A Prescription for Writers Block

 

“If I waited till I felt like writing, I would never write anything at all” – Anne Tyler

A dear friend called me today lamenting about a particularly bad case of writers block. If my factitious epidemiological data is to be believed, 10/10 writers will experience writers block in their lifetime. While writers block is usually self-limiting, resolving in hours-to-days, severe cases can persist for weeks and require the intervention of a specialist.

Signs of Writers Block are sometimes hard to talk about and include:

-avoidance of writing tasks

-frustration when staring at blank pieces of paper or computer screens

-demoralisation and loss of sense of self-worth

-sudden desire to quit

-googling new careers

The Prescription:

Stage 1 Writers Block

  • bomb2.JPG
    You’re a writer, not a bomb tech.  Don’t feel pressured.

    Plan your writing day. Schedule it. Sleep well the night before. Eat breakfast.

  • Have a reward in mind for after the task. Pizza? Yoga? You name it.
  • Make a list of things you want to write.
  • Change locations. A different room, a coffee shop, a library… find a spot where you can be alone without distractions.
  • Walk away. You have to be in a mood to write. If now isn’t the time, go do something else and come back later.

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Stage 2 Writers Block

  • Draw out a skeleton of what you need to write. See if a particular component speaks to you, and start writing about that. If none of the components seem interesting, try writing just one sentence for each one. Sometimes one sentence will turn into two, or three, or a book.
  • Post-it notes with paragraph or section titles stuck on a wall allow you to move things around and use visualization to frame what you are trying to write.
  • Write the end. The end is always the best part, and by writing it, you may feel inspired to tell the whole story. Of course, you’ll edit the end later… maybe.
  • Write something else. Rather than write what you are trying to write, write about something you want to write about. Maybe a poem about cats, or a rant about your toaster. Be silly, be tangential, and write like a lunatic. Once you start to have fun writing, you may start to gravitate back to the work at hand.  The saying is “the worst thing you write is better than the best thing you did not write.”

Stage 3 Writers Block

  • Stop writing; read.  Go read a book.  A book you want to read.  Reading will sometimes encourage creativity and you just might get inspired to run back to that writing task.
  • Consult a friend. Gain perspective. Get inspired. Be told you need to forgive yourself for your writers block, which isn’t your fault at all.
  • Ask for deadlines. Speak to your editor, supervisor, or mentor. Ask them for a due date. Commit to it.
  • Go back in time. What originally inspired you to end up having to write? Remember those emotions. Allow them to carry you through the difficult task of putting pen to paper.

If none of these ideas work, it’s ok. Consult this:

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Emergency Writers Block Algorithm

Do you have tips and tricks to write well?  Share them in the comments!

Thoughts: Make Your Patient Feel Super(Elite)

(This relates directly to medicine; give me a minute to get there…)

I’ve come to learn a thing or two about how to make the flying experience a little less painful. The year before I quit my job to attend medical school, I spent 91 nights in a hotel, 11 nights on an airplane, visited 32 countries, and flew 304,542 miles. That’s nearly 1 in 3 nights away from home and just a few miles short of flying to the moon. I’m not bragging – trust me, flying that often isn’t all giggles.  But when airplanes, airports and hotels become your home away from home, you start to notice the little things.

 

blog lines
I wonder if patients feel like passengers sometimes.

Most people fly once or twice a year, and they often find their skyward travels infuriating. Can you imagine waiting in check-in queues every day? Sitting cramped in the back of a jet for 72 hours a week? Eating chicken (or was it beef…) that tastes oddly like paper mache? You would feel unloved.

 

blog gold line
Ahhhh that’s better.

But the airlines love people like me and they have us in their sights; see, my company spent over $100 000 to fly me almost-to-the-moon that year. That’s money they airlines want, and they want it badly. Badly enough to go the extra airmile and improve my flying experience so I choose Airline A over Airline B. And you know what? It works. Over the years I have developed my loyalty, sometimes based on rationale and other times based on irrational emotions.

These perks I get – from hotels, airlines and travel companies – make for exceptional travel experiences. Flying to Australia for a week makes sense when your trip over is in Lufthansa First Class and your ticket cost nothing more than points in some bank you’ve accumulated over time, and you bypass every line an airport can throw in your face.

blog lhasa suite
Suite upgrade? If you insist.

One of the smartest tools the airlines and hotels use is to give me an honorary title. I’ll never forget the day
Air Canada declared me “Super Elite”, or the day Hilton upped my status from Gold to Platinum. With those titles come perks that start with customer service and end at every possible detail the discerning traveller could care about. These perks have one massive effect: they make me happy.

I’m often told I have great bedside manner. My patients seem to like me, and I think that means they listen to what I tell them about improving their health. By providing a great experience in what are universally shitty circumstances, I am able to build credibility and exert influence that, I hope, leads to behaviours that are conducive to good health.

This bedside manner isn’t innate; it’s learned. My experiences travelling in gifted luxury have rubbed off on me in a good way (and also bad ways, as my close friends remind me every time I get pretentious).

Here are my Top 6 Tips to make your patient feel SuperElite.

  • Make people feel welcome by connecting with them. Know your patient’s name, and use it while making eye contact. Do this at least twice; once at the start of the interaction, and once at the end. I repeat: and once at the end. We are great at starting off strong, but often we end by dashing off in mid-sentence. Close the conversation in a genuine fashion.  Did you know that hotel maids are taught to say “Hi” to guests that they pass in the elevator or meet in the hallway and hotel check-in clerks are trained to discuss the city you’re from? These are ways of making you feel like you belong.
  • Acknowledge screw-ups. The wait, the delay, the miscommunication, the odd paucity of pillows in hospitals, the terrible food. Acknowledge that we could, we should, do better. It’s not offering excuses, but it’s not hiding our limitations under the rug either.  Have you noticed how irritated people get when their plane is late but they don’t know why? A good airline will announce the reason for the delay and update passengers on when the flight might board.
  • Patients are my guests. The hospital is my home, and I am a host. Patients are not a pain in the ass, they are not intruding, and they are not a bother. Use phrases like “I’m really glad you came to see us for this” to validate their presence. Use phrases that demonstrate that you are there to help them. Small word swaps can make huge differences. When a patient asks for a glass of water, “sure” or “yep” can be swapped for my favourite phrase, “My pleasure.” Make eye contact to add non-verbal language that you actually want to get them a glass of water, because you don’t want your guests to be thirsty. I’m not suggesting we do anything unreasonable or burdensome, but small tokens go a long way.  Hilton Hotels has noted my preference for a high floor (I love skylines).  Each time I check in, the clerk says something along the lines of “And Mr. Bigham, I’ve found a room right at the top floor.  You’ll have an incredible view.”
  • Offer “perks.” It really doesn’t take much time, and it makes all the difference. A glass of water, a warm blanket, an adjustment in the recline of the bed… it’s a small signal to say “I want you to be comfortable here.” Many hotels will give frequent travellers suite upgrades, while airlines will upgrade SuperElite fliers to First Class or provide complimentary lounge access.  Lufthansa goes the extra mile: on my recent flight to Singapore, they picked me up at the lounge in a Mercedes and drove me down the tarmac directly to my A380! 
  • Watch your non-verbal language. Nothing is worse than words that don’t match their delivery. This makes people feel abused and disrespected.  Many companies will have specially-trained staff take care of their elite guests; these staff are trained in the fine points of communication.
  • Set expectations. Let people know why they are waiting and what is going to happen next. Evidence strongly shows that people who are dissatisfied simply wanted to know what was going on. “I’m going to do some bloodwork, and it should take about 2 hours to get the results. In the meantime, please don’t eat or drink anything in case you need surgery. If your bloodwork is normal, we’ll get you a sandwich.”   Part of this is to promise a little and deliver a lot. If you say 2 hours for blood work and it only takes 90 minutes, you’ll exceed expectations.

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Does this resonate?

Think about your last trip on a plane, or stay in a hotel. What made your experience particularly special? Can you be specific? Was it the tone of the gate agent, the upgrade to more leg room, the art in the foyer? It was probably a small detail… a “nice little touch” that made you feel particularly well-served. It only takes an inch to go the extra mile and make your patient feel SuperElite.

LH FC
If only every hospital bed came with a rose and mimosa… 

If I still haven’t convinced you, there is strong evidence that nice doctors don’t get sued as often as mean doctors, so re-read this post with that in mind. 🙂

A summary of tips to make your patient feel SuperElite:

Welcome people. Connect with them.

Apologize for screw-ups.

Patients are our guests. It’s “our pleasure” to care for them.

Offer “perks”.

Be aware of non-verbal communication.

Promise a little, deliver a lot. Set expectations.

“Hi Elaine, I’m Blair, one of the resident doctors working tonight. I love the author you’re reading! I’m so sorry for the wait. I heard about your chest pain from Julie, and I’m so glad you’ve come to get it checked out. I’d like to do some bloodwork, which will take about 2 hours to run. Can I grab you a warm blanket while you wait?”

//

How do you go the extra mile to make patient’s feel welcome?  Comment below!

The Amygdala Hijack

Millennia ago, before cannons and flintlocks, sabre-toothed tigers stalked our ancestors. Like most creatures of prey, Darwinian evolution led us to adapt to threats like tigers. We learned to run from danger or, when running wasn’t an option, to defend ourselves to the end. This was not only a mindset innate to humans, but a complex biochemical response: when faced with danger, hormones flood the body, blood delivery to muscles is prioritized, senses are heightened. This response, the Flight or Fight response, is triggered in a small part of our brain termed the amygdala.

blog amygdala

Fortunately, sabre-toothed tigers don’t roam modern-day streets. Our bodies, however, haven’t caught up to this reality; the amygdala is standing ready to superhumanize our bodies should our survival be in question. The amygdala works at lightening speed: it bypasses the frontal cortex, where options are considered and debated based on reason and fact, in favour of instinct. Located deep in the part of the brain we share with prehistoric reptiles, the amygdala causes us to react to stress. Sometimes, that stress can be maladaptive, harming us more than it helps. In that sense, our amygdala hijacks our brain, sending our heartrate through the roof and filling our stomach with butterflies.

blog jumper
Some jobs are more stressful than mine.

If you work in a high-stress environment that demands high performance, the amygdala hijack can be deadly. SWAT team snipers, Navy SEALs, 911 operators and emergency workers all face high-stress situations yet must remain level-headed. The conundrum? We are trained to listen to the amygdala! Pattern recognition allows for fast reactions to new information. Secret service agents scan crowds for suspicious patterns just as emergency physicians can spot a heart attack patient from the other side of the room. This allows our mind to pick out problem patterns that are dangerous – to the president, to the patient, to us – and put us on an instinctive reactive pathway.

And this is where the system falls apart; once the hairs on the back of our necks go up and we have been alerted to a threat, we have to quickly overcome the amygdala and analyze the situation. See, the amygdala overcalls threats. A car backfires, and you startle. A plane has some turbulence, and you grip the armrests. We react a little too often to stimuli that the amygdala interprets as threats, but actually aren’t.

The trick, then, is to know how to control the physiologic response set off by the peptides coursing through your veins once the amygdala sounds the alarm. Rather than react immediately, we must suppress that crocodile-brain of ours and activate our frontal cortex, the part of the brain that makes us smarter than every other species on the planet. Except maybe dolphins, I hear they are pretty smart, and they’ve never voted to leave the EU… but I digress.

blog dolphin
I think dolphins are pretty smart.  Can anyone validate this opinion?

Whenever I feel my amygdala taking over, I repeat a calming mantra to myself:

Pause, Reflect, Respond.

The amygdala short-circuits the frontal cortex in favour of immediate, instinctive action. My job is to take that intuitive signal and check it against the facts. I pause. I regain control of my brain, quite deliberately, by switching off the hormonal response. A slow, deep breath in pushes the diaphragm downwards, activating the vagus nerve. The vagus nerve activates the parasympathetic nervous system, reversing the effects of the amygdala hijack. Holding the breath stimulates baroreceptors, sending calming signals to the brain. Nodes in the heart are stimulated to slow, epinephrine is moped up and cleared out, and the fog of fear clears from the mind, restoring the analytic abilities of the frontal cortex.

blog breathe
If you have big lungs like me, replace “4” with “8”.  It only takes two or three of these cycles to change your physiology.

Alerted to danger and ready to think, the next step after pausing is to reflect. Are the facts that I am seeing congruent with the emotions triggered by the amygdala? Is the threat real? Can I obtain more data to confirm my intuition? Some of this will seem very familiar to work done on the psychology of clinical decision making championed by Nova Scotian Pat Crosskerry, and it is! You can check out some of his work if you are more curious on how health care workers think.
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Now that I have considered the information, I can respond to the situation. Note the word “respond” rather than “react”. A reaction is quick, instinctive; a response is slow, considered. That’s not entirely true… skilled and experienced health care workers can experience an amygdala alert, pause, reflect, and respond, in milliseconds – but only because they have trained their brain to do so.

Pause, Reflect, Respond is of course oversimplistic. Pausing, I find, is incredibly challenging when the stakes are high and a room full of people are looking to you for leadership and direction. Reflecting involves teasing out reality from my own perception of reality, where cognitive and social biases are deeply rooted. Responding requires confidence and ability, something I am still developing as a junior doctor, and negative self-talk, self-doubt and “impostor syndrome” frequently scare me away from a plan of action in favour of deferring to others, a feeling that I don’t (anymore) have when I work on the helicopter (and one of the key reasons I continue to do so). I am practiced at Pause-Reflect-Respond to nearly any situation I come across on the helicopter, but in the emergency department, it’s a different ball game.

Lastly, while clinical analysis is our core job, emotional intelligence is what really gets the job done. Being able to lead a team to achieve the goals required to treat a heart attack patient is as essential as knowing how to identify and treat a heart attack. Pause-Reflect-Respond applies to this realm of medicine also; understanding the state of your team, and being able to modify it to achieve higher performance, is the hallmark of an effective emergency physician.

The amygdala hijack causes smart people to do dumb things. By pausing, reflecting and responding to stressful situations, we get the best of both worlds; accessing our past experiences while analyzing new ones helps us utilize our entire mind to best lead teams to perform at their very best. High performance teams freed of the amygdala hijack –be it on the battlefield, in the cockpit, or in a resuscitation bay – save lives.

 

Are you good at controlling the Amygdala Hijack?

Do you have the tendency to:

-be deliberate and apt to survey a situation before responding?

-control your emotions?

-resist impulse under times of stress?

-describe yourself as emotionally neutral?

-not allow emotions to colour reality?

 

Have tricks to overcoming your fight-or-flight response? Comment below!

Travels: India Scribbles

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.

Thoughts: Someone in Orlando tried to kill me

“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?

 

Stories: Directions

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. By viagra soft tab objectively studying a situation you’re able to visualize performing a task that earlier used to make you nervous. It is also considered that the lower esophageal sphincter dysfunctions when stomach acids are produced more that they are levitra canada price needed. Another benefit of taking adult drivers ed online is that they are available india online viagra at a much cheaper and smart action to take. 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.

Travels: The Hostel Politik

Written in Rishikesh, India whist backpacking.  January 2015.

The dogs barking at your taxi as it rolls in.  You’re painted with inexperience, experienced as you may be, but your credentials, street or otherwise, don’t matter here, not now, not ever.  Someone smiles, acknowledging your outofplaceness.  It doesn’t take long to start talking with strangers as if you were old friends from highschool.  You get tips, orientations in half-sentences from people whose name you won’t ever remember.  You’ll be lucky to remember their faces, although before you know it you’ve told them revelations that you yourself didn’t realise until now, until your mind was alone to think in a place where there isn’t much else to do; the type of stuff you keep from your best friend for reasons you don’t really understand.  Maybe it’s because I’ll never see them again, vanishing before they can conjure judgement. Due to this, couples often experience dissatisfaction & this leads to ruining a relationship. generic cialis samples The penis will remain erect till the level of cGMP which Cyclic Guanosine cialis generico in india Monophosphate another enzyme that is essential for circulation of blood. There are mainly two categories that cause erectile dysfunction and they were forced to ingest generic viagra pill hokey cure-alls and dubious panaceas to treat their erection-related problems. Reputed UK Based offer Best Prices The reputed UK based drug stores such as ukkamagra offer these medications at the viagra india appalachianmagazine.com cheapest prices.  Now I’m getting a tour of the town from the old-timer (who is 21 years old); where to get the best lassi, the max bid for a tuk tuk (its more if its raining, or if its dark, or if the train just came in), the local price for toilet paper rolls.  The next thing you know you’re the only guy left in this place who knows the way to the secret, abandoned and overgrown ashram that surely inspired a King novel, the one you explored with your camera and your new friends and your old ghosts.  I came into their space, and now their space has been left to me, as I smile to, greet and tour around the newbies, making sure I check my sense of seniority in favour of a humbleness that begets communion.  Its the same each time one of us leaves, and one by one or two by two, we all leave.  The gathering, the hugs, the wishing of safe travels, the half-promise to keep in touch.  And then the taxi is gone, the dogs barking.

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

Teachers past are not teachers forgotten

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

Remember the rows of desks in pblog chairdeskublic 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.

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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.

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Oh, what could have been… 

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, blog bebbingtonbut 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 offblog whiteer, 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.

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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.

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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.

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While digging through old boxes in her classroom, Mrs White found a classic from 1992: “Patterned slide dines at heights to overcome vertical limits imposed by botanical growth” can be ordered in a limited edition print.

Thoughts: How to Pimp like a Teacher

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.

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While medical technology and education theory have both advanced, it’s sometimes hard not to feel like I’m in the 19th century.

 

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:

That emotionally unstable teenager would have committed suicide even if her nude photos were not posted and forwarded to her classmates. viagra 100mg for sale Kamagra tablets can benefit purchase cialis online the male and the female or both partners. As you continue to receive healing session from a practitioner, you will notice that your junk email folder is currently full of emails from companies in these industries, hounding you to use the cialis for sale canada check here money you win from their poker website to buy penis enlargement pills to take while you look at their porn. The Securitas Security Depot heist in 2006 is to date the largest cash robbery ordering generic viagra in UK history.

JUG LINE.png
A giraffe’s neck is really long.  It’s carotid artery travels through the middle like a superfast highway, while the veins are like access roads running along the outside.  This is what I tell myself when I start a jugular central line so I don’t accidentally hit the carotid.

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“Venous to the penis” is how I remember the relationship of the femoral vein and femoral artery.  Opposite to the anatomy of the neck: Mother Nature’s lawsuit-waiting-to-happen.
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This is a central line kit.  Central lines go in veins to save people’s lives.  When they end up in an artery, it’s, ummmm, a thing.  Because I am usually under pressure when putting them in, I always say “Giraffe Penis!” to make sure I do the procedure correctly.
  • 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.
  • cardiac arrest in head.png
    Left: everything I know about cardiac arrest.                            Right: Me running a code.
  • 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.

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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.

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

Talking to Antivaxxers: headache, heartache.

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 pediatblog vax stamp.pngric 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 blog slideit 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.

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Ezekiel Stephan