The Lost Decade

My great-great grandfather, William Ashburner, was a master English shipbuilder in the late 19th century. He specialized in schooners, swift racing vessels propelled by up to seven masts. A shrewd businessman and innovator, he earned himself a small fortune, investing it in a mansion for his family in the North of England.

Unfortunately the advent of steamships doomed the schooners to irrelevance and he quickly went bankrupt. He looked to the colonies for employment, quickly setting his sights on South Africa. He moved his family to the city of Johannesburg, where he took up work in the gold mines. Life was tough in this rugged new environment, but he and his ten children managed to thrive.

Unfortunately, his wife Anne did not. According to family legend, she went to her bed and “wept for two years”. She’d simply lie there all day, every day, crying constantly and barely able to do basic tasks like folding her own clothes. She was inconsolable, and the family was naturally devastated.

Reflecting back on this story over a century later, it's plainly evident that Anne suffered from clinical depression, a biological illness that affects millions of people. While effective treatments are available today, back then, all William and the children could do was watch their wife and mother languish in her bed.

I was reminded of this story last month after meeting a young woman, call her Katherine, who had been struck by severe depression for nearly a decade. She used to live a normal life, full of rewarding friendships and a meaningful career, but things changed after she delivered her first child. She would just spend day after day lying in bed feeling exhausted and empty. She couldn’t understand why; after all, she had a loving husband and a healthy new baby. On the surface, everything was wonderful in her life.

Doubtful about mainstream medicine, Katherine did not seek any treatment. Instead, she tried to plunge herself into a vigorous exercise routine, went on expensive vacations and devoured self-help books. And yet her depression raged on year after year until her life gradually fell apart, losing her job and falling back on a small disability pension. Where once she was an outgoing person, she now found it hard to even smile.

I met Katherine shortly after she was placed on a “Form 1” by her doctor, an order that forced her into a psychiatric ward. She had attempted suicide, an unsurprising consequence of a decade of suffering.

Her doctors quickly diagnosed her with clinical depression and put her on an SSRI, a potent class of medication that normalizes brain levels of serotonin. Within a week, Katherine reported a “burning” sensation of warmth in her chest when she saw her son. She was taken aback by this new, unusual feeling. But then she realized that it was actually the sensation of joyfulness, something she hadn’t felt for years.

Since then, Katherine has been discharged from the ward and her life has blossomed. She has reconnected with long lost friends and rediscovered her energetic, outgoing spirit. Whereas her eyes had seemed distant and glazed over before, they now sparkle with a happy expression, as if they are smiling right alongside her. For so long she had defined herself as an antisocial, sad person, while in reality, her real self had been imprisoned by mental illness.

Along with recovery comes reflection. Katherine looks back on the past decade with a deep sense of regret. So many years wasted, so many opportunities for new friendships and experiences lost. So many beautiful memories that could have been made. She barely knows her son, since she has been emotionally absent since his birth.

And yet Katherine could have avoided all of this suffering if she had just sought treatment at the first signs of her depression. What went wrong? While she herself may be blamed for her initial stubborn distrust of mainstream medicine, that decision was influenced by our society’s stigma of mental illness. So many patients fail to seek psychiatric treatment out of shame, feeling that it reflects some inherent character weakness.

But there shouldn’t be any shame. Just as diabetics must take insulin, so must clinically depressed patients take antidepressants. Both are biological illnesses in which pharmaceutical treatment is necessary.

In the past, the mentally ill were often crippled by their condition for their entire lives. Now, with appropriate treatment, Katherine has a bright future. She looks forward to doing all the things that she missed out on over the years, especially getting to know her son.

For the first time in over a decade, she truly feels alive. 

Grace Under Pressure

note: Any private details have been changed/removed.

The Juravinski Cancer Centre is a massive glass and steel building that dominates the Eastern part of the Hamilton mountain skyline. It is a hub of cancer-related activity, including research, treatment and supportive care. A massive 75 million dollar fundraising campaign has allowed its administrators to get their hands on every cancer specialist's dream machine: the CyberKnife Radiosurgery Robot, which can kill tumors with sub-millimeter accuracy.

I’ve been placed as an elective student with a hematologist, a specialist who works with disorders of the blood. I’ve been so impressed by his vast knowledge base, his compassion and skill in communicating with patients. A woman will come in with rapidly advancing leukemia, and he will sit down with her for twenty minutes and explain her entire disease in layman’s terms. He wants his patients to know exactly what's happening in their body, and you can just tell that they really appreciate him. 

The most inspiring case I’ve encountered so far has been a middle-aged woman with advanced multiple myeloma, a deadly disease that ravages the bones. Her skeleton is rapidly deteriorating, compressing her spinal vertebrae so that they squeeze against her spinal nerve, causing excruciating pain. She can barely walk and keeps falling, splitting open her lip on numerous occasions. Meanwhile she suffers from a serious mental illness.

And yet her husband takes care of her with incredible devotion. He sets an alarm to wake him up twice a night to take her to the bathroom, makes all her meals and drives her to appointments. He manages all her medications and has even taken temporary leave from his work to care for her full time. Unfortunately her pain and stress have destabilized her mental illness and her mood is a rollercoaster, flipping from severe rages to extreme dispair. But her husband doggedly sticks by, enduring her temper while continuing to provide care.

When I think of a superhero, I usually think of a muscly manly man dressed in tight spandex, but in my opinion, this slender, bespectacled gentleman is indeed a superhero. When he said that he would stick by his wife through “sickness and through health” on his wedding day, he really meant it. At that time, his wife was a healthy, beautiful woman. He certainly couldn’t have expected her to be ravaged by mental and physical illness. But he stayed true to his wedding vows, even while many marriages end because of far less serious problems.

What motivates him? Is it a sense of obligation wrought by religion, family values or culture? Or is a sense of loyalty innately embedded in his personality? Clubbing at Sizzle on Friday night, I looked over at all the hotties on the dance floor and couldn’t help but wonder: How do I differentiate the genuine from the superficial? And would I have the fortitude to stick by my spouse through years of illness? Looking at the husband, I can just sense a gentleness and wisdom in his expressions and words that tells me he is a caring person to his core. 

Seeing this couple struggle together through this hardship has also given me a sense of perspective on my own problems. Honestly, I've been complaining way too much lately. Yes, I’m sick again with a fever, stressed out and dealing with an inordinate amount of work, but my problems pale in comparison to theirs. They've truly shown “grace under pressure” and I hope I can find a little bit of this grace in myself as I deal with major challenges over the next few weeks. 

The Weird & the Wonderful

As my second semester or "foundation" here at McMaster comes to a close, I'm finally getting a good handle on my stress. I've returned to eating and sleeping well and doing other things besides working. For one, I bought an XBOX 360 and have now converted my bedroom into a gaming centre slash personal gym. After a hard day's work, I enjoy an hour or two of playing video games or pumping iron (not that it's had any effect on my measly muscles).

I've also taken up an elective in the anatomy lab, and now spend an hour with an anatomist every Wednesday afternoon. It's led to some weird and wonderful experiences.

"Raman, can you hold this for a sec?" the anatomist asked me last week, handing over a human brain. It was heavier than I expected and nearly slipped out of my gloved fingers. Eeek! Although at first I was paranoid that I'd drop it, I was also awed by the fact that I was holding a real brain.

The anatomist disappeared into a backroom and came back with a big plastic box. She cracked the lid and peeked in. "Ah perfect," she commented. Uh, what the heck was in there? She then popped off the lid and pulled out a whole human head, its features all squished together. Oh great! At that moment, I was second guessing my decision to take on this elective.

Oblivious to my discomfort, the anatomist launched into a lecture about the pituitary gland. Meanwhile I was wondering what to do with the brain; had she forgotten that I was still holding it? One of her colleagues passed by with a big smile. "Great weather out there, eh?" he said happily. The anatomist returned the smiled and nodded. Wait, here she was holding a human head, and all her colleague wanted to talk about was the weather? Only in the anatomy lab.

Getting to hold that brain was just one of the weird and wonderful things I've done in med school since returning from the Christmas break. Last week, my clinical skills supervisor brought out a life-like replica of a pair of human buttocks to practice rectal exams. "Just come from the side and slip your finger in," she explained, demonstrating the technique. Apparently I had quite the expression on my face, because she looked straight at me and said, “Hey, I didn’t make you choose this profession.” I was just relieved that I could learn the rectal exam on a model, and not on a real person ... but that too will come in time.

I've also been introduced to the unpleasant concept of “Fetor Hepaticus.” The doctors suspected that one of my patients had chronic liver disease. To help confirm the diagnosis, my supervisor asked me to smell the patient's breath. When the liver is dysfunctional, the breath takes on a characteristic "rotten and sweet" smell - "Fetor Hepaticus" literally translates to “breath of the dead.” In this case, my nose would literally become a diagnostic tool. Leaning in toward the patient, I took a good whiff ... Yep, diagnosis confirmed.

Like any job, medicine comes with certain downsides. Yes, those downsides may be smellier and stickier than what you’d encounter as say, a lawyer, but the upsides (like getting to hold that brain) are pretty awesome too.

Facing the Firing Squad

Yesterday was one of the worst days I've had in medical school so far. The week leading up to it was extremely stressful, packed with tutorials, studying, electives, shadowing experiences and other major time commitments. I found myself leaving the house every day at the crack of dawn and returning by 9 or 10 at night, grabbing a quick bite to eat before starting tutorial review. And then I would get a few restless hours of sleep before dragging myself out of bed to start another day. For whatever reason, all my major commitments happened to coincide to create the week from hell. 

On Monday night, I finally collapsed into bed at 2 am and decided to take a sleeping pill to ensure I got a good night's sleep for my clinical training the following morning. I rarely use such pills, and so it came as a shock when it totally zonked me out. I was asleep within minutes. It took every ounce of motivation to drag myself to the hospital. Our task was to do a basic interview with a “standardized patient”, or in other words, an actor hired by the university who pretends to be a patient. All the students (nine in total) sit in a group with the two supervisors and critique one another's performance. It's a little intimidating to be doing a mock interview as eleven people watch your every move (albeit, very nice people).

I happened to be the last to go. After three hours, I think everyone was a little bit impatient for the session to be over. My “patient" presented with severe exhaustion, but I'm pretty sure I was more exhausted than she was. I started doing a basic history, asking about when the problem started, what was happening at the time, what she had tried for relief, etc. etc. I had trouble concentrating and my interview seemed to veer way off track. I hadn't even gotten on to recommended treatments by the time the timer rang, abruptly ending the interview.

I looked to my left, at the assembly of nine students and two preceptors, all looking thoroughly unimpressed. Oh crap. The students had been instructed to be honest and critical in their feedback; after all, how else would you improve? Judging by how much I had just bungled up the interview, I felt like I was facing a firing squad.

Let's just say, I took a battering - a polite, Canadian-style battering - and it was totally deserved.

Right after class, my fever returned with a vengeance, and I had to drag myself through the rest of the day. It was exhausting and demoralizing.

Now I'm sitting at my laptop with a hot cup of tea, recovered and rested. I think the most important lesson I've learned from this experience is that, in order to be a good care provider, I really need to take better care of myself. A burned out individual exudes a negative energy that turns people off and may make patients less willing to open up about their problems. When I'm very stressed, I find it harder to feel and show empathy, and is that really fair for the patients? Sure, I can still do a good history and physical exam, but medicine should be about more than just checking the boxes.

So I'm putting myself on a regular sleep and exercise schedule, cutting down on unnecessary commitments and finding time to decompress every day. With any luck, this exhausted, burnt-out Raman will be replaced by a rosy-cheeked, smiling Raman within a couple days. And then I can hit the next interview out of the park and redeem myself. Fingers crossed.

Hottest Books, 2011 Edition

My Kindle was a godsend for me last summer while living in rural Quebec. Although speaking French, eating French food, and going to French school every day is so much fun (*cough*), it was a blessing to escape into English books every night. Sure, this was technically against the rules because the administrators wanted it to be "all French, all the time."

But since when do bad-asses like me follow rules? Without further ado, the best books I read last year!

MEMOIRS... 

I was blown away by Viktor Frankl's story of surviving the holocaust in his memoir Man's Search for Meaning. Not only does he recount his memories of Auschwitz, but also uses them to frame his inspirational philosophy: that we are all responsible for creating our own meaning in life. You go, Vik... You go.

I burned through Open by Andre Agassi and Chretien's My Years as Prime Minister. Both are honest and gripping accounts of the life of a tennis player and PM of Canada, respectively. It doesn't matter if you're not into tennis or the intricacies of the Canadian government (who is?). These books are great, period.

Then it was on to "The Heart and the Fist", the memoir of an ex-Navy Seal and Rhodes scholar. The Navy Seals undergo the most rigorous military training in the world, and Eric Greitens reflects beautifully on his experiences. If you don't buy a copy, he may just bust through your window one day and take you out.

FICTION... 

Lawrence Hill's "Any Known Blood" traces several generations of African-Canadians and their struggles with fostering a sense of identity in a society that disparages their very existence. (side note: I actually see the author around Westdale all the time!). The Game of Thrones was just epic, and only slightly eclipsed in entertainment value by The Hunger Games, about a post-apocalyptic world where one boy and one girl are selected each year to fight in a televised battle to the death. Fun stuff.  

The Poisonwood Bible is a sweeping and compelling novel about an American family that moves to a faraway land of poverty and "bare-breasted" women. And no, it's not about downtown Hamilton.

NON-FICTION...

Shortly before med school started, my reading became decidedly more medical. First was "Complications", a fantastic surgeon's memoir that reads more like a thriller novel, and then a fascinating book about the concept of neuroplasticity - how the brain can change itself.

Later in the year, I speed-listened my way through the Steve Jobs audiobook, which recounts the life and career of the quirky entrepreneur. What was Jobs' inspiration for founding Apple? "Dropping acid," he says frankly. Gee, maybe I should try that for blogging.

To wrap up the year, I devoured the Pulitzer-Prize winning "Emperor of All Maladie" - a biography of cancer. Really, it's more interesting than it sounds.

Happy reading!

Angel of Artsci Past

I suddenly became very ill last night, developing a fever of 102 degrees. I felt totally fatigued and could do little more than lie on my bed with a blanket wrapped around me. The house was cold and dark, and my parents were off dog-sledding at a resort a couple hours away. I can’t remember a time when I felt so miserable.

Fortunately my sister arrived home shortly thereafter. She made me some toast along with a hot cup of milk. Sitting beside me, she worked away on her laptop while we talked and joked. It felt so good just to have another person there, and in talking to her, I felt myself forgetting about my own sorry condition.

At the same time, I couldn’t help but wonder how so many patients in the hospital are able to endure weeks or sometimes even months of being bed-ridden. Often times they are so old that they've outlived most of their friends, or they just don’t have any direct family members. And so they lie in the sterile confines of their hospital room while their bodies fail them. Sometimes they cry out in the night for their mother or father, who are long dead. For most of the day, their only company is the nurse on staff.

Last semester, I was fortunate enough to be supervised in the hospital by Dr. Oczkowski, a young internal medicine resident. The doctor, or “Simon” as we called him, had a real gift with patients. He could walk into a hospital room with a very ill patient and make a connection within moments. He’d ask them how they were doing, explain their condition in a way that made sense to them, and joke around a bit. With a natural sense of humour, his patients inevitably felt cheered up by the end of his visit.

Simon also had an incredible grasp of medical knowledge, but I think his true gift was in genuinely caring. For the brief duration of his visit, he'd make it seem like his patient was the only person in the world. I think that the sick and dying cross a point in their illness when simple compassion and connection with another human being matter far more than any medicine or procedure.

Interestingly, Simon and I have led parallel lives in many ways. We both grew up in Hamilton, both went to the “Arts & Sciences” program at McMaster, both went on the Student International Health Initiative trip to India, and both went to McMaster’s medical school. I can only hope that I'll be even half as good a doctor as he is. 

Puppy Love

A couple years ago, Sonia (my sister) flew off to India with the intent of rescuing malnourished street puppies that had been abandoned by their mothers. She didn't have to look far. Walking down a side street of our hometown one day, she spotted a tiny black puppy lying in a ditch. The puppy, a female, was on the brink of starvation, her ribs displayed prominently through her emaciated chest. My sister tried feeding her a little piece of bread, but she was too weak to eat or even move.

Wrapping the small dog in a cloth and gingerly placing her in a cardboard box, Sonia took her to a local veterinarian, who turned his nose up at the puppy. 

"Why would you bother with a street dog? It will die anyway," he said. In India, street dogs are generally viewed with disdain, and it's almost unheard of for someone to adopt one as a pet. Instead, rich Indians have their pick of expensive breeds, which have become status symbols in a highly status-conscious society. 

But fortunately the vet agreed to give the puppy a couple of shots and sold my sister some flea powder. After giving her a bath, my sister discovered a star-shaped patch of white fur on her chest... and subsequently named her "Tara", which means "star" in Sanskrit. At first, Tara couldn't hold down anything more than water. But after recuperating for some time, she was able to start digesting heavier foods like milk and roti, a flat Indian bread. Covered in the white, chalky flea powder from the tip of her snout to the end of her tail, Tara managed to frighten the neighbours on more than one occasion.

Against all odds, my sister nursed the small puppy back to life with healthy meals, regular washings and countless patting sessions. She got a great sense of satisfaction when she took Tara back to the vet for another round of shots. The vet was shocked ... whereas the puppy had come to him before as an emaciated shell, she now had a shiny black coat of fur, sparkling eyes and boundless energy.

"This is a beautiful dog," he conceded.

Upon regaining her energy, Tara showed a particular fondness for shoes, sometimes grabbing people's chappals right off their feet. When my sister would discover some mischief - like a chewed up shoe or a missing roti - she would confront Tara, ready to give her a light smack. But the dog would leap into her cardboard box and cower guiltily... she was a master of the "puppy eyes", which made it virtually impossible to administer any form of punishment.

But as Sonia soon discovered, Tara still had the restless energy of the street dog, repeatedly escaping the property to go play in the streets. Although this bothered my sister at first, she eventually realized that it was only in the dog's nature. So she found a healthy compromise: Tara could run off every morning and then come back in the evening for a meal and a comfortable place to sleep. After two months, my sister returned to Canada, feeling like her mission had been accomplished.

Ever since then, Tara has become a fixture of our Indian neighbourhood. Not only is she popular with the children, but with everyone else as well - our prim-and-proper neighbours, the elderly, the shopkeepers... even the homeless. Each year, she greets a fresh batch of Canadians who travel to our Indian home (which doubles as a yoga retreat centre) searching for spiritual solace. They don't have to look far to find a miracle, because there's one that meets them right at the doorstep; a living, breathing, tail-wagging miracle.

Shortly after the rescue

Bath time

Healthy and happy

Puppy eyes

All grown up