Author: Blair Bigham

Here are a few short writings from my travels through India.

Searching

I first met him laying be bed next to me.  Wait, no, he was laying in the bed next to mine when I first me him.  Aaron Koppenhoefen, a young German sent to India for six months by his parents to find something, though I don’t think he knew quite what.  He looked up from his book and we executed the usual ritual as I placed down my backpack.  I had to come to this ashram in Rishikesh to find something that I was missing; it doesn’t matter what, which is good because I couldn’t explain it if it did.  Six hours north of Delhi at the foothills of the Himalayas is a fine place to be when you’ve got no where else to go.

Aaron was quiet, sitting bolt upright in bed, back pressed so hard against the cold, concrete wall you might think it would otherwise collapse.  He returned to his book, barely tilting his head as his eyes locked onto the words.  I decided to go for a walk to get a lay of the town, some fresh mountain air, and a roll of toilet paper.  It was colder than I had expected it to be and I began scouting around my backpack for a layer.  I found a 100 rupee note and grabbed it along with my forest green fleece.  I put it on and in the process misplaced the rupee note.  I ruffled around, confused, and checked my deep empty pockets.  I turned to Aaron, not out of suspicious or for help but out of exasperation.  Aaron continued reading.  His eyes never left the page.

I returned to my bag and sifted through various currencies until I found a 500 rupee note.  A bit big for buying toilet paper, but it would have to do.  I grabbed my cell phone and a novel (the novel was for appearances sake, really, as even Rishikesh cafes have wifi, and even on vacation it would be 48 hours before my book binding was creased as I instead took time to detach myself from the habit of reading news that was happening 10000 km away). I grabbed my key, stuffed it in my pockets, but didn’t feel the crinkling of paper money.  I sighed, blamed jet lag, and searched my bedding and bag and pockets again.  Then I checked the pockets of my jacket, even thought I hadn’t touched it.  Its funny, the places we look when we loose something.  Such hope, no rationale, our cortex highjacked by our amygdala.  I furiously searched places those rupees could not have been.  A visiting alien might look at me and think I was scrambling for my epipen, or my future, but it was a 500 rupee note.  The note that I had just put in my pocket.  I turned to my new roommate.  Aaron continued reading.  His eyes never left the page.

Exhausted and flabbergasted I returned to my backpack.  I found a 1000 rupee note, which was a useless piece of paper – no one would make change for the 25 rupee tea that granted me a wifi password, or a 10 rupee roll of toilet paper.  I placed it on the bed and by chance pulled out a 100 rupee note, squeezing it tight for my walk.  I grabbed the useless 1000 rupee note to shove deep into my bag (I realize as I write this that I need a more organized way of carrying my money) only to find my hand grasping at air.  I wasn’t surprised, like I almost expected it to have vanished; I didn’t look for it.  I just turned and looked at Aaron.  Wiping any irrational facial hint of suspicion, a skill I take great pride in possessing, I stared at him, still bold-upright in his bed, the wall still erect, his eyes still fixed to the page.  He this time looked up, and I looked into his eyes and his eyes looked into my heart and beyond and I felt naked and cold and paralyzed.  It was like a mixture of curare and Petro-Canada slushie were coursing through my veins in place of warm blood, like the air in my lungs was statically charged and looking desperately for a place to run.  Just as quickly as that sensation started, it stopped, only seconds having elapsed if i had to take my best guess.  Aarons eyes came up to meet mine.  They were massive and dark and through his pupils I saw a sea, or maybe, yes, an ocean, so wide and so deep and so hungry.  “Cant find it” he said, with an intonation masked by his German accent, and despite playing that phrase over and over in my mind, I still can’t tell if his sentence ended with a period or a question mark.  He returned his eyes to the pages of his book, his neck barely turning.

I’m convinced Aaron stole my money that day, but he wasn’t after my rupee.  What he wanted was something I didn’t yet have, for I hadn’t yet found it.  Not my soul, but something close.  I had come to Rishikesh in search of something important to me.  Aaron Koppenhoefen was looking for it too.

Unforgettable

I’ve never seen a cow vomit, but I’ve heard a cow vomit.  It’s worse than you think.

Routine

“1800 rupee”

“Are you kidding?”

“No sir, its a very far way away”

“I could get to Delhi for less than that.”

“No sir, Delhi is much more far away, and the roads are closed, and extra kilometres”

“I’ve been in India for 2 months”

“Yes sir”

pause.

“We have a small car, sir, 1400 rupee”

“I’m not paying 1400 rupee to get to the airport.  I’ll just have to take a bus”

“No sir, the bus is very slow, it is not a good bus”

“I’ll find my own taxi then”

“No sir, very sorry sir, there are no taxis here, only cars from hotel”

“There are 200,000 people in this city and only 1000 of them own a car.  20 tuk tuks have driven by us since I got here.  You’re telling me there are no taxis in Dehra Dun?”

“Well sir, the taxi is not safe”

“How do you think I got here from Rishikesh? In a taxi.  That drove PAST the airport.  For 1000 rupee”

“No sir, 1000 rupee is not possible”

“But I just paid 1000 rupee.”

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“Yes sir”

“Do you have the phone number of taxi services?”

“Yes sir, they are india phone numbers sir.”

“Yes, we are in india.”

“Yes sir”

“Can I speak to the duty manager”

“That is me sir.”

“And you won’t call a regular taxi for me?”

“Sir, there are no taxi in Dehra Dun”

blank stare.

“Ok, I’ll just have to call Sheraton and ask them for help”

“Sir, what time do you want the car?”

“10am.”

“Ok, 600 rupee, and the very best taxi for you, no problem Sir.”

“Thank you.”

//

Varanasi on Fire

Ashes of the dead fill the air, rising up to meet the moon.

Flickers of fire flow slowly by, lamps of grief on floating leaf.

Marchers chant, mourners wail, I stand silently.

Tourists shift awkwardly, invisible to those whose presence has meaning.

Earth meets heaven on the edge of the Ganges; life and death and life intertwine.

Smoke and emotion choke me as I bare witness to the Burning Ghat; it is both beautiful and ugly, both light and dark.  I should stay, and yet I turn on bloc and leave, the smells, the sounds, the spirits chasing me through tight alleyways, past begging children and skinny cows.

//

For more creepy writing, check this out!

For more on life as a backpacker, click here.

“What if you run out of air?”

“Are you sure it’s safe to go to Cairo?”

“Don’t walk around Cape Town at night”

“Aren’t sharks dangerous?”

“La Paz is a bit sketchy, eh?”

“What if the rope breaks?”

“Orlando? Dude, you’re crazy…”

Ok, no one ever said that last one to me.

I’ve written and re-written this post many times in the last few days.  It’s still not right.  But I’m still tearing up when I think about them.  Still getting angry when I think about why.  Still too much in despair when I think about the future of gun violence in the United States, LGBTQ discrimination, legislated hate.  So for now, I won’t write about them, I won’t write about why, and I won’t write about tomorrow.  I’ll write about me – and how what happened in Orlando has shaken me in ways other attacks haven’t.  See, I was in Paris a mile away from the Bataclan that Friday night, and I was in Sharm El Sheik a week before the MetroJet, and I was in Beirut just before a bomb destroyed the lives of people too much like me for my brain to reconcile.  But this?  This time it’s different.

This time I was half a world away in Cape Town South Africa, at a club, on a street, drinking and dancing and singing louder than I ever should.  I was wearing a blue tank top, ripped jeans, and a South African Springbok rugby toque.  When I travel, I party.  I let loose.  I take risks that I wouldn’t take back home.  Most travellers do. From inside that Bree street club, I might have been in any club anywhere in the world.  Even Orlando.  People say I do risky things.  In business talk, they’d say I have a large risk appetite – which to me sounds like I’m hungry for some street meat in Mogadishu.  My tolerance for risk, people say, is very high.  I disagree.
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I think I’m just really good at calculating risk, and that I calculate a lower estimate of risk than most.  This could be the hubris of youth, but I don’t think it is.  I think 10 years of being a professional risk calculator (aka paramedic-turned-physician and world traveller) has strengthened an aptitude for teasing apart real versus perceived risks.  Now, with my desire to live a joyful life competing with my desire to live a long one, my values certainly place adrenaline-releasing experiences over sitting on my couch crocheting.  Still, I think my global travels have taught me lessons about risk that have honed my skills as a risk analyst.

Threats are everywhere, and they are measurable, or at least estimable, most of the time.  Local violence is usually targeted – and not often (but sometimes) at foreigners.  This is why I’ve walked through a crowded Cairo souk during Arab Spring riots but wouldn’t dare visit Mombasa for a beach vacation.

That’s why this weekend has shaken me. By most accounts, what happened in Orlando was a targeted massacre of gay people.  Young gay people.  Young gay people partying on a Saturday night.  What happened in Orlando targeted me.  Only I wasn’t in Orlando – I was in Cape Town.  But I’ve been to Orlando at least half a dozen times, and on each of those trips I found myself in a club.  Drinking.  Dancing.  Flirting.  Not getting shot.

What happened in Orlando is unlike almost every other act of terrorism I’ve ever considered analyzing: it was targeted at me in a place I could have been.

I’m not sure how you feel about what happened in Orlando on Saturday night, but I feel like someone tried to kill me.  Not for my wallet, or my hat, or my phone.  Someone tried to kill me because I’m gay.

So what do I do now? What is an acceptable risk?  And do I accept increased risks as a matter of principle – of not letting terror win – or stick to the objective (though highly value-weighted) math of estimating risk and then reconciling that estimate my risk appetite?  Must I always be “op-on” – exploring everywhere I go with the persona and mentality of an operator? Can I ever really just relax? Travelling is my escape, my escape from a responsibility for making decisions that affect others directly.

Thoughts swirl in my mind as I reprogram my internal risk calculator.  Is anywhere safe these days? Can I party on Church Street, sip cocktails on Ossington, hold hands in San Fran? Do I need to memorize the exits of every club as I enter, have back up plans for back up plans, carry a gun…

And there it is. There is the fear, the irrationality, the them-versus us attitude that terrorism and hatred strives to achieve. An Orlando gay club less safe than walking through a crowd of rioting Egyptians: everyone gear up. I’ll write about homophobia, discrimination, terrorism and how we respond to it soon. Right now, it makes me too angry to even think about.

Answers will come. More questions will swirl. Like the family and friends and community of those lost in Orlando, like every human being with a mind and a heart and a soul in America and the World, I can barely ask the questions.  Who were they?  What could they have been? Why on Earth?  What now?  Am I next?

 

Tell the cab to take you to the General.  Get out on the passenger side; Marvin died getting out the left, silly bugger didn’t call an ambulance when he first felt the pain.  Through the main doors and please nod to Doris; she volunteered at the desk to your right until the day she died, and still today.  She’s much sweeter than she looks.  In front of you is a cafe, but don’t head there; turn left.  Past the benches, down the hall, and don’t mind Seymore, his sense of humour is poorly developed despite is 122 years around this place.  You’ll see a small hall to your right, which is where you would go if you needed an elevator during the morning rush when you are late for rounds, but you won’t need to head the way tonight. Mr Karpf could use the company… he rides that elevator up and down, day and night, “What floor?” with twinkling eyes that should belong to a child, not that old, worn face.  Three short halls on the left; take the second.  You could take the first, find the stairs, but Mrs Kreiger isn’t pleasant at the best of times and I won’t trouble you with having to explain to her where it is you are going (not that its any of her business).  Besides, the stairs to the basement are creepy.  5 elevators, 2 one one side and 3 on the other.  The button will trigger whichever closest, so long as it isn’t broken, in which case it will trigger the second-closest.  Only 8 floors, but they are deathly slow.  Only one of them has anyone inside who you need to be aware of, but its too hard to explain which elevator of a bank of elevators one must watch out for, so take note of a small child who offers to press the button for you; she’s much sweeter now than before the crash. How time can change a little one.  We almost saved her, truly, but she blew an arteriovenous malformation on account of the blood thinner two days before I was going to discharge her home.  Not home, of course, she had no parents anymore… I guess I never thought that far ahead.  Its pointless, you see, to plan your discharges more than a day in advance, as things change.  Brains fill with blood.  Anyways, she’ll ask your floor, and kindly tell her, and as long as its not the 7th or 8th she’ll be able to reach.  Tell her “one below, please” and she’ll be tickled pink.  Now pay attention: there’s a row of buttons on both sides of the door, and you’ll need to be sneaky and press “1 below” on your side at the moment she presses it on hers.  The curved plastic will light up and the doors will closed, and she’ll be quite pleased that she interacted with a world she has no business in any longer.  You won’t have time for chit chat but she’ll curtsey as the doors separate and you can end your relationship with her however you see fit.  Doesn’t matter which side of elevators you rode, you’ll only be able to go the one way.  Turn right, then left, then right, then down a long hall.  If you see “Microbiology” you’re on the right path.  If you see the kitchen, go back to the elevators and try again.  At the end of the hall you’ll see double doors with large metal bars that press to the outside.  Its the first door on the left before you reach this exit.  The door has no sign, no marks, just a small, fogged window in it.  It will look locked; its not.  For some reason, it never is.  My oversight, I guess. 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The medicine is available in the tablets and jelly form. overnight shipping cialis  The small room on the left with the couch is haunted, don’t go in there.  If you sneak a peak you might see AJ wallowing about, who still hasn’t forgiven herself for what happened back in the 70s.  14 years of post secondary education gives you a lot, but not everything, and certainly not what she needed the night she drew the curtain open and spat cruelly ‘is that you’re wife?”.  How we assume… how we err… He hadn’t killed her, you see, but no one in their right mind would have believed it until DNA matches came around a decade later.  Too many bad conversations, too many tears, too much pain. Oh, if I could go back and say it differently, I would, each and every time.  See, you can’t possibly find the words until you’ve experienced it.  Its not so bad, really.  Its kind of, well, nice.  But of course you don’t know that until you know that.  A little further down, and you’ll see 3 large doors leading to three identical rooms.  The one on the left is just storage, see, because there were only ever 2 of us, just AJ and I, and when AJ was gone, the new young girl.  Well, she’s not a girl, I suppose, but I think of her that way.  Vomiting at her desk all day yesterday.  My room was the one farthest from the exit, closest to the row of offices and the conference room you haven’t yet come across.  Through the door and you’ll feel the chill.  The only doctors who wore hoodies at work, we used to joke, until the infection control people got wind of it and started enforcing scrubs.  So we switched to surgical gowns, which only come sterile and cost a fortune – well here I go digressing into politics.  You’re here now, just you and me and more souls than anywhere else in the hospital.  Don’t cringe at the sight of my skin on metal, its no less comfortable than my mattress at home would be to me right now and the perforations actually feel nice.  Cold and dry and lying on a metal table.  38 years I fought the cold of this room, day in and day out, and now it suits me.  11 degrees Celsius.  I appreciate that you’ve travelled this far to serve, I know how little you relish it.  I hated doing AJ, but it was my duty to her, my privilege to loosen the ligature, photograph the abrasion, extract the layrnx.  A privilege that AJ would never be able to return to me, nor I to you.  Anyways, the scalpels and saws and the good pair of scissors should be laid out on the block by the sink.  I appreciate this, really, I do.  You were always the resident who stuck out in my mind even as the years passed and others came and went.  I know that you know this, but in case you are in a contracted state of mind, which you must be, I mean, look at the position I’ve placed you in, please do mind the parts that will be exposed outside the suit.  Oh, and don’t bother with the plastic bag full of explored organs; such a pain it is to fit it back in and close the abdomen, and I don’t want to look pudgy at the wake.  Anyways, I’ll let you get started, so that you can finish.  As I said to you a hundred times, “Why wait when you can make the Y.”  In hindsight I doubt anyone but me ever found that line funny.  “Nurse, the Betadine, STAT’!”  HA! Yes, thats a good one.  You can use it if you like.

Written in Rishikesh, India whist backpacking.  January 2015.

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The dogs always bark.  Its the only thing constant about this place.

“the secret of education is respecting the pupil.” – Ralph Waldo Emerson

Remember the rows of desks in public school? Remember the chairs attached to them with a bar on one side, as if to reduce the number of possible projectiles a child could manage to lift should an uprising occur – chairdesks, one word, filling the centre of a room lined with chalk boards, bristol boards, and cubbies for your winter boots. I had long forgotten the look of an elementary school classroom. Until, that is, I had the pleasure of attending the 25 year anniversary of the opening of my public school, Morrish PS.

25 years ago, I was in junior kindergarten, and Highland Creek Public School was bursting at the seams. Just a few months after starting the terrifying ordeal of boarding a long, yellow school bus alone each morning, half the school population, led by police escort, hiked the 2 kilometers to our new home, Morrish.

My JK teacher, who would (by her own design) also be my Grade 8 teacher, was Jan Griffen, an artist at heart with a smile that couldn’t be wiped away by even the most annoying children or angry parents. It was in grade 7 that Mrs Griffen lobbied my father to convince me to accept the role of Oliver in the school’s annual music theatre production “Oliver Twist.” Terrified of public speaking, I declined. Seeing Mrs Griffen last week, I couldn’t help but confess that one of my greatest regrets to this day is having turned down the chance to belt out “oom pah pah” in front of an audience who would applause regardless of my pitch.

How she realized years before I my love for the stage is beyond me. I would, of course, become an actor later in high school, even earning a paycheck parading around the city as part of a 6-member community theatre troupe, and who knows how life’s trajectory may have changed. I’ve always said, after my stint in acting, that “I sold my soul and went to science school,” too scared of the uncertainty (and inevitable poverty) that comes when acting becomes your vocation.

After wailing for what could have been, the two of us immediately broke out into an impromptu “Consider Yourself,” and my regret was never greater.

Next I saw my grade 7 teacher, Mr. Bebbington, who’s first name was John. My memory of Mr. Bebbington would best classify him as a hippie, and this was no less true 25 years later. Mr. Bebbington had us calculate our carbon footprint, annual water usage (read: wastage) and took us on expeditions to forests, fields and ponds where we got to touch nature rather than read about her. But the true value in Mr. Bebbington’s pedagogy came from his constant, unshakable offering of respect towards all the students in the class. He treated us like young adults, and perhaps in grade 7 we were, but it was the first time I felt an adult was treating me not like a child, but as a peer.

I’d had many wonderful opportunities to teach in the last fifteen years; from first aid to swimming to paramedics to undergraduate anthropology students to med students, I’ve often attempted to emulate Mr. Bebbington’s near-peer approach to making students feel welcome, comfortable and embraced.
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In Grade 1, I was segregated to a corner with one other student to read the Toronto Star each morning while the rest of the class learned to read. Anil, a brainiac with reading comprehension skills superseding most adults, would sit beside me as he read the front page. “Interesting situation at the United Nations” Anil would offer, and I would say “yes, very interesting” as I pretended to understand the newsprint.

For months and months I perpetrated what I can now confess was a total scam: I had no idea how to read the newspaper, except for the passages where Anil acted as an interpreter for written-to-spoken word. I suppose Mrs. White, a traditional-looking school teacher if ever there was one, saw potential in me, albeit ahead of my time. Regardless, I can trace the birth of my competitiveness and drive back to Grade 1, in the corner, with the newspaper, trying desperately to live up to expectations. Of course, 25 years later, I’ve refined these traits to compete against only myself, and drive myself to turn my dreams into reality. Thanks, Mrs. White.

Ms. Davies, the charismatic grade 4 teacher who hasn’t aged a day in 25 years, now runs an art gallery up north. We’ve been Facebook friends for years, though haven’t connected in non-avatar form since I left Morrish PS for the scary halls of West Hill Collegiate. Standing beside my lifelong best friend Thomas, she regaled me with stories of our antics, reminded me how I broke one of her mugs (and adhered to her “break one, buy two” etiquette) and couldn’t stop beaming when she heard of the career moves both Thomas and I had made.

Mr Epp never smiled, or so I recall the facial expressions of my Grade 8 science teacher. Whether growing plants in different lighting conditions or refracting light through a prism, science was fun, but not funny under Mr. Epp. With an appearance suggesting that Bill Nye owned a branch of his family tree, Mr Epp was the protoplasm of a science teacher. His green-painted classroom lined with science benches and Bunsen burners, we would funnel in from Mrs Griffen’s class to learn about photosynthesis, physics and other things I don’t remember but are likely evident all around me. Oh, magnets, we definitely did something with magnets.  And we found electricity in lemons.  That was pretty mind-blowing for a grade-eighter.

What I don’t recall Mr. Epp teaching was anything related to the human body, so credit can’t be placed here for my career choices. What struck me at the reunion last week, however, gets Mr. Epp an honourable mention in this post: for a man whose smile I can’t recall, 25 years later it was lighting the room. As students would walk past, he would instantly recognize them, and you could tell that he knew exactly which chairdesk you sat in, and much, much more. The joy he was experiencing hearing of our life adventures was touching, and reminded me what a privilege it is to teach others.

To all my teachers, past and present, thank you for fuelling my fire. Ralph Waldo Emerson once said “the secret of education is respecting the pupil.” For the teachers of Morrish PS, Emerson’s message was their mantra. 25 years later, the pupil still feels respected, and reciprocates that respect a thousand times over.

I’m hanging out on a cliff with this post… if you disagree with me, you’re not alone! Let’s start a discussion.  Comment below and let me know your thoughts.

Pimp (medicine, acronym): “Put In My Place”

Pimped (medicine, historical)): to be asked a question you don’t the answer to for the sake of making you feel small and insignificant.

Pimped (medicine, colloquial): to be taught something new

The word “pimp” is stupid. The phrase “yo, dawg, he just got his ass pimped!” is also stupid. I think Akash said it once. Doesn’t matter.   Recently, medical learners have revolted against the time-old model of medical pedagogy that involves standing in a circle and being quizzed. It shatters confidence and makes people feel vulnerable, they say. It’s for “sport”, others posit. Regardless, it’s application is highly debated by both learners and teachers alike.

Pimping can be bad.

I must admit, it can be awful if done poorly.  Pimping has certainly been used for evil. To shame, to “make an example of” or simply to draw delicious tears to feed the maniacal mind of an old-school physician to pompous to think he (or she, but let’s face it…) should occasionally leave his narcissistic mind, are all examples of pimping-gone-wrong. I should say that the most horrifying evisceration of an intern I have ever seen was executed by a female consultant, and at my institution the male consultants seem to be more vile in their treatment of learners and housestaff than the women.

But, ultimately, it is the culture, not gender, that predispose some of the smartest people in the world to pimping in the dumbest of ways. But most consultants, I would suggest, pimp appropriately. It is the learners who need to change.

Pimping can be good.

You see, I like to be pimped. It lets me know what I am expected to know, and whether or not I know it. It has identified flawed mental frames (normal speak: ideas) so deeply installed in my brain that a hurricane could not shake them. It has, quite simply, made me better at what I do.

When done well, the pimper feels like a mentor, a big sister, a teacher. But pimping is often done wrong. It shatters my confidence. It isn’t fun. It feels like the pimper is out to get me, judging me, hating me.

These episodes of “bad pimping” have given a negative to connotation to any type of pimping at all. It seems to me that if someone senior asks someone junior a question, the whole room of learners turns red with anger as their eyes roll as if the questioner were trying to light a fire with flint.

 

Pimping is misunderstood by learners

Learners, so coddled by a societal shift in education in general, and medical education along with it, feel insulted to dawn upon the idea that they might not know the answer to a question. To summarize what could turn into a rant, learners seem to think the teacher should teach until the learner has learned, that learning is passive. But learning takes work, and I think learners today don’t work as much as the learners of yesterday.

(If you read through the lines, I’m calling modern learners lazy. I don’t mean all modern learners, but I am comparing them to learners of the past, generally. This theory of mine blames societal and cultural shifts detached from medicine; I attach no negative feelings to any learners, past or present.)

Now, there are better ways to create new doctors than lectures, textbooks, and public humiliation. My MedEd Heroes can speak more elegantly than I on this topic (although it is likely to be the topic of a future post, which they will think is “cute”). But to prevent becoming tangential, lets just say that at some point in time a medical learner will need to leave the black-and-white security of a (flipped) classroom and enter the grey clinical environment, where people aren’t textbooks and procedures are harder than YouTube would have you believe. And at that point, someone smarter than you should, must, ask you questions.

Why is pimping essential to the learner?

• To get to know YOU. Each learner is unique. They have unique development needs. You don’t want me treating you like everyone else.
• To diagnose your difficulty and keep you safe. See, most of us make the same mistake as the last learner, and good preceptors can anticipate your challenges.  Maybe you think the vein is medial to the artery. (Sometimes it is, like when starting a femoral line, but sometimes it isn’t, like when starting a jugular line). By questioning you, I can get to that misconception, give you a trick or two to fix it, and watch you succeed.
  

  How I make sure I never cannulate an artery when placing a central line:

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• To advance your abilities. A house is made of bricks. Adding one brick at a time will help you become a competent physician. If I give you one brick, you can place it on whichever wall needs building right now. If I give you some drywall, you won’t know where to put it yet; it will get wet, or damaged, or you’ll just forget all about it by the time you’re finishing the basement.
• To frame your knowledge. My head has a lot of knowledge in it. None of it is useful at 4:00am during a cardiac arrest. What is useful are the algorithms, mind maps and strange stories I have created to organize that knowledge. When I shock a heart with a defibrillator, I’m not thinking about the joules travelling through the thorax or the cardiac action potential, or sodium and potassium and calcium and actin and myosin and lactate and the kreb cycle. I’m thinking “2 minutes is up, I see VF. Clear!” I became a clinician years after becoming a paramedic when a very smart critical care paramedic named Jonathan Lee drew a triangle on a piece of paper that he pulled out of the garbage can.  Five minutes later, shock made sense to me.

• 

• To keep you on track. Because we all like to binge-watch on Netflix.
• To challenge you. If you don’t like it, tell me, and I’ll stop. But I like to be challenged. I like to be confused and unclear and then set off on a mission to figure it out for myself. I like to know “why” or “why not”, the “what if” and the “unless”. I’m so engaged in sorting out my own frames that I’ll call out obfuscation by saying “Wait, but you just said…” This aggressive learning style has gotten me in trouble for being too “confident” or “cocky” or “questioning my attending” but has served me well when it comes to retaining knowledge, recalling concepts and defending my clinical decisions. Be challenged! It makes you better.

So, to all my teachers, peers, students and student-teacher-peers, let’s accept our own weaknesses, drop the sense of vulnerability that we hold dear in our construct of what it means to make a mistake, and learn always. For me, it’s a must, because medicine is way too cool to ignore, and way too important get wrong.

 

Here is How I Pimp: An example.

Please remember, I used to be good at something else [see above image] before I became a doctor, and I taught others how to do it well. I am not trying to be the PGY1 who tells his senior residents and consultants they have it all wrong; this whole pedagogical philosophy I am sharing is probably outdated and unsupported by evidence, and I look forward to developing it further through the mentorship afforded to me at McMaster.

I’m not the best preceptor, but I have about 20 emerg and critical care topics in my head that are my go-to’s. They translate well from paramedicine to medicine, and can be executed at different levels of advancement depending on my audience.

Here’s an example of my sepsis pimping session, which is accompanied by a sketch on a piece of paper that the learner can take home.  I’ve had this conversation with at least 100 learners over the past decade.

• Identify if/what the learner wants to learn

We have a few minutes, would you like to go over any topics?

• Spend a few moments sorting out where the pimpee is at

What can you tell me about sepsis?

• Set up question one for success

Can you think of a few conditions that can lead to sepsis?

• Tell a story as you flow through your pimping questions… lead up to the true message. Foreshadow future questions.

What do all those conditions have in common? *infections

What is the systemic effect of infections on the body? *inflammation

What clinical or lab signs might indicate inflammation?

Now here’s where I get really excited, since I’m a medic! *foreshadow

How does sepsis kill someone? *they got stumped!

• Explore pauses to see if the pause is healthy (is the pimpee trying to recall, do calculus, access memory?) or is the pause unhealthy (is the pimpee anxious, sweating, fidgeting?). Healthy pauses can be prolonged. Unhealthy pauses should prompt redirecting/rewording of the question.
• Have forks in the road you can take if a question is too hard/easy. Apologize/normalize when a question is too hard.

Ok, that’s a broad question, I forgot you were a CC2. *apologize

What’s the difference between sepsis and septic shock?

What clinical or lab findings might lead you to call for help?

• Make it clear you are getting to the whole point of this

Ok, here’s the punchline:

• Do brief teaching. One or two bricks, no more. Use a memory aid.

Septic shock: Think A, B, C!  Antibiotics, Boluses, Constrictors

Septic Shock: Kill a Wet Cat!  Kill the bugs, Fill with fluid, Catecholamines

• Reinforce the point of the lesson. Get the learner to lead this summary.

Septic shock kills people. It’s important to recognize and treat it early.

• Allow for questions in an open, nonthreatening environment.

Sepsis is complicated, and we went through that quickly. Was any of that confusing? Do you have any questions?

• Give homework or resources.

If you have time, see if you can sort out the difference between cold shock and warm shock. It comes up on exams frequently!  There’s a great blog post that explains it.

• Thank and encourage the learner.

Thanks, that was fun! You know your stuff, and you ask great questions. Keep it up! And remember, sepsis is deadly! Kill a Wet Cat!

Total time for me run through this with the average learner: 5 minutes.

How do you pimp? What do you think of my method? How can I improve?  Comment below or on facebook/twitter!  Thanks!

It’s a box in the top right hand side of the emergency chart, just beside the patient’s weight. I fill it in routinely, every time I’m seeing a patient in the pediatric emergency department. I systematically check the vital signs typed in at the triage desk, ask “Any allergies to medications?” and then “Are immunizations up to date?” I abbreviate it “ImmU2D” to save time. And each time I ask, my heart rate jumps for just a second, a guttural butterfly-in-stomach wave shoots through me, and I hold my breath while I await a response. “Yes, of course” most parents say, and I exhale, moving on to the next question.

Most parents. Not all. There’s a few, and I emphasize a few, who launch into a confident and slick diatribe when “Oh, we choose not to immunize” would do. It’s often dramatic, confrontational, and seems to have been practiced in the mirror over and over and over again. Of all the people I judge, I judge them the most: he who doth protest too much.  I try not to show it, the actor in me rising to Oscar-worthy performances that say “I don’t hate you, but I don’t in the least agree with you, but I’m trying to hit my quota of 16 kids this shift, so let’s just assume you’ve already been made aware of how stupid you are and have elected to be stupid regardless.”  I move on.

And that was it, I thought, until last night.

Now this isn’t a post about why vaccines are good. For the sake of completeness, the save lives, they don’t cause autism, and their utility in stamping out disease is based entirely on the concept of “herd immunity” – the idea that if two cows out of a hundred are susceptible to a disease, they can’t catch it from the 98 who are immune (since immune people don’t get the disease). It’s worth noting that some people – like babies and immunocompromised people – aren’t able to be immunized and thus depend on herd immunity for survival. If you like, Penn and Teller explain it better than I.

All of you have surely heard of the tragic death of Ezekiel Stephan, a 19-month old who died of bacterial meningitis after his parents, who are against vaccines, spent weeks caring for him with hot peppers, garlic, horseradish, and positive vibes, none of which kill Neisseria meningitidis.
This week, his parents were found guilty of “failing to provide the necessities of life,” a cop-out used by a Crown painfully aware that no jury would find well-intentioned (though stupid) parents guilty of murder. The maximum jail time is 5 years. This verdict, while better than an acquittal, angered me and, I suppose, made me extra-sensitive last night, 15 hours into my work day and still 3 hours from the end of my shift when I grabbed the next chart in the to-be-seen rack.
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NOT IMMUNIZED, I wrote in large letters, circling it twice (out of anger, not emphasis) along the entire top of the chart. I started taking a history, and immediately felt my eyes rolling as the parent recalled a years-long-battle with an “assumed” diagnosis of a rare, transient disease. I could feel the sarcasm broadcasting from my body. I performed a cursory exam, and reported to the consulting pediatrician that this patient could be discharged and follow up with their unfortunate immunologist. I could not hide my contempt, and my boss went in to discharge the patient. She came out with a signed consent to administer blood products. To save you the medical jargon, I had missed something serious that required immediate (and significant) treatment.

Eight hours earlier I sat in a lecture about being compassionate. I made a comment about trying to be compassionate towards people I dislike. And yet, primed by the tragedy in Alberta and tired of the vindication antivaxxers wear on their smug faces, I let my own judgments of a parent affect the care of my patient – a child – who was an innocent bystander in this massacre of my clinical integrity.

I’ll spare you the root-cause-analysis and discussion of cognitive biases. Suffice to say, I could have performed better. I let my “negative countertransference” towards her affect my ability to care for her child.

I’m no where near being able to throw compassion towards antivaxxers. But I’m more aware of my own reactions to these idiots, and (I hope) more capable of helping their extra-vulnerable children, lest a kid like Ezekiel be fortunate enough to end up in the to-be-seen rack before it’s too late.

This post was originally going to be a carping vent about other people who’s out-of-context assumptions about my ability to manage my own time hold me back from reaching my full potential. But as I sat down on the patio at a Queen St West pub, cider in hand, the negativity drained right out of me (faster than I could drain my pint glass). So instead, this is a post about the people who enable me.

“When you die, the most important thing you will have done with your life is mentor other people.” – Al Craig (paraphrased)

I just finished an eight-hour meeting of the MedicAlert Board of Directors. This group of 12 women and men are responsible for strategic direction and governance of a Foundation who’s mission is to save lives by providing emergency personnel with critical information at the time of need. During our meeting we discussed what we were looking for in prospective board members, and it got me thinking.

Like MedicAlert, I have a board of directors. It is a group of diverse and intelligent people who all place my interests in high regard. They believe in me even when I don’t believe in myself. They are a diverse group of experts from various fields that directly or indirectly play a role in my professional and personal lives.

One member of my Board once said something that I will never forget. We were at his retirement party at a yacht club and it was all very fancy. He stood up, thanked the crowd, and offered a reflection on his industrious 40 year career of saving lives, transforming systems, making scientific discoveries, and managing a half-billion dollar organization. These accomplishments, he said, were very nice. But the most rewarding part of his curriculum vitae wasn’t his war stories from the medical trenches, his political wins, or his list of publications. It was watching his mentees succeed.

Yep. His legacy, he sincerely believes, is evidenced in those he mentored.

 

As one of those mentees, I felt incredible privilege to have access to his wisdom, insight and investment and horribly responsible for my future endeavours lest I should let him down.

If my Board, which is spread around the globe in at least half a dozen time zones, were to meet in person, he would surely be the Chair.

 
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My Board

Who?  My Board is fluid, but most of the people on it have known me for a decade or two. They know who I am. They know what I am. And they know what I can do. Most importantly, they place my interests above their own, every time they give me advice. They make up most of the very short list of people I trust completely.

Why?  My mentors challenge me to articulate my crazy ideas. They expose weaknesses that could lead to disaster and make connections that lead to brilliance. Sometimes this puts a brakes on my plans, and other times it accelerates my path. In a few instances, it has completely revolutionized my life, putting me on a path I never would have found on my own.

How?  My mentors encourage me when I’m down, pat me on the back when I succeed, scold me when I’m insincere. They keep me honest, demand integrity and never let me forget where I came from.

Sometimes my mentors disagree with each other, but they never force me to pick favourites; I have the autonomy to accept, reject or modify their wishes so that I can choose my own path. If that path ends in disaster, they are right there to help me execute a U-turn, or pave a new way forward.

Life is complicated. My Board guides me through the ups, downs and in-betweens. I am eternally grateful to them for what can only be described as unconditional love. They care. Today’s interactions in the Board meeting opened my eyes to the importance of having a smart, diverse team of deeply committed experts behind you.  I understand what my mentor meant that night at the yacht club when he confidently preached that the most important thing you can do with your life is mentor other people.

As I move through my career, I do my best to mentor others using the examples taught to me by my Board. Those a big shoes to fill, but thanks to them I am on solid footing.

 

Who’s on your Board?

I’ve read nearly every Zombie survival guide out there, and can quite confidently state that when (not if) the Zombies arrive, arms grabbing and mouths gnawing, I will survive. While their dogged determination and sheer numbers have overwhelmed numerous B-rate celebrities in film after film, I have sorted out an algorithm of sorts, a protocol, to survive.

This protocol, the Zombie Apocalypse Protocol for Survival (ZAPS), is secret. I’m sorry – it’s nothing personal, but as you must know from 28 Days Later, displays of compassion during a Zombie Apocalypse will get you killed. I suppose you’re likely to come back from the dead as a human-eating Zombie, if that’s any consolation. Ok, fine, I’ll give you the basic components. You can try to fill in the blanks, and some of you (Brodie Nolan) are qualified to critique and collaborate on improving it.

AN ABBREVIATED GUIDE TO SURVIVING THE ZOMBIE APOCALYPSE
First, there is preparation.
Second, surveillance.
Third, rapid response, which has four prongs:
            1) Alert others as circumstances allow
            2) Evacuate if possible, else:
            3) Hide (for there are good hiding spots and bad).
            4) Fight (neuroanatomic disruption is the key)
And finally: Die heroically *in a fashion that excludes becoming a Zombie       
 *optional, depending on Zombie species.

How To Kill A Resident

With equal preparation to ZAPS, one could learn how to kill a resident. Residents are not Zombies, though if you stared into the eyes of a Resident post-call, you might mistake him or her for a creature from Resident Evil. Residents are, I feel the need to remind some of my Staff Consultants, humans. We have weaknesses, feelings, and insecurities. But since Residents are unlikely to attack you outside of the safety of their dreams, we could use their weaknesses to actually help residents live better, learn better, and be better.

There are four general ways you can kill a resident, none of which involve physical disruption of the central nervous system:

    Disengage them                Undermine their confidence

            Judge them to be incapable           Allow venomous commentary

And so, I present to you How to Kill A Resident, in the hopes that you will help inoculate us from these pitfalls of Mother Medicine and make us as invincible as the Zombies that will one day kill us all. Well, most of us.

How to Kill A Resident #1: DISENGAGE THE RESIDENT

Don’t listen to what a resident is saying.
Teach the resident something they don’t want to be taught.

Words, tone and body (or eye!) language should be listened to. If I am glazing over, staring off into the distance, or mesmerized by an environmental services worker’s mop movement, please stop teaching me how to work up cutaneous T-cell lymphoma. I DON’T CARE. Even if you think I should care, I don’t. So, either find an angle to get me to care or move on.

How do you find an angle? Treat me like an emergency resident, no matter what rotation I’m on. Find something that I need to know. Start your lesson with “here’s something that emerg docs get wrong all the time” or “let me tell you about a tragedy that could have been prevented”. No offence to consultants in internal medicine or surgery, but you don’t know what the Royal College expects me to prioritize in my Oral Board in 2020. What is important to you may not be important to me. Let’s work together to make my off-service rotation result in my development as an emergency specialist.

How To Kill a Resident #2: ASSUME THE RESIDENT IS INCAPABLE

Use the Law of Averages to think you know a Resident’s needs.
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Whenever I ask to do a procedure, I am asked “What PGY level are you?” My numeric response will determine if I am given what at the time seems to be the penultimate privilege in medical education (when in reality it is your job to supervise and guide me until I am competent in procedures). We all come from different backgrounds and through interest, chance or luck have different capabilities and experiences.

I suggest preceptors rephrase “What year are you in” to a more specific question: “how many times have you done this independently in the past? or “what step do you often have trouble with when doing this procedure?” It’s also totally fair to see if I have done my homework – “What are the contraindications to performing lumbar puncture” is a totally fair question if I ask you to let me stick a needle in someone’s spine.

Now that you’ve decided to give me a chance, I need you to be patient. Running through my checklist and fumbling with equipment takes time. It might even take another tray or pair of gloves if I break sterility. Help me prepare for success; I appreciate that screwing up is type of experiential learning, and I think it has value in simulators, but guiding me to success and following up afterwards with pearls and pitfalls is my preferred way to teach and be taught in a clinical environment.

How To Kill A Resident #3: UNDERMINE A RESIDENT’S (FRAGILE) CONFIDENCE

Show off.
Insult.

Dear Non-ER Consultant: I am a new, junior emergency resident. I am not as smart as you, and I know it. Rather than show off your knowledge, show off your teaching skills. Find my level. Help me raise it a notch. Don’t start with “what’s the FiO2 of room air” and move on to “interpret this blood gas.” If I don’t know something, I am to blame. But the system has also let me get this far without filling that gap. Let’s be practical: fill the gap to accomplish the goal of “me not screwing up again.” This is also known as “teaching.” 

During laparoscopic surgery, you can yell at me for not being able to direct the camera at the Ligament of Treitz (“Did you even go to medical school?”) or you can recognize my limitations and feelings (“Julie, can you take over for Blair? He’s very nice, but they don’t do much laparoscopic surgery in the ER, and I need an experienced camera operator during this critical phase of surgery.”)

A short guide to telling me to kick it up a notch:

My colleagues and MedEd heroes may disagree with this next part, but I think it has served me well as a preceptor of paramedics and as a learner. Save your below-the-belt punches for the end of the day. If my fragile confidence is shattered mid-shift, I might as well call it a day. Teach me what you can, and then sit me down before we part ways. “Blair, for someone who has been on this rotation for three weeks, you seemed to drop the ball quite a few times today. Is there anything you want to chat about?” is a fair way to call me out on poor performance while offering assistance. If I am below the mean, I appreciate being told “I’ve had a few other emerg residents recently, I would have expected your anatomy knowledge to have been stronger.” If I need a kick in the ass, kick me. Be obvious, be quick, and do it once. Please avoid the balls. I’ll do the rest. I am my own worst critic.

How to Kill A Resident #4: ALLOW VENOMOUS COMMENTARY

Allow trash-talking of residents
Give feedback badly

It sounds obvious, but we can forget the basics of humanity when we are working in health care. We are not perfect, but we all want to provide perfect care to every person who we interact with.

We are all learning (and will continue to do so until we retire). We all struggle. We all believe certain dogma that may, or may not, be kind of, or not at all, true. We are all inspired by our love of medicine. So we do not put people down. We seek solutions to our challenges, we reflect on ourselves, and encourage others to reflect on themselves. We feedback to each other, we feed back to ourselves.

Feedback is mandatory if we wish to fulfill our central purpose: to deliver perfect care to people in need. Please give me feedback. It can be positive feedback, or it can be negative feedback. It can be filtered, refined, or blunt. I love it all. But please give it in a constructive manner with one objective in mind: to influence my practice so that I can be an excellent physician.

Give me feedback with the intent of hurting my feelings, undermining my confidence, or disabling my curiosity, and you will be attempting to extinguish the burning fire that gets me out of bed each morning. Without that fire, I will be, by definition, burnt out.

Burn me out, and you will have killed a resident.

//

What do you think of my ideas? Please like, comment, share, tweet or use your rotary phone to dial your friends and tell them the URL of this page.

Feeling burnt out? Feel free to get in touch with me, the Doc Help Line 1800-851-6606, or check out this post here: Thoughts: On being less sad

 

For all intents and purposes, I am 24 hours away from finishing my internship. For those of you lucky enough to have never done an internship, it can be succinctly described as this:

Imagine running through a forest fire, trying to save as many rabbits and deer as you can, through acrid black smoke, without any idea where the oft-rumoured safe meadow of competence is.

Maybe that is a wee bit dramatic. Since the end of August last year, I have been assigned to work as a junior doctor in various departments of various hospitals doing various tasks that I know next to nothing about. Now, it is true that I am a doctor, but I am not a specialist. It is true that I am experienced in emergency situations, but I am not much of a discharge planner. It is true that I am a good communicator, but I am no social worker. Yet, as an intern, I must be all of those things (at three o’clock in the morning).

Emergency residents rotate through various specialties in their first year of residency. We tell ourselves we do this because other specialties have important things to teach us that will prepare us for a life in the trenches that is an emergency department; we will see post-operative complications following bowel resections, overdoses of psychiatric medications, extraordinarily complicated airways, sick neonates weighed in grams (not kilograms), broken bones exposed to air, and women who may or may not be in labour but are certainly in a heck of a lot of pain.

But the second reason (or perhaps it’s the first, and all that other stuff is the second) we do this is to “staff” services. Hospitals rely on junior doctors to consult patients in the emergency department, care for patients on the wards, discharge patients to make space, and coordinate community care, follow ups, and tests. We also provide night coverage to a hospital otherwise desert of physicians. Working up to 80 hours a week (or, as my dear friend on the surgery recently confided in me, 140 hours), we often work 24, 26 or 30 hours in a row with little to no sleep, running from ward to ward putting out fires.

That sounds crazy. Placing someone who is not a surgeon in a surgery ward to assess sudden drops in hemoglobin, or someone who is not an internist adjusting electrolytes levels, sounds very crazy indeed. However, I must say, the last 8 months has been one of the most fun times of my life. Scary, also. And stressful. But so much fun.

Thanks to WIFI, iPhones and really smart nurses, the junior doctors I work with deliver exceptional, if not confident, care 24/7. We’re pretty crafty people, and unfamiliar with a disease or procedure or situation as we may be, we are trained to find the answer, consult each other, consult our bosses (who we wake up when we are really unsure of what to do) and figure it all out. And in doing that, we learn.

Now, I’m not saying this is the best way to teach me how to be an emergency physician, or the best way to provide care to hospitalized people, but it’s the system we have, and I think it works pretty well. We can, and must, do better, and I’ll write about how another time. But on this, the eve of my finishing internship, I just wanted to express how much fun it has been, and how much I have developed and matured as a physician.
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Sure, there was that morning I was so tired I didn’t notice I put moisturizer in my hair until I had slathered my face with hair gel.

There was that time I’m 100% sure I was 99% responsible for someone dying.  That time I was yelled at by a family member, and uncharacteristically yelled back.  Times of gloom, sadness and tears.

But then, there were all of the other times. The time I picked up on an anastomotic leak at 3am. The time I influenced “flipping the plan” towards palliation for an elderly man who had the ultimate altered sensorium. The time I laughed so hard with a patient I snorted, and then they snorted at my snort, and then their neighbour, separated by a curtain, began snorting at snorts.

And then yesterday, when a nurse overheard I was heading back to the ER and offered me a make-shift going-away card.

Residency is hard. But when I look back on the last year where I played trauma team leader, paediatrician, obstetrician, anesthesiologist, internist, and general surgeon, I wouldn’t give it back for the world. There are many pejorative words we use to describe the first year of residency. But if I had to sum it up with just one, that would would be FUN.

In Part 2, I’ll discuss some of the ups and downs in more details, share a few stories I probably shouldn’t, and try to give you a good sense of the life of a resident doctor.

In Part 3, I’ll speak to the privilege of caring for people in a large, tertiary care hospital, and the wonderful people who make the monstrosity that is a Hospital function.

Thanks for reading. Have a beautiful week.