Depression, Anxiety and a virus named for a crown

If there’s one thing they don’t cover in medical school but that every doctor learns it’s navigating your own mental health.

Obviously, they teach you about how to recognize it and manage it in your patients, they teach you about biopsychosocial models, they teach you how to ask questions indirectly and how to check if someone is a danger to themselves. What they don’t teach you is how to be ok with not being ok yourself. They don’t teach you how to protect yourself. I remember a lecture in 5^th year about how to look after my finances but I never remember a lecture about how to look after my heart and mind. No one gives you the coping skills about dealing with human destruction and death that is inevitably part of the career. I think they thought we would get desensitized to it. Starting in second year standing over a cadaver with a scalpel and ending with being called to certify death in the ward at 2am in your internship years.

I realize that my medical training occurred in a grey zone where my teachers had been born in the years following a world war, a great depression and a giant holocaust. They were perhaps more sensitized to suffering than we were as a generation. They were also part of an era where mental health was stigmatized. People were trying to conquer visible disease like polio, syphilis and HIV. If you were struggling as a medical professional, you certainly didn’t talk about it. You just didn’t become the best you could be. Instead of being a gregarious surgeon you resigned to an everyday reliable GP practice. You didn’t push yourself harder you accepted who you were and made life livable. Or you didn’t. You suffered and probably caused immense suffering in your wake. In your patients, in your family, in your colleagues and trainees, in yourself. We didn’t have mentors in this area. People taught us how to suture, put up drips and defibrillate but they could never teach us how to deal with our hearts.

Now, as a new generation of teachers, we find ourselves lost in a sea of uncertainty. We, long before an invisible monster started running rampant across borders and fences, were floundering under an epidemic of sadness and anxiety in the profession. Sadness at at the inequality in our health care systems, the poverty and suffering that lives beyond the borders of suburbia, out past the airport and even further, deeper into the smaller pockets of our country. We have been overwhelmed by the volume of need for healthcare, nutrition, education and employment in our society. We have been struggling to stretch resources, apply equal rights in a deeply unequal system and do this all with posts unfilled and budgets cut.

We were anxious before all of this started. We were reading articles and listening at academic meetings about being resilient. We were rolling our eyes as they told us to sleep more, socialize more, eat healthier when we knew that no 24-hour shift one or two times a week, two sometimes three weekends a month at work, would ever encourage those behaviours. We watched helplessly as the economy slipped and the patient numbers increased but the capacity to employ more staff never came. We watched as our colleagues melted in front of us or hardened to stone. We watched some walk away broken. We buried some who simply couldn’t identify with life outside of work anymore. In all of this, those of us, not necessarily stronger but maybe more stubborn or persistent, have mentored ourselves through our mental health crises. Some crises have been short moments, some have been catastrophic. Some people have managed it on their own, some have done it with trained professionals, drugs and therapy. We haven risen, or at the very least stayed standing, taking one step forward at a time. Though we have not felt it we have been resilient even if we are not sleeping enough, talking enough or exercising enough.

Then out of the east a terrible wind began to blow. It carried with it an invisible uncertainty, something with the capacity to escalate the sadness logarithmically. The wind grew stronger and stretched its fingers further west, carrying microscopic particles of fear and panic in a steady swell. It has stopped countries, economies, governments and freedom. It has taken from mankind the one thing that is our strongest weapon – community. This virus that wears a crown has for now defeated us.

Yet, as low as we sink under the weight of what is around us – somehow, we must teach ourselves again to rise, to be tougher, stronger. We must keep standing. One foot forward at a time. We must carry each other. Carry our patients. Carry our nurses. It’s true – we have no mentors again, but we are shaping ourselves still to be mentors to the next generation.  

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.