Maskalyk - Life on the ground floor: letters from the edge of emergency medicine

Copyright 2017 Dr. James Maskalyk

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Doubleday Canada and colophon are registered trademarks of Penguin Random House Canada Limited

Library and Archives Canada Cataloguing in Publication

Maskalyk, James, 1973-, author

Life on the ground floor / James Maskalyk.

Issued in print and electronic formats.

ISBN 9780385665971 (hardback).ISBN 9780385674034 (epub)

1. Emergency physicians. 2. HospitalsEmergency services. 3. Emergency medicine. I. Title.

RA975.5.E5M38 2017362.18C2016-903009-1

C2016-903010-5

Cover art: Abiy Eshete courtesy of Makush Gallery

Published in Canada by Doubleday Canada,

a division of Penguin Random House Canada Limited

www.penguinrandomhouse.ca

v4.1

a

TO MICHAEL .

Between stimulus and response, there is a space.

VIKTOR FRANKL

Im at a friends cottage, my toes creeping off the end of his dock. It is early summer 2007, and the water is grey and cold, like the sky. I am planning to dive in, and my balls are creeping as close as they can to my pelvis. Brr. I shiver. My phone buzzes beside my crumpled clothes. I reach down and pick it up, hoping for a long conversation. It is the university director of Torontos emergency departments.

James, its Michael. Welcome back from Sudan. Ive heard about some work in Ethiopia.

Say no, say no, say no, repeats inside my head, then, Its next to Sudan.

The wind blows harder.

James?

I step off the plane, queue for customs officers, Ethiopian visa in hand. A man holds a handwritten sign: Dr. JamesToronto. Outside, the sun hurts my eyes and the air smells like home.

Aklilu leads me through a tin room, people on the floor. A few students lean against a wall. There is no nurse at triage.

Next year, we are ready to begin.

Biruk and Sofia in the learning centres wan light, feeling up and down each others throats, learning where to cut if someone cant get a breath. Nazanin and Cheryl stand near, nodding or moving the students fingers.

Yes. Right there. Perfect.

I land back in Torontos downtown emergency room. A man with his pant legs pulled to his knees, his feet black with frostbite from sleeping in the snow. A woman rolls on a stretcher, wiggling in pain. A doctor steps from a patients room, holding a clear vial of spinal fluid to the light.

Crushed between cities, days mix with nights, and I can find little time to reflect or to write. My grandmother dies. My grandfather is alone.

I move to northern Alberta, and am at his kitchen table, looking out the window.

Snow blows sideways, and the woods are barely visible through the white static. The empty red hummingbird feeder swings from its hook. Past it, a squirrel jumps between branches of the pin cherry tree, and a cloud of white floats to the ground.

Cards shuffle in the next room, then a clack as he straightens the deck. He is playing solitaire. The furnace rumbles on, and a rush of warm air pours across the back of my neck. His game is lost in the sound.

He turned ninety this year, celebrated his sixty-seventh wedding anniversary, then mourned the death of his wife. Ive come to his house by the lake, where he is struggling to remain as his body falls away. Ive come here to care for him, and to learn from him, about how to be at the end of your life, having buried a wife and a son, because hes the wisest person I know.

Ive come to write about emergency medicine, the why of it, and if the principles behind our striving to give a strangers body another minute, another day, another year, are natural ones, why does it look so different in Addis and Toronto?

Yesterday, my grandfather and I drove to the trapline hes had since such plots of land were first deeded, seventy years ago. We rumbled across cattle grates, turned from an empty gravel road to a cut-line, filled with snow. He wanted to check his small trappers cabin, make sure the door hadnt been punched in by a bear, and look at his traps. He had set three. The first two were empty; the third held a fisher, an animal like a wolverine, its face crushed into a final grimace, hard from the cold. I threw it in the back of the truck with a clunk. He would skin it later.

You dont live so close to the land without understanding that one way or another, in a snare, on the wrong side of a gun, or wasting slowly in a hospital bed, the end is one thing you dont have to look for. Its on the way.

I find myself near the end often because I work in emergency rooms. All the ones Ive seen are on the ground floor. It allows for the easiest flow of life through the curtained rooms, because for the sickest, sometimes a minute matters.

A month or two earlier, a student from Germany was in the ER to learn the type of medicine at work there. He found it uninspiring. During the first half of the shift, he saw only two patients, and despite it being busy I found him behind the nursing station, checking his email.

I tapped him on his shoulder and pointed to a person the paramedics were pushing past. She was frail, and arched into angles from lying on a bed she hadnt left in months. Her breathing was fast and shallow, her eyes closed. The paramedics took the orange blanket between them and lifted her, weightless as a balloon, into an empty bed. The nurses told me about her when she arrived at triage, no ventilator, no CPR. Comfort measures only.

You see that lady in bed six?

He nodded.

I think shell die soon, I said.

You ever seen that before?

He shook his head.

You should.

He looked away, put his phone back in his pocket. I think I would rather see someone new, he said, took a chart from the pile, and walked towards a different bed.

I let him go. I should have encouraged him more. There was something I wanted him to see. Not just the changes in her body as her story drew to a close, how the heart tracing moved from fast and narrow to slow and wide, the breathing from shallow to ragged, hitched then stopped, so he might later recognize last gasps in a someone who wanted help. I wanted him to be there for the moment after her final half breath, when all the parts were still therekidneys, brain, blood, gentle titrations of thyroid hormone, precise amounts of dissolved saltbut life was gone.

What was that thing? I would have asked.

I dont know, either, I would have said, but thats what youre here for. To help it, whatever it is.