Dis the season to be crying.

What is it about me and bad outcomes right before christmas time?

Three years ago, as a 4th year medical student in Toronto, I was part of a vascular surgery team that lost a patient on the operating table right before the joyous holiday season. The family was devastated. The surgeon, who looked so unflappable just hours before, looked so distraught I wondered if he could get over it dispite all his experience. I, naturally, wondered perpetually whether my involvement had any intricate ties to the bad outcome.

Last year, I was again on a medial team that had to deal with the tragic passing of a 1-day old newborn. It took me probably months to stop questioning every involvement I had with that case and I tried to learn from what lessons I developed from that experience to this day. That family, however, I'm sure, would be devastated for years to come.

Then yesterday, again as we stepped into the month of December, I was again intimately involved with the sudden passing of who would have been a "previously healthy female" patient. She crashed right in our emerg, and a 30-minute code couldn't bring her back. The exact cause was still uncertain, but could well have been an aortic dissection which has the potential to kill rapidly. I was the resident on the case. I don't know if I couldn't have done anything differently to prevent her death. I will probably never know. The family may even refuse an autopsy. Nothing will bring her back, however.

I don't think I am a bad doctor. I try my best with every patient and try not to ever miss anything, although that is becoming increasingly difficult as I find myself struggling with being thorough, being thoughtful, and being time-efficient. I know I did not rush yesterday. I felt I mentally covered all angles. I could always have done better on my assessment and management. That always ring true with every single bad outcome you evaluate. There was always something more I should have, could have, would have done.

Nothing could ease how terrible I felt when I had to walk into the room full of shocked family and relatives and reharsh the events that led to their loved one's surprised passing. Most of them were too shocked for questions. I would have been too shocked to answer them.

Yet another family is ruined this christmas. I don't know if other trainees are involved with bad outcomes as much as I seem to have been. Or maybe I just talk about them more. I didn't cry this time around. I felt empty inside. The sad thing was this had happened quite early on my shift. I still had hours of emerg medicine to do. I took a washroom break, shooked off my nerves, and picked up the next chart. Thank goodness it wasn't another chest pain case. I couldn't handle two in a row.

After I came home, I logged on facebook, and saw postings from my friends about their otherwise "normal" days. I thought to myself. It would be nice if having a 'bad day at work' doesn't mean someone had just died on your watch. It would be nice to not have to worry about whether your next day could be 'another bad day'. It would be nice to just go, do your thing, and come home, and that any potential imperfections do not cost lives.

But then that's all about being a doctor, I guess.

With great power comes great responsibilities. Yeah I quote from Spiderman. But it's simple enough and it's true.

The Elephant In the Room

Hey look, there's the big elephant!

Oh yeah, I've seen it lurking around for some time now.

Great, yeah I find it quite annoying.

Turning chaos into something...

Another Thursday afternoon. Another battle.

I'm really not taking a liking to my new clinic...

It's chaotic. Period. My preceptor is chaotic. The setting is chaotic. The files are chaotic. The patients....

Well I guess the patients are always right.

... hardly...

Immediately after I showed up at the clinic, before I even put down my bag and my coat, Boss went, "oh, you're here. I didn't know you were coming. Here, see Eric over there".

... did I walked into an Emerg? Although it really felt that way.

And then of course the first patient was classic.

42 yo. Diabetic. Upper respiratory tract infection. Likely viral. Too late for Tamiflu. But not doing so well. Thought I would do a CXR to make sure no secondary infection.

"You want me to do an X-Ray??? I'm too tired to go!! Can't go today!!"

Ok. Do it tomorrow then. Go home and rest.

"What? There's nothing you can do for me now? I'm so ill!!"

No. It's viral. Go home and rest. Do the xray and if it's positive we'll talk. See me again in a few days to see how you're doing.

"Why did I come all the way here today? You can't do anything for me!!"

Great way to start the afternoon. Next time I'll remember the magic pill that everyone wants. Everyone just wants a quick fix.

Just another day in the battle field. Actually, it's a good training ground.

Patients come in all shapes and sizes.

They have all kinds of expectations and demands.

Some realistic. Some unreasonable.

But they all have to be met.

The trick in family medicine, and they don't teach you this in textbooks, is to somehow, in what little time you have, find a way to satisfy all your patients.

Make all of them leave happy. Leave satisfied. That it was worth it for them to have made the trip here, waited for you, and wasted almost an entire day for your opinion.

I have to make that opinion worthwhile, no matter how trivial it seems.

That is what I have to learn now.

Integrity

I remember when we first interviewed for medical school, one classic example of the type of questions you get asked during the interviews was this:

"Please define integrity."

What a bunch of crap. I thought at the time. How pretentious a question.

But today, while being bombarded by patients at my first day at my new family medicine preceptor's office, I understood why that question was asked.

You need integrity to do your job as a doctor.

After months at the educational-focused Oak Street Family Medicine clinic and two months in the leisurely Salmon Arm medical clinic, I started the last-leg of my family practice residency training at a busy semi-Asian high paced family practice office. Compared to what I had seen before, it was a gong-show.

Between an anxious Chinese Mom who kept asking about her son's cough and fever, two elderly chinese folks who kept telling me their histories into separate ears simultaneously, an over-zealous patient who kept asking me about every one of his blood test numbers, and a whole host of unhappy patients who had waited too long, felt too neglected, grumpy about the weather, and generally unimpressed about seeing a resident and not their beloved doctor, I had no time to think. Moreover, I knew nothing about each patient, the chart was all hand-written in what looked like foreign languages, and we were at least an hour behind.

I rushed. I omitted things. I cut corners to catch up.

And then I remembered, I cannot do this. I am their doctor today. They waited long but they endured to see a doctor. I must do due diligence to each one even if it means making others wait a little longer. I cannot be pressured by patients, by parents, by anyone to do any less of a job than I would in a more perfect setting. Yes it isn't ideal, but the medical care that they should get here should be no different than any other clinic I had been in.

Integrity is to hold your own in the presence of immense external or environmental pressure to do otherwise.

Today I finally learned it.

Uploaded: Glacier Series on newleaf gallery

Finally uploaded some pictures of my Glacier Series onto Newleaf Gallery. I chose 10 selected pics from our Alaska Highway roadtrip. I really enjoyed these ones. Even staring at them right now reminded me how breath-taking these glaciers were. I wanted to do a set of pictures that could reveal up close and personal how timeless these ice sheets seem to be. Hope you enjoy them!

Newleaf Gallery (or use the link at the R sided menu)

http://newleaf.my-expressions.com/

Saturday morning.

6:45 am. Saturday Morning.

Actually woke up about two hours earlier. Just had a baby.

Instead of filing back home to sleep I decided it was a nicer moment to enjoy a McDonald's breakfast by the pier.

Afterwards I managed to spend the rest of the morning in bed with my book.

By myself again in a great big house.

Roommate moved out, landlord left town, parents visited and left, I moved all my stuff from my basement room into one of the upper-stories bedroom. I moved the desk up here as well, making it very home-like. The soft-toned walls, the nice sheets and comforter, the tight but functional space, the brighter windows and lighting. I'm amazing how conducive I am to my environment. From migrating up from basement to cozy bedroom, I feel more liberated, more inspired to work and enjoy my time here. It's starting to feel like home. It's a little quiet, being here all by myself. But I like the privacy, I like my isolation, I like my alone-time. 

I've discovered that I like to organize all my stuff in a neatly laid-out display on my corner table. It gives me a sense of tidiness in my otherwise chaotic mind. 

How did I managed to yet again pack so much stuff for my 2 months stay here? I quickly filled the closet. But then again, I have my car to transport all my stuff. I could have taken more. 

Surrounded by hills.

The light rain and on-coming thunder has washed away the ashes from the nearby forest fires. In the sky, the smoke is clearing. 

Three days into my stay here at Salmon Arm, I realized that we are surrounded by mountains. 

It's quite beautiful, actually. All around, low-profile mountains act as guardians around this quiet, private lake-side town. The bay at the edge of the Shuswap lake is quiet, and the water usually still. 

Looking out, the horizon meets more mountains, forming a doorway in the water, preserving the privacy of this intimate community, and reminds me of being in a quiet little fishing village in rural China. 

But in town, the charming, tidy downtown reminds you that you are still at the heart of civilization. The small shops that lined Lakeshore drive carries productions that actually generates an interest from the passerby. The classic movie theatre carries small-town flare with hollywood-made entertainment. Tonight, I enjoyed a quiet meal of Beef Don and Salmon Roll in a neat Japanese restaurant with Vancouver-quality dishes. 

And best of all, coming here with my car makes all the difference between feeling like stranded in a foreign place versus feeling completely at home in a new environment. The car is my sanctuary, my nest. Climbing inside, I am reminded that I am not here alone, but with the luxury of a trusted sidekick that can carry me wherever I want with ease and excitement. 

It's a comforting reminder of a home away from home. My object of familiarity when everything else is new. 

An Epic Roadtrip

"You're crazy," I was told. "It's too rushed"

Insanity. It's too much driving. 

Over 4000 Kms. 9 days. 

From mile 0 of the Alaskan Highway at Dawson Creek, to Fort Nelson, Watson Lake, hit Whitehorse, cross over to Skagway, Alaska, then double back and then down the Cassiar Highway to Smithers, then cross the Yellowhead past Prince George and hit the straight-away home down Highway 1 back to Vancouver. 

So that I can have one day of break, before I hit the 5-hour drive to Salmon Arm for my next 2 months for another rural family medicine rotation. 

Yes it's tight. But with two glorious parents who were willing to drive all the way up from Vancouver to Dawson Creek to meet me for this insane roadtrip, with our lovely little Nissan that also did the trans-Canada trip, I felt that we could do it. 

For we had always wanted to drive to Alaska. This is the best opportunity. 

I had it all figured out. On average we would drive about 6 hours a day. That's enough time left for side detours, photo stops, lunches, and a few stops to check out the scenes. It works for people like us who seldom like to stay at one spot for too long anyways. Plus we just love the open road, the leisurely freeway cruise, the soaking-in of the road-trip music and the ever passing sceneries before our eyes. All while we act silly in our car all day. 

We just love to go places, covering the more ground the better. 

It's gonna be neat. I can't wait until we hit the mountains. It's gonna be quite a journey. 

Bongy and Bernice, wish you guys were here with us. 

Learning to fly an airplane

Ever since medical school, I've always felt skeptical at how anesthesiologists like to compare their work to that of a pilot flying a commercial airliner. How arrogant, I thought. Airline pilots are much cooler people. 

Now I am starting to see the reasoning for their altered egos. 

Doing anesthesia IS very much like flying an airplane, and I think that's why it's starting to really appeal to me. You have to be very anal retentive, and quite organized and thorough in your approach. Before each case, you go through a mental checklist with your pre-op assessment to build a detailed operative plan, much like a flight plan before each takeoff. You consider all variables and options and balance all risks and benefits, all the while trying to put your freaked out patient at ease. 

Then you enter your work station, the OR. You again follow a practiced routine in checking all your monitors and equipments. Your work space is ladened with all sorts of bells and whistles, and you can be as complete as you need to be in monitoring all parameters of the patient during the operation. In certain types of cases such as ears-nose-throat surgeries, you lose access to the patient and the airway once the case begins. You are then depended on your monitoring as you "fly by instrumentation" to ensure a safe and peaceful journey to your patient in order to live up to the promise that you have given them before the case began. 

Once the case is on the way, you essentially keep an eye on the patient by a series of second-hand parameters. Everything is a surrogate, but with enough experience you build a good understanding of what is happening to the patient at each point in time with those surrogates. The respiratory rate went up, oh he must be in pain, let me give him a little more pain control. He's fighting the ventilator, oh he must he "light", let me top up his anesthetic. The goal of the exercise is to do everything preemptively. For you want to foresee what might happen and prevent it before it ever does, much like an experienced pilot foreseeing any wind turbulence and change altitude to ensure a steady and smooth journey. 

Finally, when all is said and done, you have the landing, or emergence from anesthesia. Careful planning make for a smooth landing, and proper timing of your reversal agents and stopping of anesthetic agents make for a smooth dreamy wake from surgery as if the patient had just taken an afternoon nap. When things are done beautifully, the result is a very rewarding experience for both the patient and the anesthetist. With modern medicine, it is amazing what you can do to a patient under the right anesthetic without them experiencing a frightful and painful experience such as surgery. 

Anesthesia really is quite a neat specialty. With powerful drugs and effective monitors, you can pretty much control every facets of your patient's physiology. But more rewarding, however, is that you are in the field of relieving suffering, whether that suffering is physical pain or emotional fear. From the very onset when you go and greet a patient, you are exerting your therapeutic relationship in an attempt to calm and reassure them from all the fears and worries they have of their surgery. Show a sense of confidence, and the patients will feel that they're in good hands. Toss in some humor, and they might relax a little bit more. Hold their hands, and they will feel that they are cared for. All this, before you have even given them a single drop of medicine, and they are already ready to begin. 

ATV on Crack.

Yesterday, my friend Ian, a student up here on an elective, took me Off-Roading in his 1999 Jeep YJ. I've never done off-roading before, and wasn't even sure what it would involve. All he told me before hand was, "wear some shitty clothes, because you might get muddy". In a CAR? I wondered. But good thing I listened. 

It was incredible. I had never really witnessed what a vehicle can do when you push it to the rocky limits. It really made me respect these Jeeps, and not your average SUV at that. These machines are like ATV on Crack, with roll-bars and all. The experience gave me a whole new appreciation on 4-wheel-drive (for quite often our trip depended on just two or sometimes just one wheel to keep us going). There's quite a lot of technical skills it takes to do off-roading safely. You don't just go recklessly into the woods and tear up the trail. But it was amazing. He even let me drive his jeep for a few practice trails. I've always wanted to drive a Jeep. Working the long stick of this heavy-duty machinery was just a blast. 

Ian preparing his blue beast for the trip. 

Entering into the trails. We choose trials that were meant for ATVs in the summer or snowmobiles in the winter. They are like obstacle courses, basically, with hills and poddles and mud and all. We went about 30 minutes south of Dawson Creek into the Bear Mountain and Radar Lake area. 

Me behind the wheel of his blue beast. 

The mighty Jeep tackling another muddy route. 

Ian and I scouting out this mud pile to find the best seam to take. 

More surveying the area before keeping on. 

This was probably the riskiest area. Down a steep slope and onto a bridge that was blocked, so we had to go on the side and into the stream where we almost got stuck. 

Our car richly embedded into the stream and the front bumper catching on the log. We successfully backed the car up and got enough of an angle to craw up the log and get out of trouble. 

Success!

The muddy ride. I even got mud in my HAIR at the end of the trip. That's how much mud we kicked up. 

Ian and I with our proud moments after we finished the trip. 

Dawson Creek Rodeo and Fall Fair

Every year, Dawson Creek holds an annual "Fall Fair" (even though it's in the summer), rich with Rodeos, Chuckwagon races, rides, fair games, and an abundance of cowboys and cowgirls and horses. It's quite a bit thing here, and plenty from nearby towns come by for a piece of the action. In the evening, the fireworks kick start a night of good times and the vibrant beer gardens keeps the fun rolling. It was quite a treat to be here at the right time to be a part of this crazy event.