Dr. Zaza takes empathy to a new level

Empathy is one of those things that is important for a doctor or a nurse to have. Empathy is putting yourself in someone else's shoes and feeling with them- understanding their suffering. It's important because if you are going to put a patient through a procedure that is painful, frightening, embarrassing or just plain uncomfortable, a little bit of sensitivity goes a long way. Apparently, the number one factor that distinguishes between doctors who get sued and doctors who don't get sued is whether or not the patient likes the doctor. In other words, I can be an incompetent idiot, but if my patients love me, I'll be fine.
Although it is something that comes naturally, I've always worked on cultivating empathy. When I was a nursing student learning how to give injections, I injected myself to see what it felt like. So now when I give a patient a needle I can truthfully tell them, this just feels like a little pinch, you'll hardly notice it at all. And then when I'm done they say, wow, I hardly felt that. It's kind of tough to put in your own IV, but when I was learning, I had a very accommodating friend Anna who let me practice on her in exchange for popping all the veins in both my arms. The next day when we walked around with matching bruises I could honestly say, getting an IV in is no walk in the park. But sometimes it has to be done.
I took my own blood pressure, I (attempted to!) suture my own wounds, and I let a classmate draw blood from me. But most recently, I took patient empathy to a whole new level. I intubated myself. Yes, that's right.
The other day at the hospital the Anesthetist was very nice and let me intubate two patients. He was using a special kind of tube called a laryngeal mask. It has a large rubber tongue-shaped piece attached to the end of the tube and it slides down the throat and seals off the entrance to the lungs and is hooked up to a machine that breathes for the patient. It isn't as difficult to put in as the tubes I'd tried before, and after I successfully got it in on the first try I was elated. Because of a very intense physiological gag reflex to having anything in one's lungs, it is necessary to have the patient unconscious first and lubricate the tube so it slides in. But this type of tube has less potential to damage the teeth or vocal cords. I told the anesthetist, if I'm ever operated on, that's the kind I want to have. He laughed, holding up a tube.
“I'd use one this size on you. Go ahead and try, haha!”
I guess he didn't know that I would take him seriously.
“I've always wondered what it felt like.” I said. “And if I'm going to do it to my patients maybe I should know what it's like.”
He looked at me like I was crazy.
“You must be kidding.”
“No, I'm not.” I took it from him and sat down on a chair to the side. There were a couple of nurses standing there and they all stared at me.
“Do you want some local spray to freeze the back of your throat?” The anesthetist asked dubiously, smearing lubricant over the tip of the tube.
“No thanks, I'll be fine.”
I did consider the fact that I might choke myself, but with an extremely experienced anesthetist standing in front of me and three surgical nurses watching, the chances of something going wrong seemed pretty slim. I put the tube in my mouth and began to advance it down my throat. I had to fight back the gag reflex and for a second I thought I couldn't do it. Then I just decided to go for it and I pushed it down and suddenly I was breathing through the tube. At that moment the surgeon and his surgical resident walked into the room. They just stopped in their tracks and I gagged up the tube and began to cough, tears pouring down my face.
“I'm fine!”
Everyone was laughing and patting me on the back. Later that day someone came up to me and told me that I had become legendary as the girl who had intubated herself. At least, I thought, I can truthfully tell my patients, this is one procedure that you will definitely want to be knocked out for. And it makes your throat sore after.
My dear readers, I wish I could tell you that was the extent of my empathy-inducing experiences. As a matter of fact, two days later, I decided that the intubation hadn't been too bad, but what I really wanted to know was how it felt to be catheterized. (A catheter is a tube that goes through your urethra into your bladder to carry urine out.) I've put catheters in patients before and I always tell them, this won't hurt, it'll only take a second. Well, I won't tell you all the details of that particular procedure, but I did indeed catheterize myself. And I can now truthfully tell my patients, this will hurt, for more than just a second. But it has to be done.
I stopped in at the bank the other day and was sitting across from the bank teller when he suddenly doubled over and began to clutch his chest.
“What's the matter?” I asked him. “Are you feeling okay?”
“I'm having a hard time breathing.” He said. “I think it must be allergies.”
“How long have you been experiencing this difficulty breathing?” I asked him.
“On and off for a couple of months.”
“Do you have any pain or tightness in your chest?”
“No, just a little pain in my neck and back.”
“Whereabouts is the pain?” I asked. “Does it radiate? Is it an achy, dull pain?”
“It just kind of aches here in my back and radiates down my left arm.” He said.
“Has anyone in your family had any heart attacks or other heart problems?” I asked him. “When was the last time you had your blood pressure checked?”
Right then and there I gave him a mini medical consultation. Then I told him as soon as he was finished cashing my check (hey, I'm not completely empathetic!), he was to go across the street to the clinic because it was quite possible he had something going on with his heart. Don't wait for tomorrow, I told him, go right now.
When I walked to my car I had a good feeling thinking I might have saved his life. Then as I drove away I pondered on whether he'd take my advice and go or just stay at work and have a heart attack and die. Then I turned on my ipod and thought about what was for dinner. Suddenly it hit me. I felt completely unemotional about that man. I honestly didn't care if he lived or died. What happened to empathy?
At times I've struggled because I've gotten too emotionally involved with my patients. Sometimes it is hard. I remember once treating a baby girl who was dying of cancer who was lying in her mother's arms in exactly the same way that my little sister had lain in my mother's arms when she died. After they left I had gone outside and leaned against the building and cried.
There has to be a balance, though. On the one hand if I don't learn to distance myself a little, I'll be even more of an emotional basket-case than I already am. On the other hand, if I distance myself too much, I won't be a likeable doctor and I'll end up getting sued. (That sounds trite, I know.) But I do care, deep down inside. I care very much which is why I try to cultivate empathy.
Although at this point I'm not sure which is worse, my sore throat, or my sore urethra. Either way I might just take a break from trying new procedures on myself.

This is my city, these are my people

This week we had some friends, the Strides , staying with us for a couple of days. Technically they are relatives of friends of ours, but they have become our friends too and we've really enjoyed hanging out with them. Matt is my age and on Friday I took the day off of studying and we decided to go on a long intense excursion.
We decided to bike from our house (Burnaby) to downtown Vancouver, through Stanley park, over the Lion's gate bridge into North Vancouver, up the mountain to Capilano suspension bridge, and then back to Burnaby via Commercial drive. Matt and I have done some running and biking together before so we figured we were up for the challenge. We got ready in the morning and set off expectantly, after making sure our tires were pumped and we had enough sunscreen on. (Okay, I'll admit I didn't have any on.)
We biked up the hill in the morning sun and then along a few busy streets and eventually made our way into south Vancouver where we followed bike routes almost all the way downtown. The streets were lovely, with roundabouts overflowing with flowers and kids playing on their lawns in sprinklers and people walking dogs and little stores and a moving truck and some construction and a few little hills. I remembered being a kid and running through sprinklers like that and the sound of lawnmowers and I felt at home and part of it all. We stopped in at Surplus Sam's to get some pop and other things and when I introduced Matt to the cashier, she had a funny look and I hastened to explain.
“Matt is my.... sister-in-law's sister-in-law's mother's aunt's son”.
I'm not sure which was easier- explaining that we weren't a couple, or explaining how we were related. We continued downtown after discovering that I'd locked our bikes up but left the keys in the lock. Oh well.
I love camping and visiting my family and friends in the Okanagan, but I have to admit that I'm a city girl. When we got downtown with the traffic and all the people and the noise and the smell of food and the screech of construction machinery and water fountains and reflections in glass windows, I felt at home. We locked our bikes and stopped to do a bit of shopping. I remembered years ago when I was studying at VCC and I would take the skytrain to school every day and look at all the colorful people and feel part of it, feel alive.
We left downtown into Stanley park and huffed and puffed our way along the main route, being passed be lots of cars, and up onto the Lion's gate bridge. The view of the city was amazing and the sun was glittering on the surface of the ocean hundreds of feet below. I felt a little giddy being so close to the edge and we took pictures of Stanley park with people walking on the seawall looking just like little ants. In the distance were the mountains and we crossed in to North Vancouver. Up the hill.... there were a lot of nice cars parked in the driveways in North Van, Mercedes and BMW's and cute houses nestled into the evergreen trees. We crept up the windy road and eventually made it to Capilano park and outside the suspension bridge were all sorts of tourists lined up. We paid our money and joined the masses, clumsily staggering across the wobbly bridge and looking at the starkly beautiful canyon below. There were people from so many different countries around me, all tourists, and I heard snatches of French, Spanish, Italian, Arabic, German, Mandarin, Turkish, and other languages I couldn't place. I listened to the words I could understand and spoke English with Matt and felt happy to be part of such a multicultural country. We wandered through the forest with Japanese tourists and took pictures of the huge trees and totem poles and in the gift shop I tried on raccoon fur caps and looked at the maple syrup.
When we'd seen enough we got back on our bikes and headed down the hill. Back over the lion's gate bridge. Down into Vancouver. We turned along Hastings and wove our way into China town. Now the streets were darker. There was garbage and broken glass and people sleeping under coats on the sidewalk, and a man standing there yelling at me as I rode by. Two guys were shooting up on the curb and I cringed when I thought of the pathogens they were contracting with the dirty needles. So many sad, broken people. One old lady had a huge bruise on her face that looked like a splotch of makeup. We rode silently and I didn't know what to say. This is my city. These are my people.
We turned down Commercial drive and we were starving hungry and we stopped at Tony's deli and the man behind the counter was from El Salvador and had a massive head of black dreadlocks. While he made us sandwiches he told us he had been part of the mafia back home. We sat outside and watched people cycle by while we ate. We looked around in some stores and on the grass of a park there were buddhist monks playing drums and moms watching their little kids on the swing sets and some crazy looking hippies tying hemp around handfuls of lavender.
We rode along the skytrain route into Burnaby and there were Asian kids walking home from summer school and teenagers loitering around Metrotown and a little boy that had been punched by his brother in a water park and was crying for his mom in a voice that meant he wasn't really hurt, just wanted sympathy.
When we got home I had a shower and opened a can of beer (gasp! In the middle of the day, too!) and sat and did nothing for a long time. We'd gone around 50 kilometers, up and down hills.
Did you know my Dad snores when he sleeps? And that my sister has a wart on her wrist that she can't get rid of? And that my mom gets furious when the rats get into the garbage cans and that she has about three different types of rat traps? Did you know that I am afraid to stay at home alone and that I tried smoking twice and threw up both times? Did you know that my brother Sam hates cold water and Will hates being bossed around? (Are you wondering where I'm going with this?)
We all have our flaws, and idiosyncrasies, and our hidden talents, and the beautiful things and the ugly things and the just every-day things, all the things that make us human. In a way, just like Vancouver. Of course I wanted Matt to experience all the beautiful parts of the city that I know and love. But it is not all the way I want it. Some of it I am proud of, some of it I am embarrassed of. But it is still my city.
And so it is with people. When you make a choice to love someone, anyone, you make a choice to accept them along with the parts you can be proud of and the parts you can be embarrassed of. I could leave if I wanted to, many people do. The next time I have an argument with my family I could pack up and pretend I belonged somewhere else. Instead I choose to be a part of where I am, with all my heart, and to love and accept those around me for all that they are. They are my family. And they are my friends. I'm not writing this because I had a fight with someone in my family and I'm trying to apologize in a roundabout way. I'm writing this because I've spent many hours watching airplanes take off from the airport and wished I was on them, wished I was flying somewhere else to have exciting adventures. But right now, for however long it will be, I belong here. I am part of what is going on with my family and friends. And I want to be here with all my heart.

Beauty

I've never really considered myself a super vain person- I don't take a long time in the bathroom in the morning, I don't pore over fashion magazines, I don't buy expensive clothes or wear a lot of makeup. Beauty is inside, I believe.
Yet today while spending some time in surgery I was confronted with a few very strong emotions that I had a hard time rationalizing to myself.
I entered the operating room with Dr. D and another medical student and the patient was already lying on the table asleep.
"She had a lump in her breast," Dr. D explained. "We're just taking it out for biopsy."
As I drew close to the patient I noticed how smooth her skin looked, how relaxed the lines of her face. I picked up her chart and the other medical student leaned over my shoulder and pointed at a number. She was only 18 years old.
I watched anxiously as the surgeon made the incision around the girl's nipple.
"Is it going to leave a scar?"
"Actually, she will hardly be able to notice it. It's amazing how normal it looks after it heals."
The biopsy went smoothly, except for the other medical student getting squirted in the eye with blood, and when they bandaged the patient up I tried not to imagine what she would be thinking when she looked in the mirror for the first time. Hopefully it wouldn't scar too much.
The next patient was an older woman who had had a mastectomy (breast removal) for a cancerous lump, and was in to have the other breast removed and reconstructive surgery. A team of 7 surgeons and nurses (plus myself and the other student) were around the table. I was intrigued to see the details of the operation. A blue radioactive dye was injected into the breast tissue, and after a few minutes, the surgeon passed a gamma ray detector over the breast and confirmed that the dye had moved into regional lymph nodes in the armpit. The surgeon cut through the skin of the breast, lifted it up and cut away all the tissue underneath and removed it en masse. Then a wide swath was cut across the lower abdomen (only leaving the belly button intact and dangling like a forgotten limb). The pocket where the breast had been was hollowed out and all the skin and fat lifted from the abdomen like opening a giant envelope. Then, still attached to it's arteries and veins, the graft from the lower abdomen was stuffed up into the breast pocket and stitched into place. The lower abdomen was pulled down in the fashion of a tummy tuck, with the belly button re-inserted and stitched into place. The involved lymph nodes were cut out and on the instrument tray the surgeon waved the detector over them and it beeped loudly. Then she waved it over the armpit and breast and it was silent. They'd got all the radioactive cancer out. Amazing.
But while the patient had the shape of normal breasts, they were covered in incisions.
"how will the scars look?" I asked.
"Not too bad. At least we were able to get all the breast tissue and involved lymph nodes out."
"What about her nipples?" I asked dubiously.
"Almost all my patients elect to have reconstructed nipples." the surgeon explained. "We tattoo them on and use a polymer implant for shape. They look not bad."
I'd seen patients who had had breast reconstruction or implants before. On the outside it looked all right, but underneath their chests were covered in ugly scars. I hugged myself and determined to look for lumps when I got home. I didn't want to end up on this table.
I felt desperately sorry for the poor woman. Perhaps she felt sorry for herself too. Or perhaps she was glad to be alive and rid of the cancer. I'm afraid of breast cancer. It's not like skin cancer on your shoulder that you can cut off, or colon cancer that you can get a part removed. Somehow it is very different and I think it strikes a chord very deep in the heart of many women. Even though we know it shouldn't be, a lot of our sense of personal worth comes from our physical beauty. For a woman to have a mastectomy and to lose her hair from chemotherapy is devastating in a way that pain and nausea isn't. It can crush her dignity and her sense of feminine beauty.
My brother's mother-in-law died last week from cancer. I saw her last in February standing outside in the snow, her eyes were bright blue like a summer sky and she was so very alive. It's hard to imagine that she is gone now. I think it takes a tremendous amount of courage to not only face one's own death, but also the gradual disappearance of one's beauty and dignity and feeling of worth. I know that Pat will be remembered not only as someone who was beautiful on the outside, but someone who on the inside possessed that inalienable beauty and strength that does not diminish.
As hard as we try, we can't keep what's on the outside looking good forever. We don't live forever. But the scripture says that as the outer person grows weaker, the inner person grows stronger and stronger and more beautiful as it conforms to the image of Christ. And that's beauty that does not fade with scars laced across the body; it only grows stronger and brighter in the twilight of a life that is slipping away.

Bad, bad nurse.

I'm writing this blog with the following three assumptions: a) no one who has anything to do with my nursing license reads it, b) no one who reads it would report me to the nursing licensing body, and c) if worst came to worst I'd still think I did the right thing.
My big confession is that I have transgressed my professional code of ethics as a nurse, not once, but many times. I thought about it tonight as I worked an evening shift and found myself consciously doing things that likely wouldn't pass the ethics radar. Ironically, I consider them to be the moral and loving action, even if they weren't 'ethical'.
In nursing school we were taught never to call our patients by pet names. It was unprofessional and disrespectful- they should always be addressed as Mr. or Ms. or by their first name. Good luck. What do you do if you have 30 patients and can't remember any of their names? You call them 'honey' and 'love' and 'dear' and 'sweetheart' and 'gorgeous', of course. Whatever works. Today I went into a smoking lounge looking for my patient Jack and when I handed him his pills he asked, “Are you sure you're looking for Jack?”
“Well, I don't know about Jack,” I said, “But on the chart it said to look for someone with a really big nose, so I figured it must be you.”
He laughed so hard he nearly spilled his drink. He really did have a huge nose.
And then there was a time I was helping an old confused man to bed, he was frail and dying and losing his mind and as I turned to leave his room he asked in a bewildered voice, “But aren't you going to kiss me goodnight?” I leaned over and kissed him gently on the forehead before I went out.
I know, shocking. But I'm darn sure that if I was hauled up for inappropriate conduct I would still feel the same way. That old man had no one. All of us humans, whether we like it or not, need physical touch to feel human. We need to be loved and cared for. We need to be appreciated and treated gently. And I don't know how long that old man had gone without receiving an affectionate touch from anyone. That moment stuck in my mind and now I always make a point of touching my patients. Appropriately, of course. A hand on their shoulder, a handshake, actually looking into their eyes and caring. I remember giving a young woman a hug once and she began to cry. She was 23 years old and she told me that her parents had never ever hugged her and she thanked me for touching her. Another girl once told me that she felt like a leper because no one touched her. Am I ugly and diseased, she asked? No, honey. The world is just selfish and paranoid.
And then this evening I asked one of my patients if there was anything I could pray for him for. I know, I know, proselytizing and forcing my religion on my patients is completely unethical and I could get the book thrown at me.
Yes, he said. I am constantly anxious and I feel like I have no peace in my heart.
I sat on the edge of his bed and prayed with him and he had tears in his eyes and when I left he thanked me over and over again.
Later in the evening instead of taking a break I sat and played a game of crib with two old patients who had nothing to do. One of them kept sneezing and drooling and every time it was his turn to shuffle the cards I envisioned the germs all over the deck of cards and I had to think brighter thoughts.
I know that sometimes I've been negative about nursing. In a sense I believe that God allowed me to be disillusioned with nursing so that I would go on and continue down the path he has for me as a doctor. But at the same time I am seeing more and more that whatever we do, whether it is nursing or medicine or teaching or homemaking or any other job, it's never just a job. It is a ministry. It is a calling. You can do what you love (like medicine, for me!) or you can learn to love what you do. I'm glad I'm not going to be a nurse forever, but in the meantime, I have learned to love what I do. I love special moments with my patients. I love being able to love them.

God loves you!

The other day I was looking through some old blog entries and I was surprised at how upbeat and optimistic they sounded, about the time when I first started medical school almost a year ago. There was no reason for them not to be.... but I noticed the tone beginning to change over the course of the year.
It's not like medical school is that difficult, I explained to someone yesterday. Actually I found calculus and chemistry a lot more challenging. It's all the other stuff that I didn't know I would be learning, that has kicked the stuffing out of me a bit and made my blog entries a little more real and a little more raw. Not all the stories responsible made it into my blog, I'm afraid. The things I didn't write about will probably stay that way, although I don't mind talking about them. But they are the things, unlike long hours in microbiology class, that actually make me into a better doctor. They are the things that have taught me what it means to be humble and to forgive and to demonstrate self-control and to not judge someone because I know I'd do the same things given the chance.
They are the things that have made me depend on God like I never have before. I think I would be completely disenchanted with medical school and with life in general and with my love life (or lack thereof!) if I wasn't so stupidly optimistic. Sigh. Some mornings I wake up with tears still sliding into my pillow, and other mornings I wake up and everything seems new and fresh.
I read an awesome quote the other day that resonated so deep in my soul and gave me hope.
“God loves you, and has a difficult plan for your life.”
A friend explained to me once that the Christian life is like a football game.... If you're running the right direction, expect to be tackled. Yes, you can learn to run faster. Or you can work out and build yourself up so that the next guy who hits you is the one that gets knocked down. Or, if you're 5'3” like me and don't have a lot of hope that you'll be able to knock someone else over, when you get knocked down, you can laugh....and then get back up.(Okay, I know that's not exactly the way football is played...)
God loves you, that's the truth. And he has a difficult plan for your life. Difficult, and wonderful.