Declaration of Death: First Day on Call in Palliative Care

*Disclaimer - all identifiable characteristics have been changed*
*Trigger warning - description of examining a dead person and what happens to a body after death*


My first call. Pager? Check. Stethoscope? Check. White coat? Check. Granola bar? Check. Confidence? Well you fake it till you make it so "check"

At a gentle walk, I moved through the corridor of the obstetrical ward. My white coat trailing in the wind like sails of boats venturing through uncharted waters. The distant newborn cries echoed until I crossed into silence. I had made it to the Palliative Care ward. Ironic to have life and death in the same hallway, but in the wake of construction that's how it worked out.

I went to the nursing station, introduced myself and asked if there were any unstable patients requiring my attention. The head nurse replied, " Oh well thank goodness you are here, could you please declare a death? He's been dead for two hours now, the family is waiting for you."

I gingerly stepped into the room with the nurse and introduced myself to the family. I offered my condolences and support, and then explained the necessary steps for the declaration of death. They were offered the opportunity to stay for the exam, but they chose to leave.

There are three criteria used to declare someone dead, you must have at least two of them:
1) Pupils dilated and non reactive to light
2) No palpable central pulse (such as the carotid pulse in the neck)
3) No respiratory effort or breath sounds for 1 minute

Thank goodness I had the teaching on this the day before. We were also taught that despite meeting the criteria for death, the body can remain in many ways "alive" for hours after. From muscle twitches to sounds of digestion, these and many more processes may occur as the various parts of the body break down. Death is not instantaneous despite turning peoples' world upside down in an instant.

Alone in the room, grateful for the nurse at my side, I began to examine a man whom I had cared for for days. Whose labored breathing I helped to calm, whose grimaces of pain I helped to relieve, whose spirit in whatever sense you believe it was no longer there. I approached the patient's face and delicately opened his eyes. Criteria 1 was met. I place my hand gently along his neck, no pulse found. I listened with my stethoscope and watched for one whole minute. Criteria 3 was met.

I went out to inform the family and assist them with funeral arrangements. They expressed their gratitude for everything we had done and left a box of chocolates at the nursing station as a token of their appreciation. I carried on with my day as best as I could but I felt distracted. The events of the morning still lingered like hot coal in a christmas fireplace. I can't help but reflect on the way I see life and death now. It's not static, it's not black and white, it is just grey zones. One can be alive and not living. One can be dying but so full of life. One can be dead to those around them for decades and others can live on through those who loved them.

At the end of my shift, I walked through the same familiar hallway - the gentle wails of new life piercing through sadness of losing my first patient. As I stepped out into the afternoon sun, I sighed deeply. I made it.

A New Beginning

The gentle clamoring  of clammy hands clinging and flinging papers onto the floor next to my filing cabinet. I know it's in here somewhere. Brushing the beads of sweat out of my eyes, I continue my pursuit - the tiny white fan my only solace in the June summer heat. I continue to dig until I grasp the familiar tubular structure, folded upon itself just as I had left it: my stethoscope. Like a long lost friend, holding it felt exactly the same and yet different.

The last few months have been a whirlwind of activity; from the seemingly never-ending travel for residency interviews to the intense studying for the our licensing exams to an equally intense period of rest and untamed hedonism. To go from complete freedom to the impending rigid structure of residency is most certainly a shock to the system. From ID cards being made to sifting through mountains of emails, and meandering through a forest of new colleagues is both exciting and overwhelming. All the while I'm still trying to reconcile that my name appears on a diploma that says M.D.C.M. Doctor of Medicine, Master of Surgery. The title still feels foreign despite four years of work towards it.

As I embark on this new chapter in my medical training, I can't help but reflect on everything and everyone who has led me to where I am today. Growth paving the way for new growth. Here's to a new beginning, a new blossoming from old roots.

Changing the Culture of Medicine

We are months away from graduating medical school and starting residency. It doesn't feel real. In a delirious haze we have our heads buried in books and computers, our thoughts consumed by the upcoming exams. But today I was forced to reflect on how far we've come both as people and as physicians. I asked the question what can we do as individuals to change the culture of medicine? The reply was role-modeling. "Be the change you want to see".

Be kind in situations when you wished someone would have been kind to you. Show vulnerability to those in vulnerable positions so that they know they are not alone. Confront those whom you thought were your enemies, when in fact they are just as caring and loving as you. Friendship can blossom once you both remove the same disfiguring stress you both carry. Remove it together. Be present in times when you have felt abandoned. And lastly, speak up when there is something that needs to be said for your voice will carry in a sea of fearful silence. 

Just Let It Go

Tonight marks the final night before our residency selection lists become final. Tonight is the last night of agonizing over which program I want most, which city would I be happiest in, or which path would afford me the greatest opportunity in my chosen field.

I spent the night surrounded by friends at my medical school's Christian association at their first event in the new year. Faith is something that I have struggled with my entire life. Whether it be faith in myself, faith in others, or faith in the divine, I have tremendous difficulty in sustaining faith of any kind. As we went around and shared our experiences with residency applications, I was envious of my colleagues' sense of peace and the complete acceptance of the unknown.

My interview period was marked by anything but acceptance. Traveling from city to city nearly every other day, I felt increasingly lost in the vortex of choices, decisions, and opportunities. With each passing interview came a new challenge, further clouding my ability to know what I truly wanted. Instead of letting my horse run free, I gripped the reins even tighter. I must work harder, I thought, then I will know what I want. I spent hours calling people, making spreadsheets, and reading program descriptions.

Tonight, I felt the familiar call of exhaustion, and I had looked forward to an evening of exercise and relaxation. But that's not how plans work. By a series of seemingly random events, I got out of class late and ended up at this event instead. As I listened to the wise words of those around me, I had an epiphany. Be it the word of God himself, coincidence, or some strange combination, I felt a sense of peace rush over me for the first time in months. Like slipping your head underwater in the most perfect bath, all sounds muffled and all worries subdued. It's time to let go.

I have no idea what my future holds, and part of me still wants to bury my head in the dirt like a frightened ostrich. All I know is that no matter what happens, the outcome I get will be the right one. Now it is time to sit back, let the algorithm and all upstream forces work their magic, and finally relinquish control. 

What Burnout Looks Like

"Take care of yourself, you don't want to burn out." A phrase I've heard many times again. That could never happen to me I thought. The cynicism, the apathy, the loss of compassion. I always believed I had an endless supply of compassion, that it was one of my strengths. But no matter how resilient you are, everyone is at risk. Everyone has a breaking point.

It can start out so subtle, sneaking up like gas prices until one day you just can't. It starts out as just feeling "more tired" than usual, despite sleeping at least seven hours. Then, you slowly stop doing things. You justify it as "I'll treat myself to take out" when in reality you've exhausted the mental reserve required to make dinner.  Scotch tape atop the cracks, trying to keep them from spreading. You stop studying, telling yourself you've done enough work for the day and deserve a break. Next, you find yourself overly annoyed waiting in line at the grocery, I mean how long does it take someone to get out their debit card really. You justify it as "oh what annoying people, how are they everywhere", while behind that your subconscious is screaming the mantra of "I can't do this anymore, I can't take anymore".  You stop going to the gym and spending time with friends, justifying it as "I  need me time" which although true, you don't want to even give people a chance to figure out that something is wrong. You don't even want to acknowledge the downward spiral you are on.

Sleep begins to intrude into wakefulness and wakefulness intrudes into sleep. You spend the entire day trying to stay awake, coffee after coffee, and lie in bed awake at night trying to silence your forever active brain. Stifle its cries for help. You find your eyes filling up with tears randomly throughout the day - quiet rides in the elevator, making your coffee in the cafeteria. You tell yourself it's from that difficult patient interaction you had the other day, but you know it's not.

Burnout looks like smiling faces, and kindness, all the while on the inside you are rolling your eyes as the 6th patient that enters your office cannot answer basic questions like "what brought you here today?", "what medications are you taking?",  and "when did the trouble start?". You begin to wonder what you could possibly do for the 3rd patient in a row who denies having diabetes and refuses to take their medication, all the while begging you to fix their diabetic neuropathy. You begin to see your patients as inconveniences, frustrations, numbers, morons. Morons? I knew something had snapped inside me the moment that crossed my mind. Never in 4 years have I ever thought of my patients as anything less than remarkable. This is not what first year me would have wanted. But frantic residency applications on top of 10-12 hour shifts, and studying...you lose yourself. Day in day out there is always someone reminding you that you may not match.

I spent the weekend in my pajamas cleaning out all my old clothes, things I didn't use anymore, trying to desperately use my physical environment as a way of grounding my mental head space. I took the time to gently trim the leaves and water my many spider plants. They aren't mad I forgot to water them, they love me just as I am.

Burnout looks different for everyone. The only commonality is you often don't know it until it's too late. Do not ignore the red flags, the warnings, the changes you see in yourself. Catch it early, because it is a nasty hole to fall into, and even more difficult to climb out. 

Residency Matching and Panic Attacking

12:00 PM The platform is now open, you may begin your application.

The email caught me dead in my tracks, so much so that I nearly missed the elevator I was waiting for. Can it really be? Have three years really flown by in the blink of an eye and soon I will be a resident?

The last few years were replete with memories from touching patient encounters, exasperation from the many obstacles and shortcomings rampant in our healthcare system, and a better understanding of who I am as a person. My white coat no longer feels like a Halloween costume; it is now a tattered garb of pen stains, food stains from many meals in the middle of the night, and pockets stretched and misshapen from stuffing them full of medical equipment. The latest batch of clerks have been dispatched to the wards, looking as overwhelmed and perplexed as I did a little over a year ago.

In a few months I will no longer be a medical student, I will be a resident. I will be able to prescribe. This future reality is both terrifying and exhilarating; I often alternate back and forth between these two emotions whenever my mind wanders to the topic. Now faced with the immediate stress of hunting down reference letters, gathering documents, selecting schools and programs, it feels as though there is no time to process this new impending chapter in my life. Once the applications are complete, my focus will then shift towards visiting schools and interviewing for positions, and then subsequently studying for my licensing exam.

My mind can only begin to process how far I've come and how much further I have yet to go. But for now I take it one day at time. On patient at a time. One document at a time. One breath at a time. 

My First Week in Rural Medicine

I was given the choice of doing a rural family medicine rotation anywhere in the world. In the end, I decided to go to a Cree community in Northern Quebec. "What do you see ?" My friends and family ask. Let me tell you.

(View from the plane)

I see a community. A community of loving caring people with a beautiful set of traditions that I can only aspire to. I see an obesity epidemic caused not by laziness, nor by lack of self control but by poverty and an environment that does not make the right lifestyle choices an easy option.

I see nature; the great river, the towering tall trees in the distance that seem unwavered by the change in season. I hear the musical songs and chirps of birds, some of which are very familiar and others that I am hearing for the very first time. I see dogs that look like people's pets that have no home and roam these gravel streets alone.

I see broken glass and bottle caps and candy bar wrappers - the litter of self-medication against trauma and injustice. I see the concerned look from a mother to her child, who lies there feverishly half asleep and coughing. I see a another pregnant woman for her 28 week visit. It is her 5th child, she's only 20. I see the elderly man, whose lips are blackened with the charcoal that saved his life from bottles of pills ingested in yet another suicide attempt to block the pain and loss.

I see smiles, I see laughter. I see families whizzing by on 4x4s and pick up trucks, honking loudly in celebration of weddings and hockey games. I see children playing in the streets, riding their bikes in groups. They own the place. Some young girls run up to me, curious to know where I'm from and what I am doing here. They proudly show me their blisters from a long day of playing and they ask for band-aids. I come back a few minutes later with band-aids and the group of children has doubled. They wear their band-aids like badges and excitedly show me the slime that they bought at the corner store.

For the first time in my life, I'm a minority. Everyone around me looks different from me, speaks a different language. I can feel myself being watched everywhere I go. And yet I feel safe, except at night. I'm not supposed to go out walking alone at night, a driver is to bring me home.

No matter how much I've been taught in textbooks and in lectures, being here brings everything to life. I have so much to learn in a few short weeks and so little time to soak it in.