Tuesday, 23 May 2017

Sundowning


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.


I wrote most of this post late yesterday, when I had retreated back to my call room after a consult. The anticipation of the pager's shrill beep was keeping me awake during that precious potential sleeping time, and my mind would not shut off. I was agitated. I was frustrated. And I was so tired.

Usually, I find sundown to bring a lot of peace. The transition times of day - as I watch the sun fall off the edge of the horizon and as the earth rotates to reveal it once again - have always been my favourites. I'm someone who finds strength in quiet.

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

Unwell

I'm not doing terribly well right now. I can't focus on a damn thing. I'm reading sentences multiple times and still not retaining sufficiently so I'm spending hours and hours and hours pounding away at my study materials and I'm getting nowhere and I can't recall things which I absolutely do know. It's very frustrating.

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

Blows

I am a very anxious person, always have been. I tend to get stuck on seeing the worst that can happen and occasionally I'm paralyzed by that anxiety - this has been particularly bad during my current rotation where, during my day-to-day clinical activities, I'm freezing on what to do.

The funny thing is, though, that in an emergency I'm actually very calm, collected, and I'm comfortable taking control of a situation if it is appropriate for me to do so.

I've gone through first aid training a number of times, and I think that helps, since I've been this way well before I started medical school.

Today my youngest - she'll be 7 months on Tuesday, which is incredibly hard to believe - was having some eggs and started to gag. Then she stopped gagging and just moved her mouth a few times while looking at me. I whipped her out of the high chair, cleared her mouth, inclined her downward over my arm with her mouth open and delivered five hard back blows. She started crying, but it was soft, so I did it again since I felt she might be partially obstructed. She brought something up in her mouth and was none too happy but seemed okay. I took a listen to her lungs, and all fields seem clear and I don't think we need to take her to emerg. I'm studying (well, I'm on a scheduled 10 minute study break right now) so my husband is watching her carefully and if she seems off at all, we'll bring her in.

Thing is, I didn't even think about it. Even with relatively little experience - I've only had to do this once before and it was nearly ten years ago - I still just shifted into the problem-solving algorithms I was taught. I didn't panic, I just got to work.

It's funny how I can be someone who panics at the sight of a bee but when faced with a scary situation, I'm fine. I'm so anxious about my kids getting hurt but when it comes down to the line, I don't feel a second's guilt about hitting my infant hard on the back to clear her airway.

At my stage of training, within the hospital the vast majority of the time my role during a code is "stay the hell out of the way until told to do something" and then probably doing compressions because apparently med students are the muscle during codes at this site.

But outside of learning situatons, I have had to manage emergencies/urgencies - babies choking, person passing out in front of me, witnessing an assault, kid having a seizure, amongst others - and I've been totally fine. Assess the situation. Call for help. Give individual people single instructions. Get to work.

This Mother's Day, I'm grateful for the fact that I have skills which help me keep my kids safe. I'm grateful for the fact that my husband does too; that in an emergency, I know he will be equally quick to put his first aid training to use.

I'm reminded that my job as a mother - like my job as a soon to be physician - is one not only of guidance but of protection, and sometimes you've got to hurt to help and anxiety be damned, I've got a job to do.




If you are someone who cares for young children, please make sure you have first aid training and ensure you have taken infant CPR so that if you are faced with something like today, you will also be comfortable knowing what to do.

Friday, 12 May 2017

Within Doors

First week of internal was... probably my worst week of clerkship so far.

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.

The very last day of my program is less than a year away, and honestly I've never felt less prepared than I do today.

Logically I know this feeling will pass. I know I will get through this, I will learn, and I will be fine because I always am and I tend to 'anxious' myself into a far bigger mess than I have any right to be.

But anxiety isn't logical, so despite logically understanding that like all things, this too shall pass, it's still hard until it does.

I'll get there. Just not soon enough.

Tuesday, 9 May 2017

Eep

So day one of CTU and I'm basically deer-in-headlights level terrified, feel completely out of my depth, and feel like all of my classmates - many of whom have done CTU electives and so actually have some idea of what we're supposed to be doing - are way, way better off than I am right now.

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.

Today, I'm feeling very, very student-y. Unprepared, unknowledgeable, and almost paralyzed with anxiety about screwing up.

I know I'll get over that feeling, and I'll figure out how to make my studying time work because I always do, but in the meantime, I'm going to just have to remember to breathe.

At least I'm usually able to do that.

Sunday, 7 May 2017

I'm Not Very Good at Plans

So a few days ago I got really excited, thinking I had it all figured out, that I'd do family med and focus on women's health and low-risk obstetrics and just be done in two years and be happy with that and I'd go on my merry way inserting IUDs, doing endometrial biopsies, delivering babies, and giving everyone HPV vaccines.

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.

They graduate on the 25th and then we're the senior medical students.

I really need to have my future figured out pretty soon. The end of medical school is approaching rapidly (I'm sure I'll feel differently around 2am on Wednesday when I still have 6 hours to go before I can leave) and I just feel like I can't decide.

When you compare the first two years of, as an example, Mac's OB residency and the first two years of the family med program back home around half of the rotations are the same. The big difference is that 9 blocks (36 weeks) of the FM residency is community FM, so you're working generally better hours than OB residents for 8 months.

Realistically, a family med residency isn't going to be *that* much easier over the course of those two years. And the last half of an OB/Gyn residency is less school than it is practice with eventually irrelevant training wheels and lower CMPA premiums.

It would be lovely if the answer to my indecision would just fall out of the sky.




Friday, 5 May 2017

Kay's Tips for Being a Good Clerk

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

Re-evaluating My Options

Five facts that are causing me some stress:
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

I See You Little Bones

My husband made chili and homemade biscuits for supper. This has absolutely nothing to do with the rest of my post, but I just wanted to document somewhere that he actually made biscuits using my family recipe, and did an amazing job. He keeps saying he can't bake, but he keeps proving himself wrong.

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

Finding Silence

After my current rotation - internal med selective - I have my ortho rotation and then I'm done with two week rotations until my electives this summer. Because I had a 6 week elective block followed by my anaes/selective/ortho block, I'm doing six 2 week rotations in a row.

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.

My exhaustion is coming across in my functioning at work (school, whatever.) I'm not performing at the level of which I am capable because I am so tired.

I think this weekend I'm going to just shut myself up in my office for one day and just do nothing.

Sunday, 16 April 2017

Will I in the Quiet Moments

I'm sitting here, nursing my baby who will be 6 months old tomorrow, and trying to figure out my plans.

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.

When I've asked some staff about it, I've gotten very encouraging and positive advice about pursuing what I love and the fact that residency is working as a doctor even though you're still a trainee. It's all reassuring and all but the fact of the matter is that most of them did not have school-aged children when they started residency. Several I spoke to did start their families during residency, but that's very different.

As much as it sucks to be super busy during your child's earliest years, the reality is that they probably won't remember it very much if at all. My kids are old enough that a long residency is going to happen during a very significant part of their most formative years. When they are adults they will remember me being in residency and I cant help but worry that they will look back on those years with sadness.

I realize an OB/gyn residency is 'only' five years compared to the 25-35 year career I'll have afterwards, but my kids have their entire adult lives to come and I don't want to negatively impact that.

My kids will be 16, 12, and 6 by the time I finish a 5 year residency. I've been in school since my oldest was 5, my second wasn't yet two, and my youngest was still an arrested primary oocyte.

It is extraordinarily tempting to choose the relatively easier path (no path in medicine is easy, but some are shorter) and go for family medicine, apply for a sponsorship so I graduate with less debt, move home next year when I graduate, and finish my training back on the Island. Then start in family practice, work a relatively normal working lifestyle, get to know my patients extremely well, be there through the trials and triumphs of their lives. See my youngest patients grow up and then care for their children. Leave clinic at 4:30 or 5 and spend every evening and weekend with my family.

But I would have to give up managing deliveries (family doctors don't really do deliveries back home,) and scrubs and my ugly-as-sin waterproof clogs - that I totally love because they're so comfortable - and surgery. I wouldn't be walking the halls, room to room, ushering babies into the world and women into motherhood. I wouldn't be in the operating room doing that somewhat ridiculous but eminently ritualistic dance to close my gown.

As much as it surprised me to learn it, I fell in love with surgery and the thought of spending the rest of my career without seeing the inside of an OR on a regular basis is more than a little disheartening. I think I could be happy in family med, in that it's a good job and it is medicine so I can be there to help people with their health. Family doctors are extremely important for tying everything together for patients, for being a first and major point of contact for the rest of the health system. If I match to family, I won't be depressed about it or anything.

But if I pursue family exclusively, I wonder if in those quiet moments after the patients are gone for the day, when I sit back in my office with a tea and a digital stack of lab results to review,  will I look back wistfully at the choice I didn't make, or will I be satisfied with the one I did?

I've given myself until the end of June to decide.

Sunday, 9 April 2017

Breathe In, Breathe Out

Anaesthesia is done, but I'm right off to ICU Medicine starting tomorrow.

I've been spending much of this weekend studying. Well, trying to. Also trying to find time for my family. My integration of concepts is simply not where I want it to be, and I really need to go back to basics in some areas. This means lots of reviewing to make sure I don't hesitate and doubt myself constantly when asked something. 

I did get feedback during my anaesthesia core that I need to work on my confidence. This is something  I really struggle with. Im always pretty sure that everyone around me is completely annoyed by my presence and that the best thing I can do is shut up and get out of the way. I feel the need to apologize for my presence, for the space I take up.  

While I realize this sounds irrational, this is what social anxiety does. It sucks. I realize it's not normal, but at the same time, I've spent most of my adult life trying to fix this and haven't managed to yet. It's quite frustrating. 

But the preceptor I had on Wednesday night was right; I need to find confidence. Or if I'm not able to actually have some, fake it. "You have to show confidence," she said. "You're the doctor now."

The lack of confidence is sometimes paralyzing. I have all this knowledge in my head but when a preceptor (or a peer) asks me a question to assess my knowledge, I stumble and doubt and sometimes end up saying the opposite of what I mean and I make an idiot of myself even when the question is something I know extremely well. It's not a problem with patients, funny enough, and I have no problem at least faking confidence when I'm with patients, but with preceptors and sometimes peers, I'm so self-conscious it's painful.

I'm also still very much finding my feet in clinical medicine. I find it very jarring to move from staff to staff, to never know how they want things done, to do something on Tuesday that I was told to do on Monday and have my knuckles rapped over it. I understand it's the nature of the training, but it's really aggravating to feel like you're constantly wrongfooted and useless.

It's a matter of getting comfortable with it all, I know. I'm doing stuff now that I simply do not know as well as OB/Gyn and I have to do better with accepting that I won't and can't be as strong in everything as I was in my favourite discipline. I need to be okay with 'okay.'

Might take me a while to get there.

In the meantime, here are my girls being cute. M is pretty much in a constant state of happy flailing so it's hard to get photos where her limbs aren't blurry. 


Monday, 3 April 2017

The Minutiae

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!

Saturday, 25 March 2017

Pink Fluff and Career Stuff

My bird is still alive. After my last post, he took a turn for the worst and we were pretty positive he was going to die. He couldn't hold himself up well. He was shaking. We kept him on a heating pad, under his basking lamp all night, on the couch with us. We figured the best we could do is ensure he wouldn't die alone, in a cage. 

He survived, and that morning I noticed something thanks to my experience with birds which lead to us getting a med that has turned things around. 

So thanks to a lot of intensive care - tube feeds, crop washouts, IM meds at home - he's still alive and is actually improving. He's on six different medications, but he's doing surprisingly well. A week ago he was so emaciated you could have cut paper with his keel bone, but in the last few days he's gained back over 15% of his lowest body weight and he's got his attitude back (which includes taking swipes at me.) Birds with this disease never live their normal lifespan, but a rare few have survived a few years with it, so there's some hope we may be able to manage this long term. 

There's my update on the fluffy roseate dinosaur. 

The aforementioned fluffy roseate dinosaur, at the vet's office. He climbed up onto my shoulder which just does NOT happen. 


Now, to medicine. 

I've now finished my last OB/Gyn elective and have wrapped up three straight months of OB/Gyn (which for the rest of this post I will shorten to just OB.) I figured this stretch would decide for me once and for all whether I want to apply to OB. 

Well, I definitely love OB. All of it. I think I can handle the lifestyle too. 

I am not positive I can handle assisting in vaginal surgery. Specifically assisting; I think I could handle being the primary just fine, because then you're seated or standing straight. But assisting in vaginal surgery means being stooped over, half under the patient's leg, twisted sideways, with your arms outstretched, retracting without moving for hours at a time.

Spending 7+ hours in one day in a position that seems especially designed to be excruciating for someone with pre-existing back issues is... not optimal. My back has been screwed up since a bad fall I had when I was 15. I manage just fine most of the time, even though I deal with pretty much constant pain from it, but sometimes have to be a little extra cautious with my movements. 

There is a LOT of assisting in vaginal surgery during an OB residency, as one would expect. I am honestly not entirely sure I could handle five years of doing that regularly and I worry that I might make the already chronic pain I cope with so much worse. 

That's my one big hang up. I have no worries about my ability to manage the other requirements of the job or training for it. The five year residency is certainly daunting, but I'm up for it. I just feel so at home in OB. It's the part of medicine that comes to me most naturally, that I have the most interest in, that feels like where I belong. I don't want this one thing to hold me back from it, but at that same time, I don't want my career to disable me. 

I've given myself a deadline for making a decision about what residency/ies I'll apply to. End of June. That gives me time to apply to the family medicine sponsorship if I do decide to do family med instead. 

Thankfully my school has us have a mandatory career counselling session and mine is scheduled for early April, so I'll be able to get some feedback on my thoughts, I hope.

It's hard to believe that in less than a year I'll know what kind of doctor I'm going to be. 

Sunday, 19 March 2017

Under the Lights

I've been baking this weekend. Probably not the best past time, but enjoyable nonetheless and quite honestly I'm baking to feel like I can do something useful. 

We have our cockatoo home now, but he's dying. We're basically doing palliative care and waiting for him to die. There is a small, vanishingly small, possibility his illness may remit for months to years, but it's highly unlikely with him as sick as he is currently. He does not seem in pain at all or we would have him euthanized. He's enjoying eating his favourite foods, and spending time under his heat lamp and snuggling up to us. He's very sick, but essentially on a slow downhill trajectory. If he goes downhill fast or seems to be in pain, we'll call our vet to come to the house to euthanize him. As it is now, we're just trying to let him enjoy the rest of his time with us. 

My kids are learning some important lessons through helping take care of Gallifrey. We're coping with some big emotions, as we'd expect. 

I wish I could make this better. If he were human, there would be options. The virus would be better understood. The treatment options would be better than "we think this might help, so that's what we're doing." 

This illness - formerly known as macaw wasting disease, then PDD, then ABV, and now avian bornavirus ganglioneuritis - has been around as long as I've had birds. The virus is everywhere. Almost every flock will have a bird or two who carries the virus asymptomatically. It's somewhere around 25-40% of pet birds who have the virus. Whether it will progress to a clinical syndrome, as it has done in my bird, is unpredictable. This is the most likely time of year for it, because they're entering breeding season and the hormonal activity is stressful. 

I've been poring through what little literature I can find to see if there's anything else we can do, but he's already on the generally accepted treatment regimen that, in some birds, helps them live for years longer. 

It's pretty obvious he's not going to live for years more at this point. He's hanging out under his heat lamp and eating a bit. We're feeding him some hand feeding formula as easily accessible calories and fluids. 

We've done our best by him, and that's all we can do. Now we just have to help keep him comfortable and let him pass in his own time, in his own space, where he is happiest. 

He needs a bath, but I'm hesitant to give him one because he's having trouble maintaining his temp already. :-/




Wednesday, 15 March 2017

Vale Viceni

And just like that, I'm thirty. 

It has not been the most festive of birthdays. For two reasons. The first is that a friend's husband died on Monday. It was one of those extremely sad cases of stage four cancer out of nowhere followed by a rapid decline over a handful of weeks. A group of friends are all trying to support her; I absolutely cannot imagine what she is going through. They'd just had a baby a few months ago and so it's just an absolute mess and I'm feeling very sad for her and can't help but spend some time having a bit of a deep think about life. 

Beyond that, my cockatoo is very ill and is probably going to die. He's been at the vet since Sunday. We went to see him this evening and he's very, very ill-looking. It was quite sad to see him so poorly. He perked up and said "hi!" when the tech brought him in to see us, and we spent some time with him. 

This is the hard part about pets. Even when you take very good care of them, things happen. With birds in particular, there is often very little you can do. Last year, when we tried to save our cat, there was at least an aggressive course of action we could have tried to see if we could save her. With a parrot, there's little research on treatments so you just kind of have to hope that what you try will work. I've kept birds for twenty years and I have often not had access to an avian vet so I've had to learn some avian medicine and I can comfortably manage some stuff, but I'm very glad to have an actual avian vet guiding us now. 

It's just very hard to see him so sick, and to know it's probably not going to get better. My son dearly loves this bird - as do we all, but he's very close to him and few other beings - and I know losing him will be hard. 

So this has not been the best week. The fact that it's only Wednesday is not very reassuring. 

This will be a good week to see the back of. 


Sunday, 5 March 2017

Catching Up

This is the longest I've gone between posts in a while. The reason why is that I honestly just got really sick because of my stubbornness.

It took me 14 hours to drive home from Ottawa - a five hour drive - because I kept having to stop to sleep.

I had strep throat (lab confirmed) which essentially knocked me off my arse. I ended up with a fever on and off for five days, though basically medicated myself into some semblance of functionality for the bulk of it and since then I've essentially been asleep any time I've not been at work. I come home at the end of the day, get my stuff ready for the next day, and go to sleep.

In the last week and a half, I've spent almost no time with my kids, have let the ball drop on several commitments, have let pretty much every single thing in my life fall apart, and I'm still outright bloody exhausted. Clearly, I need time to recover that I simply don't have. It is taking absolutely everything I have to be at my best while at work and I have nothing left by the end of the day. It's a damn good thing I don't have call right now because that would just be a mess.

My current elective isn't even that physically demanding. I'm walking around most of the day, but that's hardly taxing. I'm at a fabulous clinic with some absolutely amazing staff, and some really wonderful residents I'd already come across. It's honestly a really good experience and I am very much enjoying it and am learning a whole lot. I just wish I wasn't so tired.

This is honestly making me wonder if I have what it takes for a surgical residency. I am so exhausted from a stupid strep infection because I didn't have enough recovery time. How will I manage being sick during residency? What if I have an asthma exacerbation and end up in emerg because I can't breathe, or there's a flu outbreak? Maybe OB/Gyn is a better option because I'll mostly be working with otherwise healthy patients? I don't know. I'm too tired to think very rationally right now.

I am planning to see my doctor about my currently disproportionate level of exhaustion since I have a day off coming up. My schedule for my next elective just kind of worked out that way, so I'm cramming all of the errands I need to run into one day because time off on weekdays is rare. Probably not the best plan, but there's no real way around that since I have time-sensitive things that need to be done.

As for the moment, I'm going to go lay out my clothes for the morning and then get to sleep. Have to be up at 5:30.

Thursday, 23 February 2017

By the By in Bytown

I've really been enjoying my elective here. That is, until today.

I woke up feeling a little off - just that sort of half-sick, not quite awful feeling. My throat was a bit scratchy but that often happens in the winter. So I just got on with my day.

By noon, I'd spiked a fever (max temp I measured was 38.8) and was shaking and sore and my tonsils are scarlet and awful looking. Centor Score: 4. 53% probability of strep pharyngitis.

The residents I was with, understandably, had me leave. I'm holed up in my hotel room, under a pile of blankets, feeling pretty sorry for myself. I have bottles of water, acetaminophen, benzocaine lozenges, and my pajamas.

I only missed 4 hours of today, and my residents said I could return if I'm afebrile tomorrow so I'm just trying to will my body into health. There's sort of an unspoken "Thou Shall Not Take Sick Days" culture in medicine (I actually was told explicitly by a physician that doctors can't take sick days so I suppose it's not truly unspoken.) It's understandable, particularly for specialists who might have patients waiting months or years to see them. Cancelling your clinic or OR day may result in unacceptable waits for rescheduled patients.

But I'm just a student. The care I deliver is not so critical that my being absent for an afternoon will cause unacceptable issues for patients, and it's just plain irresponsible for me to stay there if I could make a newborn sick because they go downhill reaaaaally fast.

I'm hoping that my fever breaks overnight because I really, really want to work tomorrow. I had planned on returning to Hamilton tomorrow after work, so I didn't actually book my hotel for tomorrow night. I have to check out in the morning. But if I end up working a long day tomorrow to make up for today, I'm going to need to sleep before I make the 5 hour drive back. Honestly may just kip in my car for a few hours, or ask a friend if I can conk out on their couch for part of the day.

Right now I need to get my hotel room ready for the morning. Have to take my suitcase out to my car and lay out my clothes, make sure I've done my going-over of the room because I would hate to forget something.

It's been nice being back in Ottawa. I like this city a lot, and have missed living here more than I realized. I'll be a bit sad to leave, to be honest.

I just really hope that I'm feeling better in the morning so I can at least work on my last day here.

Wednesday, 15 February 2017

Happy Birthday!

Today is my husband's birthday. I'm rather sad that I can't be with him tonight. He's sick, and the baby is just getting over being sick herself, so he's also tired. But from here I couldn't do anything for him for his birthday and I'm sad.

I will be seeing the family tomorrow. My husband is driving up with the kids tomorrow evening. I'm switching hotels as well, since this one isn't really ideal for having the whole family here for 6 days, though it's been workable for me for the last few days. It doesn't cost much more, but I wanted to save money where possible. There's actually a program that reimburses clerks for travel for one elective per year within the province, so I'm going to be reimbursed for my travel and accommodations, but I still wanted to be reasonable with my costs (even though my nightly rate at both hotels is below the cost limit.)

I'm a bit tired at the moment but it's more because I'm not sleeping well rather than anything to do with my elective. I'm not doing any call or anything, so it's just a normal 7-5 schedule (which I find amusing. A 'standard' week is 50 hours. Plus whatever call shifts you are scheduled for.)

The residents and staff I've been working with are amazing. Not that anyone at Mac wasn't awesome, but I really like the atmosphere here. It's different. Not better, but from my first few days I think I've just gotten my feet under me a bit better. I also really like being back in a bilingual environment. It hadn't occurred to me until I got here how much I'd missed hearing French regularly. My expressive fluency has also taken quite a beating over the last couple of years since I've not had many opportunities to speak with adults in French, so it's nice to be where I can use it. I think my desire to come to Ottawa for residency is certainly increasing.

This is a good city. My husband grew up here and I did live here for ten years, so we both know it well. While we did move to my home province after some rather difficult events (I knew multiple people who were murdered in a very short period) I have always liked Ottawa. Plus I know my way around well enough.

I'm very excited for my husband to get here tomorrow and be able to revisit his old stomping grounds and see his old friends. I think he's been wanting to consider coming back here himself, so I have a feeling he'll agree with me that this'd be a good place to go.

Not that I have complete control over that.

Still, it's so-far been a good trip. I'm enjoying myself. I just wish I could be home with my husband. At least the kids insisted he buy a cake, so they had that for dessert.

Sunday, 12 February 2017

Canadian Warp Speed

Ever driven quickly through heavy snow? My husband and I jokingly refer to this as going warp speed, because the effect is similar to how they illustrate entering warp speed on Star Trek.

We're nerds and we make no apologies for that fact.

I'm just settling into my hotel in Ottawa right now, having washed off the road after a very long drive. According to Google, the drive should take almost exactly 5 hours from my house to this hotel. I left my house at 1pm. I got here at nearly 10pm.

The weather sucks.

At the moment, I'm just reviewing hospital policies and my orientation guide for the morning. I am very much looking forward to getting started on my first visiting elective, though I am quite nervous. This is definitely a program I'd rank very highly, given the opportunity, but I know sometimes Mac students have a bit of a reputation of being less prepared than other clerks. It's something I've only really heard rumoured, and seen on the Internet, but I can't help but worry. Not only am I only a year and a half into med school, instead of 3+ the way other clerks on visiting elective would be, I only have one core under my belt at this point. I'm still learning the ropes as a clerk.

But I just have to roll with it. I think I'm very strong material-wise for this specialty, but it's the ins and outs of being a clerk that I'm still navigating. Learning exactly what is acceptable for me to do on my own, what residents and staff expect me to take initiative on, how much I'm allowed to do paperwork-wise before having something checked or signed off ahead of the next step. I know some of this is going to vary service to service and place to place, but I don't even really have a range of what's normal at my home school yet.

I generally prefer to lean towards 'check more/don't assume too much' but I know that can annoy residents and/or staff. I don't ever want to overstep, but at the same time I don't want to create more work than a clerk should.

It's a bit of a balance, and one I'm still working hard to find.

Still, we'll see how things go tomorrow!