Originally posted on Dr. Sprague's personal blog, Life on Abram Lake, https://lifeonabramlake.com/
Trigger warning: Child non-accidental trauma
In the end, it was her eyelashes that broke me.
Impossibly long, feathered midnight against pale skin. The tips, crescendoed upwards with perfection. Those eyelashes, masking the horror of what lay beneath.
As the solo physician covering our local ER overnight, I was called to her bedside by the triage nurse. “The on-call worker brought her in,” reported the nurse. “She said she’s been sleeping the whole time she’s been in care since last evening.”
The first alarm ringing pressingly in my brain.
Laying on her back, her chubby arms and legs splayed across the parchment-like paper covering the ER gurney. Her chest rose and fell gently, seemingly unperturbed by the chaos of the nightshift playing out around her. Cherub-like cheeks lay slack, her expression serene. Her posturing reminded me of those long, torturous nights when Alice and Henry had been babies too – endless rocking, bouncing and shushing to coax them into dream-filled sleep. Then, finally, with a sweaty, sore back and a successful transfer to the crib, I wouldn’t be able to tear my eyes away from them. So captivated by their trusting, peaceful slumber.
Clutching the ER chart, her bruises immediately told me a story that wasn’t necessary to speak in words. Gently pulling back each eyelid, her pupils gazed unfocused beyond my penlight. Black inky pools. Transfixed in another world. My left hand, tenderly caressing the crown of her head, confirmed what I already knew. Underneath the downy softness of her wispy hair, her scalp was stretched taught, bulging outwards over the diamond-shaped opening between her unfused skull bones – pressure rising dangerously within. The natural soft-spot accommodating the volcano inside her brain.
A hustle to the trauma bay, an IV, a breathing tube, medications dripping into her veins. Alarms beeping, the ventilator bellyaching resonantly as always. ‘Breathe, baby, breathe’, squeezes the Ambu bag, driving air into her lungs. My iPhone hot against my cheek, I direct the orchestra of the ER with one ear listening to specialists hundreds of kilometers away circuitously debate which centre would be best to receive the transfer. Which plane? Which crew? What equipment? I grit my teeth, impatiently.
Hours later, the glass entranceway to the ambulance bay sweeps shut with a definitive air. Beyond, the doors of the ambulance are flung wide as if in expectation of an embrace. I watch as she’s loaded into the back in a carefully, premeditated dance of cords, monitors, tubes and personnel. Then she’s gone.
It’s 4:45 am now. A man hollers from a stretcher in the hall. I hear someone else retching nearby. I imagine myself walking out into the night. Crickets chirping, the birds warming up their morning ballads. I wonder how long it would take for anyone to notice that I was gone.
Instead, I plod into the doctors’ charting room, closing the door against the hustle of the central ER nursing station and rip off my mask and protective goggles. On the desk, the upturned mask cradles a slurry of tears and snot that I hadn’t realized had even been there. The hospital-grade tissue scratches my nose as I attempt to mop up the mess that is my face. “Fuck”, I spit out. “I need a goddamn hose!” Flopping into my chair, I spit out a soliloquy of expletives. Face tight with rage, I curse feverishly – railing against no one and everyone. My curses fall vehemently on the systemic dysfunction and generations of trauma left behind in the wake of hundreds of years colonization and assimilation practices. I cuss out an overwhelmed, ineffective child welfare systems that time and time again fails to keep children safe and who had failed massively to keep her safe. I despair with fury at the hopelessness of it all – the vortex of addiction, suffering and violence.
Beside me, my anesthetist colleague and friend sits silently, expectantly and unhurried. Out of breath, I finally meet his eyes. He says little and we don’t touch, yet I feel connection deeply. I know he understands fully. It’s enough comfort for me to pick up the next chart, see the next patient and numbly, continue on.
I close my eyes. Those goddamn perfect eyelashes.
In my medical training, I learnt much. Into my brain I crammed the intricacies of the nephron and the flow of blood through the heart, looping through each ventricle and across each valve. I mastered how to advance the spinal needle millimetre by millimetre through spaces of the vertebrae until it popped through the ligamentum flavum – the shock and joy of clear cerebrospinal fluid dripping into my specimen tube like sap running from the sugar maples during the syrup making-adventures of my childhood. I memorized the diagnostic criteria of Psychosis NOS while my hands learnt the pathway into a woman’s womb to gently coax the afterbirth to come, a lifesaving maneuver as blood swamped my shoes, a syrupy puddle around me on the floor.
Interestingly, without instruction, I also seamlessly mastered the art of dissociating, separating effortlessly from my body. Pushing through sleep deprivation, ignoring my bladder’s plea to be emptied, surviving on saltine crackers and peanut butter packages from the patients’ snack area on Labour and Delivery – all were engrained deeply within the culture of medicine and thus were accepted to be normal behaviours. It didn’t even occur to me to question it and more curiously, the more I disregarded my own wellbeing, the more I was rewarded and praised for being hardworking, a selfless team player and a better doctor.
“We split from our bodies so we can learn to be doctors. Isn’t that ironic? We deal with corporeal failures, but we think we can program bodies, our bodies, to run without sleep, or food, or hydration. We learn to work through utter exhaustion. We dismantle the safety valves evolution built to keep us from doing anything important or dangerous on too little sleep… Medical education says: You know why that ancestor of yours needed sleep? Because he was an ape. And by extension, if you can’t function without sleep, well, that can only mean you’re an ape too.” Dr. Jillian Horton, We Are All Perfectly Fine
To counter medicine’s age-old practice of eating their young during their training, occasional offerings of ‘Resident Wellness’ were enforced during my medical education, but these random half days of mental health lectures and guided meditation felt like throwing someone a life vest in the middle of a Tsunami. I was going to drown anyway and I could never stay awake past the introduction of those mindfulness sessions, I was so desperately spent.
Continuing the drift away from normalcy, throughout medical school and residency, I was schooled rigorously in pathophysiology and pharmacology, astutely memorizing each disease entity and its treatments. Yet no one ever tutored me in ways to cope with the inevitable trauma of a lifetime career in witnessing and carrying others’ suffering.
Instead, without an alternative strategy, I continued the trend of blind dissociation and began to package each experience into its own Uhaul box, labeled and stacked perfectly onto tiered shelves. Tucked away neatly in the shadowy basement of my mind, lest anyone realize that I couldn’t cut it in medicine. Truthfully, it was only a matter of time before it was discovered that I didn’t belong and that my entrance into medicine had been a result of a glitch in the system.
That time I feel asleep on my General Surgery rotation, assisting in the nauseating wee hours of the night, exhausted from being awake for god knows how long. My head nodding down into the surgical field, the retractors going limp. The scathing words from the surgeon. The shame, the feelings of inadequacy. Shoved into a Uhaul box. Duct tape closed, labeled with a perfectly pointed Sharpie.
The time on a Trauma elective at St. Mike’s, I was called to assess a gentleman post-operatively who was labouring to breathe. I didn’t know what I didn’t know. I failed to recognize how his heart was rapidly failing him, fluid backing up into his lungs and drowning him as he lay in his ward bed. I ordered a chest x-ray and medication, but didn’t reach out for help from my senior resident who was endlessly in the OR and who had explicitly requested not to be bothered with ward issues. That was for me to figure out. By the time I checked on my patient again, his face shone with the effort of each breath. I neglected to see he was clearly in what we call ‘Impending Respiratory Failure’ – his body skirting the edge, the Reaper hovering close by. My fingers on his wrist in a panicked grip, his pulse thready until I felt it slip away altogether like a glimmering walleye – gliding silently back towards the lake’s murky bottom. Ribs splintering under my hands. Code blue. PEA arrest. Another box, taped tightly, pushed high up on the shelf.
Over time, I began losing track of the stories and experiences. A practiced response over and over, the boxes piled higher, soon hastily stacked haphazardly with no time for labeling.
Once released as a staff physician, working full-time as a family doctor in a rural centre, I had learnt no other way to cope. I was so focused on learning the ropes, getting established in my practice and staying up-to-date with my knowledge. One foot in front of the other, grab the next chart, see the next patient. Each day, I collected stories of sorrow, violence, despair to be dumped into a box at the end of the day. A neonatal death after running a Code Pink – into a box. Cradling a 22 week fetus in my heads, dead before it had been granted the ability to breathe – into a box. Stitching deep scalp and face wounds and stanching the flow of crimson after a woman had been beaten violently with a bat – into a box.
Something in me had been completely undone during my training. Looking back now, I wonder if that thing had been my humanity. That ability to dissociate which had served me so well in medical school and residency also had left me fractured. On a cerebral level I understood the diagnosis of PTSD but deep down, I couldn’t understand why those affected by PTSD couldn’t simply push on like I did. It never occurred to me that I was the one who might be broken.
“Most doctors look fine, perennially, until the day they don’t. That’s because doctors are excellent at compartmentalizing. We are also compliant and conscientious and rigidly perfectionistic, characteristics that put us at risk for choking to death on our own misery…” Dr. Jillian Horton, We Are All Perfectly Fine
This summer, I read a memoir written by a Winnipeg Internist, Dr. Jillian Horton. I devoured her words, like I ate donuts on the way out of the ER after a nightshift, gulping down their stale sweetness without bothering for air. She introduced the concept of medical education as trauma using metaphors like her pager as an explosive device involuntarily strapped to her body and the medical ward as her own ‘personal Vietnam’. Not capital ‘T’ trauma, but a series of daily events and distressing experiences that exceeded her ability to cope. All of those boxes, taped tightly shut, piled sloppily on shelves.
“Burnout isn’t a clinical diagnosis, right? It’s a phenomenon. But you take a bunch of people who are altruists and perfectionists and have the same baseline predisposition to mental illness as the rest of the population And then you put the in ‘jail’ for five years, and you script everything they do right? You limit their sleep, you limit their food, you cut them off from their loved ones; they kill a few people by accident and you tell them everything is their fault, but if they keep their mouths shut maybe nobody has to know what they did. But in return, they have to take over running the prison. Do it to the next generation.” – Dr. Jillian Horton, We Are All Perfectly Fine
Unapologetically, Horton points to the destructive way in which we are trained to become doctors, revealing the glaring connection between these experiences to not only the excessively high rates of physician suicide and burnout, but also, simply, to our inability to practice self-compassion and to be well ourselves. I was rapt. Could this be indeed possible? Had I missed this the whole time?
“…doctors look fine until the very end. This is a silent emergency, and even if the people around me can smell something burning, none of us has made the connection that the thing on fire is me.” – Dr. Jillian Horton, We Are All Perfectly Fine
“Medicine dose something to us,’ describes Horton. ‘It teaches us another language, one only other doctors can understand. Eventually it scripts our emotions, neutralizing them whenever they threaten to overwhelm the senses. This also happens to police and firefighters, coroners and soldiers and paramedics, a misguided Clockwork Orange rewiring of the motherboard. But it’s not by accident.’
Each story in Horton’s book resonated with me deeply. Her anecdotes, so similar to mine, and likely to many others, clung to my brain. I read and re-read her words, desperate for an answer. But Horton’s memoir was not a self-help book with a step-by-step guide in becoming whole again. What Horton strongly preached, however, was meditation and mindfulness practices as way of ‘rewiring the motherboard’.
Ugh, mindfulness and meditation? It always seemed so futile to be offered these strategies as a way of coping in medicine. Breathy instructors urging me to ‘just notice… just be aware…'(why, goddamn it do they always need to start every sentence with ‘just’?!) in a whispy and irritating air. Meditating always made me feel impatient and angry, to be truthful. It felt like there was a gaping chasm between what I was experiencing in day-to-day life at work and the seemingly fruitless act of asking me to breathe repetitively. I AM BREATHING, damn it!
I also abhorred meditative practices because asking me to sit still and notice my thoughts was akin to requesting that I walk headlong into a massive bonfire to be slowly and painfully burned to the core. There is a reason that I have a strong aversion to ‘just sitting down and relaxing’, as my husband Blake is constantly requesting of me. Being still in mind and body gives space for all of those images and stories, all of the times that I wasn’t perfect, all of the cases that I messed up, all of that shame and suffering packaged tightly away. After a decade of stuffing it all into dark corners, I wasn’t even sure anymore what exactly might be released to haunt me. My dreams were already haunted enough.
In late May, news headlines across the globe screamed of the atrocities of the Indian Residential School System in our country as remains of 215 children (and now, not surprisingly, so many more) were found on the grounds of the former Kamloops Indian Residential School in BC. Nightly, I laid awake, imagining Henry and Alice being ripped from my arms by force, loaded onto a float plane to some unknown destination, abused and violated in unimaginable ways without my ability to protect them and end up underground before their tenth birthdays.
I was already drowning in hopelessness and despair over our collective inhumanity when the baby with cherub-like cheeks and perfect eyelashes was brought into the ER and forever into my brain. At 4am, in the back doctor’s room in the emerge, I felt something give way.
Too immense was this suffering of the intergenerational trauma left behind by the legacy of the Indian Residential School System, so blatantly in front of me during that shift, and frankly, every shift before and after it. So overwhelming was the hopelessness of broken systems of government, of child welfare and of mental health care that were supposedly in place to heal. All of this, could no longer be put into a box.
This fall, I no longer will be working at the Meno Ya Win Health Centre in Sioux Lookout, my medical home over the past seven years. With a locum job set up at the local family medicine clinic in Kimberley, BC, a small town in the Kootenay mountains, I am taking a year of leave. Although awash with guilt for literally running to the hills, without a taxing clinical schedule, no call and only run-of-the-mill family medicine problems to deal with, my hope is that this stretch of time may eventually be one of self-healing. It’s easy to have compassion for others but much more labourious to direct loving kindness inwards. As Horton explains, “My training was an apprenticeship in the art of self-immolation. I excelled at it: I strove to master it the same way I applied my full self to everything. You don’t just undo that overnight. If you ever undo it at all.”
The work is not easy. I struggle, resist and sometimes even resent walking toward the bonfire. However, with help from a physician therapist who specializes in using focused mental practice, I am learning how to be still, to let the pain come and to hold space for the suffering. Daily when I sit, her eyelashes always come into focus but less and less I am overcome. I imagine her safe, cuddled in her mothers arms, babbling with bright eyes. ‘May she be well, may she be happy, may she be free of suffering,’ I hear my therapist soothe. I breathe in for me, out for her. In for me, out for her. In for me, out for her…
Dr. Celia Sprague is a family physician in rural Northwestern Ontario where she works for Indigenous communities in Sioux Lookout, ON. Although a generalist by training, she primarily focuses on ER and FM-OB in her practice. When not at the Meno Ya Win Health Centre, Celia enjoys the natural beauty of the area with her husband and two children.