The Space Between

“The seeker embarks on a journey to find what he wants and discovers, along the way, what he needs.” 

― Wally Lamb, The Hour I First Believed

I learnt a lot of things while I was a paediatric registrar. I learnt how to interpret paediatric ECG’s (mostly). How to ask the right questions about a headache to know if it warrants a CT scan. I eventually figured out the physiology of left-to-right shunts and diabetic ketoacidosis. I experienced first hand how you don’t mess around with Staph septicaemia or a neonate with persistent pulmonary hypertension. I learnt how to pace myself on 30-hour shifts, to avoid the ward during visiting hours and that drips are never done quickly just before lunch.

Fortunately, registrar time isn’t forever, and so for the last 9 months I have been floating between unemployment and temporary locums. Tomorrow I start a 2-year fellowship in Paediatric ICU.

This is as a reflection on what I learned (without being taught) in the space between.  

Firstly, I rediscovered quiet.

Quiet hours at home with my books and my thoughts.

Quiet days of being the only doctor in a practice, getting through the patients in my own time, making my own decisions.

Quiet adventures on the road between Bethlehem and Qwa-qwa, taking the long way home through Golden Gate and stopping to get coffee in Clarens.

Ghostly quiet 3am drives on empty roads to an emergency caesarean section.

Quiet, un-dramatic, low-maintenance friendships, that were strong and solid foundations when I leapt into uncertainty.

Secondly, I experienced working in extremes.

I went back to doing things that I haven’t done since medical school. Weighing and measuring, checking temperatures, giving immunisations and vitamin A drops. I went to plenty of elective caesars with APGARS of 10 and 11. I saw a lot of rashes and runny-noses, coughs and colic.

The simplicity of a well baby check is surprisingly refreshing. Ticking the boxes of growth and development and having a chance to chat to a parent about how parenting is going. It’s not something I really did in my training. Being part of the process that makes a sick child well is an intensely rewarding aspect of my job. I realised however, in these moments, the sparkle (maybe tears of relief) that comes with telling a tired mom that she’s doing a great job, is equally rewarding.

In other moments, I morphed into the Paediatric Consultant. Instead of writing the prescription and doing the bloods I now checked them. Instead of making the phone call to ask for advice I know dispensed it. I had to learn how to step out of the ‘hands-on’ role – a comfort zone where you have almost complete control – and let the system function. This was possibly my biggest learning curve and a skill that definitely did not come naturally.  As paediatricians especially, we rely heavily on what our own eyes see and hands feel when we walk into a room with a sick patient. There are subtleties in the way a baby is breathing that you unfortunately only learn through experience, which can either reassure you or warn you about an imminent respiratory arrest. The hardest part about being responsible for children you are called about is distinguishing between a junior who has made the right assessment and is in control and one who has completely missed the septic shock and needs gentle but firm redirecting. 

In the space between these two roles I have realised that there is still so much to learn. I didn’t finish registrar time thinking that I knew everything, but I had a sense that I had summited a mountain. Now that I have caught my breath and rested from that intense pace with which you work and learn at in your junior doctor years – I can appreciate that I am only at the start of this expedition. There will always be new concepts to grasp academically. There are lessons to be learnt in building relationships with not just the children but also their parents. There are lessons in knowing what you, your facility and your staff are capable of doing. There are lessons in digging deeper to fight another day but also in accepting defeat graciously. There are lessons to be learned in training the juniors that work for you – building them up without breaking them, yet fostering resilient spirits that can be advocates for themselves as well as their patients.

And then there is the constant challenge to learn how to not be consumed in all of this learning.

To sustain and nurture relationships outside of work.

To have skills that are not all about vascular access and intubations.

To have time in the fresh air.

To stay hopeful.

To be at once, both the master and the apprentice.

Never say Never

I can’t remember exactly when or where but I have definitely thought it a few times. I may have even spoken the fatal words once, if not twice.  

“I will never work in the Free State Province!”

But yes, here we are.

Despite having seventeen years to think about it, I didn’t really have a game plan when I finished specialising. Then quite unexpectedly, I was offered the opportunity to come and do some locum work up here and it seemed like a breath of fresh air after four grey years of registrar time. The change that would be as good as a holiday. A great opportunity to try something completely different, stretch my wings a bit and shake up my comfort zone. Incidentally I had also planned to take a few weeks off and this job coincided perfectly with when my savings would run out. Was I aware it was in the Free State? – Yes. Was I aware it was in the middle of winter and likely to be 10 degrees colder than what I was used to? – Yes. It really was only after I crossed the Orange River that it dawned on me that this might be a lot harder than it looked.

I don’t want this blog to be about what’s been tough about the first 3 weeks. I don’t want to rehash the fact that there often aren’t the basics like running water at some of the hospitals, let alone luxuries like ventilators, x-rays and doctors. It’s been tough and eye-opening and hopefully doesn’t stop shocking me regularly (because the danger of desensitisation is that it facilitates this failure).

I’d rather tell you about things that made me smile, and that make me love the work, the profession and the people. I want to tell you about lovely patients that I encountered this week.

The first was a shy, sweet, 9-year-old girl whose mom brought her to the practice with the long-standing complaints of a poor appetite and not being able to hear very well.

They spoke enough English to get through the consultation and the patient could actually answer most of the questions herself. (Always such a win in paediatrics, which often more closely resembles being a vet examining combative baby tigers). After chatting a bit about the problems I got her up on the bed to examine her. She was wearing a pink dress with a beautiful winter white jersey and wool-lined ankle-high boots, exposing her skinny little legs.

“Nana – aren’t you cold?” I asked her.

“Yes” she said.

“Then why did you wear such a pretty dress?”

“I didn’t want to,” she replied. “My granny made me!”

The second was a little boy, about 3.

A pink-cheek, chubby face, blonde haired chap who came for the winter special – cough, blocked nose, vomiting.

He didn’t look too sick and dived into the toy stash unashamedly while I got the story from his mom. He also was very quick to spot the sweet jar on the desk.

“Tannie, kan ek ‘n sweetie kry asseblief?” (Aunty, can I have a sweet please?)

I let him pick a sucker out of the jar.

He carried on playing with the toys, I examined him and reassured his mom that his symptoms were all viral and he would be back to his normal self in a few days.

While I was finishing up notes and a script, he saunters up to the desk, sucker in his mouth and casually asks “Tannie, kan ek nog ‘n sweetie kry?” (Aunty, can I have another sweety?)

In an effort to nip this request in the bud quickly I shook my head.

“Nee, sweeties is eintlik net vir kinder wat inspuitings kry.” (No, sweets are actually only for children who get injections).

I’m assuming this will a) dissuade him from more sugar by the possibility of what all children fear the most at a doctor, and b) make him aware that he actually got a sweet for free today.

He is standing across from me with his rosy cheeks and little head just sticking out above the desk. Sucker in his mouth he tilts his head to one side thoughtfully, then removes the sucker and asks a bit more calculatedly…

“Is dit ‘n baie groot inspuiting?” (Is it a very big injection?)

I never regret choosing to work with children or combative baby tigers.

* “Tannie” which directly translates to English as Aunty is a respectful term used to address female elders.

This is not a medical post - this is me trying to fix me.

Dear Friend

I think that’s what we were for a brief moment – like a supernova, or a firework display – something brilliant and breathtaking and so distinct from the sepia tones of every other day. Friends.

I’m not sure what we are now. Where there was colour and wonder and excitement there is now something grey and blurry, indistinct and uncomfortable.

For the longest time I have been turning our relationship over in my hands, like a rubix cube – trying to figure out how to make the colours line up, but the more I try to create order the more I cause chaos.

I think that is what hurts me first – I am trying. I, alone, am investing. That has always been a poor prognostic factor.

With the hindsight of days, actually probably more like months, I am forced to accept that the first problem was that I didn’t see you as my equal – I saw you as better than me. More beautiful, more intelligent, more disciplined, more adventurous. I saw pieces of myself in you and it gave me hope for me. I put you on a bit of a pedestal, set you apart as someone to aspire to and when one day you approached (or maybe it was me) with an offer of friendship I was so flattered and honoured I let you into my heart without doing my usual safety checks.

We had some great moments. We had some great laughs. We dragged each other through tough days. We talked sometimes too late.

And then one day it stopped.

A wall went up that I feel like I ran full-speed straight into. I was unprepared for the puff of smoke that you disappeared into. It left me winded, and blinded, coughing and spluttering and crying frantic tears.

Of all the possible options, the most likely explanation seemed to be that you had figured out you were too good for me. Whatever that brief fusion of stories had been it was over.

I cannot figure out how to get back to you. I have asked gently, I have groveled pathetically. The wall stays.

And so I find myself having to choose between the possibility that the problem is you, and the fault is beyond my locus of control, or that the problem is me and I must mourn my deficit and accept that I cannot be more than what I am.

They are both impossible situations – each with it’s own mix of frustration and despair.

More than once now, I have tried to overcome this in my heart, forgive you of wrongs I’m not sure you’re even aware that you committed and convince myself to fight for what could be one of those magical-movie-inspiring friendships. But you have retreated into a shell that I cannot force you to come out of. I feel like a lion cub that tries to play with a tortoise and while my intentions are not harmful they seem only to be frightening you and pushing you further away.  Instead of a friend a weed of self-doubt grows.

  

I cannot continue. My heart will not survive.

So this is goodbye.

I’m setting you free.

Always I will wonder about what we could have been.

Always I will miss you.

Exam Crazy

The home stretch…

The list is out. The schedule is finalised –the date, the time, the examiners.

I’m about 90% fear and 10% loathing.

I don’t know if exams get worse as you get older, because you are older or because they become more significant and so weigh a little bit heavier than they did when you were at school. Even in my last year of medical school I don’t remember feeling the pressure quite this bad.

I do know that the first round, a little over 6 weeks ago, was a very unpleasant experience. I also know that for all intensive purposes, the anonymity of the written papers was probably far less nerve wrecking than the potential train wreck that a face-to-face-up-close-and-personal clinical afternoon poses. This is what drives the fear. The rest of this post explains the loathing.

The preceding weeks before the written papers were like sharing my body with a mad person – a fully blown, off her rocker, bat-shit crazy lunatic. Trapped with this person inside the four walls of my little house; surrounded by mountains of past papers and journals and coffee cups in various stages of decomposition; the only connection to the outside world being the sunny, smiley, love-my-life-it’s-awesome social media selfies of people who made better life choices.

The first thing I lost was the ability to sleep – which is great in the one sense because you stop falling asleep on the couch after supper as adrenaline keeps your brain in 5^th gear after spending 8 – 10 hours on your feet at work. The downside is that when you’re on your feet for 8 – 10 hours every day and then trying to understand the latest PMTCT* guidelines or the difference between Schwachman Diamond syndrome and Diamond Blackfan syndrome, you generally need more than 3 or 4 hours of sleep.

Mental Health red flag #1.

The second thing to go was my appetite (something that I’ve only lost once before due to pure terror in my 6^th year orthopaedics rotation), and with that any incentive at all to produce healthy meals for yourself. It is very much a first world problem that Woolworths ready made meals can eventually become quite nauseating (although I suspect they are not as healthy as their attractive packaging would lead you to believe anyway).  And so I found myself living on a diet of Pronutro (which the box claims, contains all the nutrients and minerals of a 3 course breakfast in 1 serving), Steristumpies and the occasional charity meal of a friend.

Mental Health Red Flag #2.

And in between all of this I had to stop seeing people. My only human interactions were with people at work, and the sushi delivery guy.

There were ‘strong arm’ and ‘thumbs up’ emogi sentiments.  

My parents called – that’s what parents do.

But I mostly spent hours by myself, pep talking myself into one more chapter, one more article.  When I did venture out, for walks or church or ‘Four-and-twenty’ coffee, I felt strangely detached from everyone around me, as if the world wasn’t even really aware that I was there. My only contribution to conversation would involve immunization schedules and seizure syndromes in infancy – because that’s exactly what people at church want to talk about after their awesome weekends mountain climbing, beaching and wine farming. I was a complete hit.

Mental Health Red Flag #3.

I become a shadow of myself – a very knowledgeable shadow, capable of naming obscure x-linked dominant genetic conditions and the differential diagnosis of an isolated splenomegaly. But the substance of me was replaced with some wispy, fidgety, teary, self conscious, self-doubting, adrenaline-wired zombie.

And then, the day after – I found myself catapulted back into the sunshine, and the universe was shouting that finally everything is back to normal.

It wasn’t really though.

The world actually seemed strangely empty. My mind that had been a hive of worry and acronyms was a cavern of quiet. My phone was quiet.  I had hours of nothing to fill, lists of people I’d been neglecting. Yet as the dust settled I found life had gone on without me. I was a wallflower watching everyone dance, not sure how to have a conversation about something other than what had completely consumed me for a good 3 months. I didn’t really know how to start reintegrating into this #squadgoal society.

I almost wanted to have an exam to study for again – at least I knew how to do that.

THAT’S CRAZY!

The whole thing is crazy!

Why did I sign up for this again?

Like I said, 90% fear and 10% loathing.

Celebrating miracles

“The shadow proves the sunshine”

            Switchfoot.

It’s taken a long time to put these words onto paper. Many times I’ve started writing them and had to stop. But the celebration of this little boy’s first birthday seemed like the most fitting way to share his story.

Some of you already know it; have heard it over cups of tea when it was still fresh and raw and uncertain. The four hours I spent with him changed so much about the way I see the world and people – but not for the worse… for the better. It is my hope that when you read this story you see what I see – not the tragedy, but the miracle.

5:25 am.

The call should have been winding down as the first wash of sunlight began to run across the black night sky.

I was aware of the time because of the colour change I could see through the tiny windows in the paeds room in casualty, and because I had just turned off my alarm that would normally have woken me. Today it was almost two hours behind the casualty officer who had called earlier about some admissions.

I heard the sister call me to “just quickly see if this baby is alright to go upstairs” and turned to see a young man, early twenties maybe, cradling a mass of pink and yellow baby blanket. All I remember about him is the panic in his eyes.

I could only see the baby’s face – big eyes, a soft little cry, dusky pink lips.

“No, he’s fine to go upstairs”.

He was a BBA (born before arrival). This was straightforward labour ward stuff. I had enough to deal with down here.

Still, something turned in my stomach when they had left the room… a nagging feeling that maybe I should have opened the blanket.

“You’re being paranoid,” I distinctly remember thinking.

5:35am

My intern called - for some reason the time on my phone is a clear flash of memory.

“Hey Scotty. What’s up?”

“Linda – I don’t know what is going on here but this kid has a hole in his trachea…”

“A what?”

“A hole… in his trachea…I don’t know…”

“Ok Scotty, where are you?”

“4^th floor.”

“I’m coming.”

In the back of labour ward I found him holding an oxygen mask over the baby’s face, and the obstetrics registrar plugging holes in the neck. The baby was still fighting, kicking his little legs and waving his little arms. There may have been a bit of cry but I really only remember the shrieking of an angry saturation monitor; partly because it was struggling to pick up a nice trace but mostly because when it did the oxygen saturation was 40-something percent (less than 90 is bad).

The air was tense and uneasy. Scotty’s eyes were full of intern distress. I could see the obstetric registrar was desperate to get away.

“Someone’s hurt this baby,” she said.

I took over from Scotty at the airway and counted maybe seven or eight puncture marks on the front and right side of his neck and chest. Some were bleeding, some were bubbling and some were jagged. One or two were clean and elliptical. Flashbacks to forensic medicine in 5^th year - textbook blade marks.

The realization of what I was seeing hit me hard – a physical blow to my stomach that stopped my next breath. For a split second I felt myself pulled back tight, like an elastic band stretched, as if leaving would undo what had been done; and then just as abruptly with the next breath, snapped back to reality.

So I started with what I knew.

Airway. Breathing. Circulation.

Everything around me became irrelevant. All I registered for the next hour was the little person in front of me, Scotty on my right and the obstetrics registrar on my left.

We decompressed a tension pneumothorax but even so the oxygen saturation only climbed into the fifty’s. I knew a tube was unavoidable, but as I started to explain to the obstetric sister how to mix intubation drugs for a three-kilogram newborn, I realised in one breath the futility of the exercise and the fact that any kind of anaesthetic at this point was probably going to kill him.

So I haphazardly ticked that ICU intubation checklist in my head (I now understand the exercise completely) and proceeded with an awake-intubation.

It is a cruel thing to do I’m sure – but it probably saved his life. Because he never stopped breathing there was time to find his cords amid all the blood at the back of his throat, time to watch them flick open and slip the tube in without his oxygen levels plummeting and his hear rate dropping to a virtual stop.

By this time Scotty had a drip up and was pushing a bolus of fluid and just like that we had oxygen saturation of 98% and a trace on the monitor. I think we laughed at this point because a sigh of relief was not big enough.

In the process though hands came off his neck. Fingers stopped plugging holes and it was less than ten minutes and we were losing our circulation again.

We tried pressure bandaging, which didn’t work.  I didn’t have any other ideas.

A second fluid bolus settled things for a few minutes again and the realisation that we had blood.

Good old un-typed, O-negative, emergency blood.

It was probably about 6:45am.

At this point I decided my consultant had slept enough…

“Hi…so I’m dealing with a bit of a unique situation… I’ve got a BBA here that I’m resuscitating…who’s been stabbed in the neck and the chest.”

Silence…

Maybe a soft “ok”.

“I’ve tubed him and dripped him, I’m about to start emergency blood… but I need you to come…”

“Ok.”

“I need someone to make phone calls, and write letters and I just need more hands…”

“I’ll be there in 20 minutes”

There were still enough veins to get a second drip up. The first bolus of blood made him pinker. He was textbook fluid responsive.

We managed to move him up to NICU where there were brief moments of control, but mostly the growing sensation of sand slipping through my fingers.

Too be honest, I don’t think I even considered that we were actually going to save this baby. I only knew at each point what the next right thing was to do and in this resuscitation the next right thing involved a vascular surgeon. I was out of options on this end. I could only keep running through ABCD, looping back again and again, like a song stuck in your head, until we reached the point where the blood that was saving him turned toxic. I knew when we crossed that line we would not be able to pull him back across. I also knew that that was the only way I was going to stop fighting.

My consultant arrived and got hold of the surgeon at Red Cross*. The trauma team knew we were incoming. I told them to let ICU know. The flying squad was booked.

The responses were always the same.

“I need to transfer a 1 day old baby”

“What’s the diagnosis?”

“Stab neck and chest”

“Excuse me?”

“Yes… ”

Around 8:30/9am

“So it’s true?” the paramedic said when he arrived for the pick-up.

By this stage my baby was bleeding not just from his wounds but also from his drip sites and his nose. If we hadn’t already crossed the line, we were walking dangerously close to it. I had given him a whole adult bag of blood (just under one and half times his normal blood volume) to try stay on top of his circulation, but in the process I had flushed out most of his hope of clotting. On the gas his pH was undetectably low, his lactate was undetectably high, his potassium was approaching double digits. We were hovering perilously close to a cardiac arrest. I was flabbergasted that we hadn’t seen one already.

My consultant went with in the ambulance so someone could keep pressure on the neck for transfer.

I watched them go certain he would die… if not in the ambulance, not long after he got to Red Cross.

I was sure he was never going to make it to theatre.

As the adrenaline rush tapered, like the tide being sucked out slowly before the tsunami rushes, the magnitude of what had just happened hit me when I walked into the on call room. The city was only just stirring on New Years day. No one I could think to call would possibly be awake yet. Those who were, were all working like me. In the silence I felt heavy and tired, sad and angry and defeated.

I worried about Scotty, who was still so new in this profession and not yet conditioned to the violence that we had just witnessed. Even worse, there was actually so little to say. These are the moments you must wrestle through in your own mind and decide to keep going despite them in this job. Often you must do it without being able to really understand how something like this happened. There are often no answers about motive and means. You write a chapter in the story, but you never see it as a whole.

I have deliberately left out the who, the how and the why because the bits and pieces I have heard are jagged and broken, and mostly speculation and conjecture.

I left somewhere between 11am and middday. In the hours that followed there was a bit of sleep, a few phone calls, and a fair amount of tears. I knew no one would be surprised if I didn’t show up for work on the Friday.

The details of what happened on the other side I know from what others have told me.

Not long after he arrived, his heart stopped.

As far as I know, three paediatricians, at least two surgeons, a trauma doctor and an anaesthetist resuscitated my baby.

After twenty minutes there was some debate as to whether letting him go would be kinder, but for reasons only a Red Cross doctor can explain, no one would make the call. After forty minutes, there wasn’t much of a pulse, but there was a heartbeat, so they took him to theatre.

Altogether the surgeons stitched up twenty-two wounds.

Neither of his carotid arteries were touched but both of his external jugulars had been hit. His trachea was fine; the bubbles must have been coming from his lung. The wound on his abdomen hit nothing.

Almost 12 hours after he was probably born, he made it to ICU. His blood pressure was too low. His blood wouldn’t clot. His kidneys and liver stopped completely and he needed dialysis. His lungs looked horrible. He started having seizures.

No one could quite understand how he was alive. No one expected him to survive.

He proved us all wrong in the end and just kept going.

After two weeks his kidneys and his liver turned around.

After three weeks he came off the ventilator.

After a month he made it into the general ward.

After two he was discharged into a place of safety.

I saw him after about three months when a friend spotted him at a follow-up clinic and called me.  He was still so little, but he smiled.

A year down the line one of the loveliest ICU sisters is fostering him and in her home he has fattened up and flourished.

He is chatting and crawling and full of little boy mischief.

His story is surely one of the happiest I ever get to tell. His smiles and cuddles are the most precious I get to see.

Almost everyone I tell this story to say I saved his life – but so much more saved this little boy.

Scotty saved him.

My consultant saved him.

The trauma team saved him.

The anaesthetist. The surgeons.

The ICU team saved him.

And in the end, it’s the family that have taken him and loved him desperately and deeply that save him every day.

* Red Cross War Memorial Children’s Hospital