If you need paperwork filled out, let your supervising staff/resident know early on in the day.
7. Get to know the nurses and other allied health. They almost certainly know more than you do about what you should be doing especially if you're brand new on a service.
8. Waterproof shoes.
9. If you feel lightheaded in the OR - and it happens to lots of people! - let the surgeon/resident know, hand off your tools/retractor and step away and sit immediately. Don't try to fight it. Don't risk passing out in the field. For one, it's not good for the patient. Two, no one likes it if the med student creating a mess of paperwork. (I have not passed out, but I nearly did.)
10. If your staff or resident tells you to go eat, rest, or grab a coffee, do so. As in immediately. Don't wait around, don't ask if they're sure. Run for the call room/break room/washroom as fast as your little legs will carry you.
11. If you're asked if you'd like to go home early, the answer is yes.
Tuesday, 2 May 2017
1. I love obstetrics and gynaecology. A lot.
2. I have concerns about the physical toll of an OB/Gyn residency on me and the stress it will place on my family.
3. I will likely not be able to return home for a long time if I do OB/Gyn.
4. I do not greatly enjoy the full scope of family med nearly as much as I like OB/Gyn, but do enjoy some parts that are not part of the OB/Gyn scope (well-baby care, breastfeeding concerns)
5. We all really want to go home.
So I'm looking into the possibility of being a women's health-focused family physician who does low-risk obstetrics including deliveries. As far as I'm aware, there's really only one family doctor on the Island who does deliveries routinely, but I know in Ontario there are multiple family doctor groups that do low-risk obstetrics and women's health.
There is at least one physician on the Island whose practice is primarily women's health, and there's another I'm aware of who receives referrals from other family physicians because she does things like IUD insertions and pessary management. They're also establishing a women's health centre out of one of the hospitals, and last I heard they've been looking for someone who will work there.
I think I'd be satisfied with not having gynae surgery as a part of my practice if I were still able to do obstetrics and women's health as the majority of my practice.
In Ontario, I know it's entirely possible to do that.
I don't know about how achievable that is back home, but if it can happen, I want to make it happen.
It would be the best of both worlds if I could manage pregnant patients through pregnancy, parturition, and postpartum, see their babies for well-baby checks at the same time as postpartum checks, see them for breastfeeding concerns, do contraceptive counselling and IUD insertions, STI screening and management, do initial nonsurgical management of gynae issues like endometriosis, prolapse, and PCOS. Do low-risk OB, primary care gynae, some paeds.
None of that is outside the scope of a family doctor. Most family doctors don't do deliveries nowadays, but it's more a practical consideration - you basically always have to be on call to manage your own patients' deliveries - but that's manageable if it's done as a call group, and I know for a fact that there are family doctors who do that.
I figure, if a family doctor can do primarily emerg, or hospitalist, or geriatrics, or palliative, why can't I do women's and infants health?
If I could go into a family medicine residency being sure that I could make that sort of thing into my future, I would do it in a heartbeat and I don't think I'd regret the fact that I wouldn't be doing surgery.
I love OB/Gyn, but if I could be something between a family doctor and an OB/Gyn, I'll dive in with both feet.
I think I'm going to call the offices of the doctors back home who I know do more women's health-oriented practice and see if I can speak with them, and I think I might try to change my family med elective this summer to be with a women's health focused family doc.
Thinking on this, it's actually feeling like this might be a workable solution, and might be a good way to shape my career the way I want it to be, combine all areas I enjoy, and provide a desperately needed service to my home province.
It would also mean we could go home, potentially as early as next year if I match to that family med program. That is incredibly tempting.
I'd have to leave for a year (possibly) to do a women's health fellowship, but there's also the possibility I could do that in the maritimes, so I could potentially just be gone during the week.
This seems workable, but I need more information so that's my next steps.
Sunday, 23 April 2017
Anyway, to medicine.
For my final assignment for my ICU rotation - which was a fantastically educational rotation to have done - I have to write a two page reflective paper.
This is not what I would call a challenge, given my tendency to reflect at length about absolutely everything (incidentally this is public post number 1060. I have 142 in draft.) The question was which topic to pick of the many I identified whilst there. Eventually I settled on something that might quirk a few eyebrows, but I think provides very strong material for reflection. Only problem is that I've written three pages and have to trim it down.
Damn my prolix nature.
Next up is ortho, which feels like it is going to be rather intimidating. Ortho is not my natural milieu, and I had a baby three days after the end of that unit so most of what we did has gone completely out of my head.
This is a bit of a problem with all these two week rotations. I just do not have enough time to learn and actually absorb information before I'm onto the next one, and I have no time in each of the rotations to really absorb and apply the information. My exam for ortho is ten days into the rotation.
I'd planned to spend this weekend studying intensely, but between my husband being at Cub camp with our son yesterday, spending the evening in emerg with the wee one for x-rays (she's fine! Just very sore after her big sister tried too enthusiastically to get her to roll over again and accidentally twisted her backwards onto her arm. She can't move it very well, but it's not broken) and feeling just awful today, I've not gotten as much studying done as I'd like and I feel like I'm going to show up and be a huge idiot tomorrow.
But then I feel like that for every rotation, and so far only one preceptor has actually thought I'm an idiot. Or has at least expressed as much.
As for now, I'm going to go listen to some Tragically Hip (I'm doing paediatric ortho...) and read about classifying fractures.
Tuesday, 18 April 2017
It's nice to rotate through a bunch of services and all, but by the time I've learned how things are done on one unit, I'm moving onto another. I have three days left on this rotation - I've only done 6 because of the holiday weekend - and I'm just now getting to the point I feel like I'm able to comfortably do actual work that contributes to the team instead of primarily learning through observation or needing to be babysat through my work.
This is also just a really, really awful week for me right now. M is not sleeping at night and while I try to trade off with my husband so that at least one of us ends up well-rested, many nights neither of us is getting much sleep. I'm averaging probably 4-5 hours a night for the last 2-3 weeks, and that's really not an exaggeration. I can usually manage fine on that for a couple of weeks, but I am reaching the point of exhaustion saturation and I desperately need a reset.
I also have pretty much no downtime at all. I come home from work at 5-ish. Hang out with the kids, maybe catch up a bit on Facebook while my kids do their homework or use their screen time allowance, eat supper, play with the baby a bit while my husband gets the older kids to bed, and then I study until around 11pm, get ready for bed and lay out my stuff for the next day, then crawl into bed around midnight. Often the baby wakes up right around then, so I nurse her back to sleep (I'd have to pump if I didn't) and then get her settled right around then.
Then I get up around 5:30-6am, shower and dress and get to work for 7-ish.
Weekends are spent with my family, evenings once kids are in bed are spent studying.
I am almost never alone. Usually I'm nursing while I study, or I'm attempting to spend time with my husband - well, at least in proximity to my husband if not actually interacting with him - or I'm with the kids.
This weekend I took two hours - during the day when the kids were awake, at that - and went and played video games in the bedroom. All by myself for two hours straight. And I realized that was actually the longest stretch of time I had spent alone not doing something either for school or my family since I got back from Ottawa almost two months ago.
Sunday, 16 April 2017
I had my pre-CaRMS career counselling session last week and it went fairlywell. The counsellor said he's confident I could match to OB if I choose to go that route, but said he understands my concerns. My problem is pretty clear and I explained it to him: the career path I want is not really the best career path for me to take for my family's sake.
I've given myself until the end of June to decide.
Sunday, 9 April 2017
Monday, 3 April 2017
Med school, like med life, comes with a lot of paperwork.
Fortunately, the school is nice and organized and reminds us with plenty of time.
Also fortunately, I can submit my prenatal blood work from last year which will cover a bunch of the new requirements. It's quite possibly the first time having had a baby during med school has saved me time.
I've ordered my vulnerable sector check (which can be done online, yay!) and so all I have to do is do my TB testing since I think I'm considered as having exposures now because I've had clinical placements in hospitals with more than 200 beds.
My current placement is going middling to well. I'm not at all a natural with anaesthesia and feel very wrong-footed a lot of the time because I'm not confident in my knowledge, but I need to develop that. The way the rotation goes is that we work one on one with a different staff anaesthesiologist every day. Unfortunately it doesn't give them long to get to know us, so if you have a bit of a weak day, which everyone does now and then, you don't have the opportunity to improve on your performance for that preceptor.
It also means you're in a constant state of unsteadiness because different staff want things done differently. Basically, no matter how you do something, there's a pretty good chance you're not doing it to the preference of your staff. Not that it's necessarily wrong, but that it's not how they want it done. It's a bit tedious to learn each person's preferences each day, but I can understand that everyone has their own way of doing things. It would be nice to have a single preceptor for this rotation, though, and I think that's likely the feedback I'll give at the end of it.
You just don't have enough time with any one staff physician to get to know how they do things, and they don't have enough time with you to get to really assess your abilities.
After this I'm off to ICU for two weeks, then orthopaedics. ICU feels more than a bit intimidating and I feel like I'd feel more comfortable with it if I were doing it after my medicine rotation. Ortho looks quite interesting - I've been on the other side of the drape for several ortho surgeries - and it'll be nice to have a better view for those cases.
Overall I'm still really getting to that point where I feel like it's okay for me to actually do things as opposed to just observing or being taught via discussion. It's quite the transitional period and I expect it'll be a while yet before I really feel like part of the care team as opposed to a somewhat annoying outsider who asks lots of questions.
Look how big she is now!