Paeds ICU: This place I love and hate

“an intimate friend and a hated enemy have always been indispensable to my emotional life...not infrequently…friend and enemy have coincided in the same person”

Sigmund Freud

The first time I rotated in the unit as a registrar, I had been a doctor for almost six years and working in paediatrics for just about three. Despite this, it was unlike any kind of medicine I had ever been exposed to. 

It was intense and pedantic. It was pathology on steroids - literally and figuratively. At it’s best it was every kind of complication straight out of a text book and at it’s worst it was vaguely referenced on Google. There were medications I had never heard of, procedures I had never seen and
equipment that looked science-fictional.

It felt that if you touched something you would break it (including the kids) and if you said something it would be ridiculously stupid and probably invoke the famous sigh of deepest disappointment from the boss.

It was the worst kind of feeling a doctor can feel, overwhelmed and out of control and not surprisingly I hated it.

I’m not convinced all that much was different the second time around, except maybe that  I am regrettably a little bit older, theoretically a little bit wiser, and unfortunately a tad bit tougher.

It’s still crazy busy.

On a good day it is well controlled chaos and on a bad day, concentrated visual mayhem. Eight hour work days are still just a human resources guideline and afternoon handover rounds routinely stretch into early evening.

There is always light, always noise, always movement.

Empty beds are filled again quickly, families hover on the edges, shuffling in and out. You can get through a day and night without ever really stopping. Eating while writing notes and hydrating with coffee and energy drinks.

The kids are still the sickest of the sick.

Replaced by some strange robotic version of themselves – faces hidden by CPAP masks or ET-tube strapping, fed with tubes and drips and flattened with sedation so that their cries are replaced with the beeping of monitors.

They come, sometimes failed by the systems that should see them fed properly, immunized properly or managed earlier properly. Sometimes they come for no clear reason at all. Well fed, well cared for, overwhelmingly loved – struck down randomly by a particularly devastating infection, or a car, or a bullet, or a fire.

The stories are still raw.

On one of my recent calls I took over a beautiful baby girl who’s body was shutting down in the face of overwhelming sepsis. After a long night of struggling, all of the tricks had been tried without success and in the early hours of the morning she started to slip away. I explained to her tired parents that there was nothing left to do and watched her sweet dad stand next to her bed, take her little hand and say firm and loud… “You can go now my baby. You can go.”

I know exactly what you’re thinking. How could you like this? Could you ever even love it? 

So why was my heart heavy all of the last week at the thought of walking out on the last day?

Could it be some strange version of Stockholm syndrome?

You see; I love the mayhem less than the controlled chaos, but it does keep me on my toes.

I love the chatter, the team work, the friendships that form on ward rounds and coffee breaks, and in the inappropriate laughter that follows a serious situation – a misunderstood form of debriefing.

I love the babies. I love how they are resilient despite what they’re up against. I love taking them off ventilators and finding their faces. I love watching them peel away their sickness and sedation to show you a smiling little person underneath.

I love how much it teaches me… not only about physiology and pharmacology, but about myself and what my strengths are as much as exposing my flaws; how it pushes me to be better at being a paediatrican and a person.

Lastly, I love that it’s raw – because I think it means that despite being more mature, less naïve and thicker-skinned, there is still plenty of heart left.

Shades of Grey

Sometimes it’s easy to have an opinion on things.

They’re black and white. Chalk and cheese.

Education is always better than leaving school.

There’s enough medical evidence for smoking to be a bad idea regardless of its ‘coolness’.

 But then there are other things that are less clear. Those run on a gray scale spectrum of good or bad – pregnancy termination, death penalties and such.

 When people ask me the question – “Do you enjoy your job?” I always pause before I answer. It never comes to me as a resounding yes or no.

In the same moment on the same day I can love it and hate it equally and in a different moment on a different day the one emotion can far outweigh the other.

Similarly my Christianity, my pursuit of a relationship with God,

is a constant battle between blind faith and certain disbelief. Yet it is something that has been growing in my soul for so long, a solid mass with so many delicate vessels and connections it could never come out without certain risk of death.

In a strange new space recently, I have experienced polar opposite emotions within situations, in one space in my heart. There is no spectrum – just one feeling on one side of a line and another on the other. Clearly separated yet together – like cerebral hemispheres inside a skull.

The first was earlier this year when in the early hours of 2015, I found myself standing over a 3kg, brand new baby boy, desperately trying to make sense of the 22 stab wounds to his neck and chest.

I felt my heart tear in 2 down the middle, slowly and crudely like a piece of paper. On one side, a picture of a person walking backwards out of the room, curling up with horror, revulsion and nausea at the evil that must have circled this little boy while he waited to enter the world and how his first few cries would have been from pain and shock not just him catching his breath.

On the other side is a picture of a robot, running through the ABC’s of a trauma and a neonatal resuscitation. Cool and calm and 2 steps ahead. No emotion. Just doing what it was programmed to do.

The second was yesterday.

I could feel the hospital buzzing from the moment I got the call about 2 kidneys that had become available for transplant at 5:30am. However, when I went up to theatre to give them the names of the recipients, on the list, above the 2 kidneys and liver transplants was the name of a little boy in ICU and ‘organ harvest’ in the procedure column.

The whole day I found my mind clambering clumsily from one side of the fence to the other.

Obviously, the excitement and relief that comes with the hope of 3 children being pulled back from less life is worth all the bubbles in all the bottles of champagne in the whole world. At the same time though, in the same building but on a different floor, another family is grieving. Saying goodbye to a slugs and snails and puppy dogs tails 4-year-old little boy who hopefully never saw the car coming. The tragedy of that is heavy and unimaginably dark.

Science dictates that light and dark cannot exist together – the presence of the one negates the other.

I’m not sure I agree.

It seems to me they can.

365

At the end of every 12 months on the rotation we are forced to sit down and produce some vague attempt at self-reflection. 
This is what I came up with 3 months after that deadline...

            A year is nothing anymore. Months are swallowed up by call rosters and weekend rounds. When time is measured in 3 month rotations it doesn’t take that long for 4 of them to fly past.

Self reflection sounds easy enough when you say it – in reality, putting these words on paper has been trickier than sedating a ‘Downsie’.

But ok, here goes.

I swear a lot more – if you spent 60 minutes with me you’d probably never say it, but it’s true.  In my head mostly, but occasionally under my breath when I’m running to a resus, or I’m struggling to intubate the 800g prem. Almost always when I put down the phone after the lab has called with a potassium result and pretty much after every phonecall from Hanover Park MOU.

It’s been an education in people.

 In how they wear their insecurities - interns and consultants alike. Some cowering behind them and some disguising them as impatience or condescension.

 Also, in how some people have no willingness or capacity to give beyond what is expected to the detriment of the group,  and equally so, how others struggle with the ability to say no to the detriment of themselves.

The most interesting skill I’ve had to acquire is the ability to work quickly and thoroughly and under pressure. Interesting, because it is completely contrary to my slow metabolism.

In my comfort zone I like to work at a pace that enables me to be thorough and thoughtful, and beyond a certain pace my brain starts missing things.

In reality though the workload is mostly too overwhelming for slow, but the kids are sick enough to demand thorough and thoughtful. At the same time they’re sick at 3 in the afternoon when you’re relatively fresh on a shift, but they're no less sick at 3 in the morning, when you’ve sat down for maybe 30 minutes in the day and your brain is running on cortisol and red bull.

I’ve had to start treating calls like a series of short sprints and less like long marathons.

The second is negotiating a healthy balance between me time, work, friends, God, fiction and non-fiction reading. I get the feeling this is a learning curve your whole life – and different seasons lend themselves to the waxing and waning of different demands. Some days the balls are miraculously being juggled in the air. Most days they are all over the floor.

Do I feel smarter…

            Mostly no.

I don’t fee l any more skilled in telling the difference between a pansystolic murmer and an ejection systolic. What I know about intropes is embarrassing. I’ve worked in ICU for 3 month and I don’t think I could find the Newport Ventilator on switch if I had a manual. That being said – I’ve spotted a DKA on the triage bench, clerked in a kid with hippus and a ‘milkmaids grasp’ and recently even a congenital rubella.

Baby steps.

Do I still love this?

I think so.

I mean at least once a month I dream about leaving it all to go run a well baby clinic in a Karoo town and bake cupcakes in my spare time.

But I work with some of my all time favorite people.

I get to go on ward rounds with some of the most respected names in Paediatrics in the country.

And the little people – they never stop amazing me.

Take home Teddy

Thursday morning after Wednesday OPD chaos - the folders in the box are remnants of the previous afternoon, told to rather come back in the morning than sit on the uncomfortable passage bench, to be seen somewhere in the vicinity of midnight.
None of my follow-ups have arrived yet so I pulled the first folder - green triage sticker, complaint - 'sores in the mouth'.
So typical of MOPD, the real reason for coming is not always well captured by the triage nurses, and in this case it was a complete red herring.

A very cute little 3 year old girl comes into the room with her mom. A pleasant little pair.
Her mom speaks a slightly broken, Eastern Cape version of English; her grammar giving it away more than her pronunciation. Her daughter is a sweet little poppet who barely says a word the whole consultation, just sits quietly next to her mom and wanders around the room with her eyes.

Sores in her mouth - not so much. Sores on her hands and feet - yes. More alarming is the blood in her urine and then very nonchalantly she tucks in this statement...
"The other thing doctor, I almost forgot... she was raped last year."
No, not how I like to start my Thursdays.

So we stumble through the story which is a good year old and sadly, probably the story of a thousand other little people.
Mom can't actually tell me what happened, at the time her daughter was too small to talk for herself. The only real clue may have been that she was suddenly reluctant to go play next door with the neighbors kids. The clinic had done a courtesy examination and said nothing was wrong and left it at that. The police had said a case wasn't necessary as there was already one opened by the first victim.
And so the system let her down.

For most of the examination she is a honey. She sits quietly, not a peep. Only right at the end when the consultant joins the examination do the tears come, and our promise that nothing is going to hurt fall on deaf ears. Surprisingly, we get through it with very little kicking and screaming and as a bit of a lackluster consolation prize the kids get to pick a take-home-teddy
What happens next is a moment I want to burn into my memory forever.
A little face, with big, sad, uncertain eyes slowly melts into a smile when the teddies are presented and she is allowed to choose one. She spots one in a pink dress, plucks it out of the bag without a moments hesitation and hugs it close to her little heart. By the time my notes are finished and social workers have been called, the teddy has been inspected from every angle, wrapped up in a blanket and rocked to sleep.
It is in those moments that she melts back into the shape of a normal three year old girl, and the reality of the morning is a deep contrast to this innocence.

In Her Shoes

Edit: I would just like to say that having worked with the person in this post for more then a year now I have to say there is nothing wrong with her work ethic. She is one of my favourite people around and has never shot me down or not been obliging when I've had to phone for help or advise. Perhaps the first conclusion is more appropriate. 

You could spot them from a mile away - so out of place at seven-forty-five-ish on the cardiac morning round. Surrounded by Trainers and Crocs and the occasional cheeky sandal, they looked as at home as a slinky catwalk model in the middle of a 'Vroue Federasie' AGM.

The female obsession with footwear is not poorly documented. Most of us dream of a shoe-closest like Carrie in 'Sex In The City'. I love having a reason to slip on a pair of heels (not just because they add a few centimeters to my shortness) but because they make you feel more ... I don't know...stylish and grown-up. It's the way they finish an outfit, the way they sound when you walk in them, the way they show off a pretty pedicure and most importantly, make legs look skinnier. No one pulls off a power suit in pumps.
But they are made for women who do a fair amount of sitting. After a few hours they start pinching, and feet start burning and muscles start aching. That's why they come off when the party gets going, why they are work shoes and occasion shoes, not holiday shoes, or weekend shoes.
They certainly aren't intern shoes, or ICU shoes, or call shoes. In fact, they aren't hospital shoes.
This is not a job where you get to sit a lot. This is a job where you do a lot of standing, and walking, and every now and then when people stop breathing, occasional running. These are not 8 hour days, they are sometimes 12, sometimes 18, sometimes 28 hour days.
It just concerns me when someone has been around in the profession long enough to have an MBChB and a Fellowship Qualification, and then doesn't choose their shoes with the same wisdom they apply in choosing antibiotics and inotropes.

I know they say you shouldn't judge a book by it's cover, and probably in the same vein a doctor by her shoes - but I cannot help but wonder about the person who willingly chooses heals over flats in this profession.
I have to assume that

1. They have no idea what is about to hit them, in which case shame for them, or  

2. Their work ethic is going to be a problem, in which case shame for the rest of us. 

Little man G.

Little man G.

What a pleasure to have you in our lives for this little while.

Your home has been Red Cross for the past 6 months. You’ve moved around in the wards and left stories all the way.

A couple of memories you have imprinted in my heart.

When I just started in ICU your were living in bed 9 and coping on a bit of high flow oxygen. And I remember one day you sitting up in bed and being entertained by a mountain of colourful toys…. And how you’d cry for your mom when she went home in the evenings.

What I most remember about your second stay with us is your big round eyes watching us work around you, the little clicking noises you made to get our attention, your big sister sitting on your mom’s lap having long conversations with you.

Your mom, sitting tirelessly at your side.

And your tube – coming out your nose similar to a  little elephant ‘slurpie’ – and how it became like another limb and you just accepted it. Wide awake, playing with your toys, hooked up to the ventilator.

I’m sorry the last 6 months were so yucky beautiful baby boy – time to sleep now.

The Scenic Route

It feels like I take the long way around a lot...and I spend a lot of time waiting. 

Waiting for a plane. Waiting for the luggage to come. 

Waiting for the nice boy to notice you’re amazing. 

Waiting to get into med school. Waiting for second round applications. Waiting for a registrar job. 

Waiting for the sats to come up...waiting for the Scoline to work. 

Waiting for the spinal. Waiting for the surgeon. Waiting for ICU to get a bed ready.

Waiting for the call to end.

Because I belong to the microwave popcorn, smartphone, PVR generation I generally don’t love it and I very seldom admire the scenery along the way. 

But why?

I always learn just as much in the waiting, if not more, as I do in the action. 

I’m not sorry I had to do a BSc first - I got to be a normal university student for a while. I got to ‘blommetjies vou’ and Serrie and Teddy Cheer and lie on the ‘Aula gras’ and sleep 3 hours a night for a week in Orientation week, twice, voluntarily... and I wouldn’t swop that for being 32 and a consultant. 

I’m not sorry I had to go work in the North West for 18 months while I reluctantly watched some of my peers walk into nicer  jobs...those were probably the 18 months I have enjoyed medicine the most. Those are the patients who taught me the most, the mistakes I will never forget, the saves that made me feel like I was swimming and not just treading water, the friends I still chat too even though we all live in different corners of the country now.

And now, at the end of another season of waiting I find myself acknowledging that I’m not sorry about waiting for this registrar job really. 

I’m grateful that I got to sink into the system slowly. Grateful for a few months of quiet supervised responsibility. For a few months when I could spend weekends off not working on research proposals and academic presentations. Grateful that I could read fiction novels and not journal articles at bed time. Grateful that there was time for drinks, and dinner parties and weekends away with lovely people. 

Everyone loves instant gratification - getting their way without much of a struggle - no red robots, clear highways - but nobody enjoys a person who is impatient. 

No one has time for the weaver on the N1 or the person who jumps the queue. 

So mostly what I have learned in all of this is how to wait graciously despite the frantic pace that everyone else seems to, or wants to be living at. 

And I’m still waiting for some things, so I hope I get better at waiting quietly and optimisticallly and  if they do ever eventually come around...I hope I’ll be greatful for scenic route.