We Are All Perfectly Fine

by Dr. Jillian Horton

  The bell in the hall rings. We won’t get to hear the rest of Joss’s list. I don’t think we have to, though. We all know what’s on it.

  That’s why we’re here.

  20

  Get Out of the House

  Mick brings us all into formation in the great hall. He starts by asking how everyone is doing. People call out words. Anxious. Rested. Excited. Impatient. I giggle to myself. Roy, a few seats over, catches my eye, raises an eyebrow. I mouth the joke: Inpatient. He doesn’t catch it. He puts on his glasses.

  “What?”

  “Forget it, I’ll tell you later.”

  Mick’s wearing a black tracksuit. He looks like he’s going to rap at a funeral. He puts up a slide. When things go wrong. The energy in the room changes. A slight, perceptible shift.

  We all have these cases. The saying is that every surgeon has a graveyard. People who stalk us our whole lives. Things we often can’t speak about, because we’re supposed to be perfect. Also, because people might sue us. And because of shame.

  Mick puts up a bunch of numbers we’ve all heard before. How many of us will make mistakes, how many of us will struggle as a result. After a complaint, a doctor’s already elevated baseline risk of suicide will increase five-fold.

  A lot of medical errors are thinking problems, but most don’t have their root in negligence or incompetence. We’re easily swayed by external influences. A colleague tells you a patient has pneumonia. Because you like and trust him, you ignore the nagging voice in your head protesting that there isn’t much evidence for pneumonia, and the next day the patient has a massive pulmonary embolism. Or a patient with a history of addiction comes into the emergency department with confusion. Nobody does a spinal tap, because someone has written in the chart that confusion is how this woman presents when she’s high. Later, she dies of meningitis, a diagnosis you never even considered. Or you think a patient has a rare disease; you work him up, you tell your residents, you say to every consultant, “I’m sure this will turn out to be sarcoid.” But when the evidence mounts that it isn’t sarcoid, or whatever uncommon disease you’ve hung your hat on, your mind can’t change lanes. You’ve invested too much. These are cognitive errors. Our brains get stuck in one gear.

  But there are other reasons we make errors. Inexperience when we’re young. Fatigue. A system that constantly asks us to play the odds that most people won’t die if we only skim the surface of their history. Pressure to look after more and more patients whose problems are increasingly complex. New and cumbersome electronic systems dumped on us with increasing frequency and too little training, more paperwork, more regulations, threats of repercussion if we don’t comply with having email addresses affiliated with each clinic or hospital where we work, requiring us to sift through piles of duplicate messages sent each day to our multiple accounts. And more expectations that we expand our services to become the solution to a reduction in resident work hours, we who are still under-slept and under-resourced and doing the most we can with what we have, and frequently have no more to give to anyone, we who ourselves are struggling with grotesque rates of burnout, addiction, depression, suicide. People like me, here for all the right reasons, people who have loved this profession and believed in it with our whole hearts, and have been brought to our knees by it.

  Mick is setting up an exercise. He asks us to find a partner. I’m really not into this right now. I don’t feel up to walking a stranger through my personal cryo-preservation unit of people whose names I will remember until I die, or at least remember until I am very old with severe dementia looking after one of those rubber baby dolls in the nursing home.

  There’s a young woman I haven’t met before, sitting to my right. She’s wearing a shapeless brown knit dress that looks like a tuque with armholes. She has asphalt-black hair pulled into a bun at the nape of her neck. While I’m eyeing the body toque and wondering if she knitted it herself, she turns to me.

  “Partners?”

  I nod, unconvinced. I had designs on Joss. I don’t feel like getting to know any more strangers. Especially strangers who look young enough to be crying in my office or complaining that I haven’t referred them to cooking classes in a timely manner. I’m tired. I want to build a cushion nest in a space under one of the windows where there’s a patch of sunlight and go to sleep. Why don’t they let us sleep more here, anyway? Why do we finish every night at nine and start meditating before the sun is even up? I thought this was going to be a retreat. Do I feel better? I don’t think I feel better.

  The woman’s nametag says “Ikiru,” and that she’s a senior surgical resident. She has a round face that reminds me of a kewpie doll, with heavy green eyeshadow and a lot of eyeliner, and a small tattoo of a butterfly with one wing on the back of her neck. I noticed it in one of the other sessions. In my head I tried out a joke to Jodie and Greg about the parlour running low on ink, and then another joke about it being a koan. She has a pierced eyebrow.

  I would never have come to a retreat like this when I was her age. There weren’t any retreats like this then. I might even have thought it was presumptuous. It took me twenty years to end up here. Why should she get to fast-track? I had to graze a certain kind of rock bottom, over and over, just quick communes with stones before resurfacing, before I became aware that spending so much time at the bottom wasn’t normal. When I was her age, I coped by spending hours jogging through the downtown core until I coughed up mucus streaked with car exhaust. Sometimes I was post-call, and I’d sprint in a state of delirium. Laughing at my own private jokes, the sound of my laboured breathing masking the turmoil in my body, the way you might turn up the radio to drown out something terrible going on in an adjacent apartment. Sometimes a streetcar would glide by me, silver rails appearing behind it like columns of mercury as it retreated into the distance, and I would think, It could have hit me. I would have been fine with it hitting me.

  Then I wouldn’t have to go to work tomorrow.

  Did Ikiru go through all that too? Even if she did, she hasn’t proved she can choke down another fifteen years of it. Is she going to try to tell me she knows what if feels like to do this for half your life? Please. She hasn’t driven this car long enough to know how it handles on the road.

  Mick is talking about deep listening. Oh, God—really, Mick? My entire day is spent listening. And then talking and wondering if anyone is listening. And then going home, where, granted, it’s possible that I don’t always listen.

  Okay, maybe even that I rarely listen. Because by that point there’s nothing left.

  Mick gives the instructions. Pause, relax, open. Talk in such a way that the conversation flows, without interruption. Pick up on what your partner says. Follow, like a piece of music. Respond to one another, be responsive. And listen, really listen.

  Ikiru is looking at me out of the corner of her eye. She hops out of her chair onto a cushion. The large group begins dissolving into pairs, seeking corners, distance from others.

  “Where are you from?”

  She tilts her chin, looks at me with annoyance. “America.”

  Ikiru, don’t go there with me. We’re at a conference. That’s not what I meant, and I know you know it.

  “Yes, I meant where in America? Don’t you have fifty states?”

  “California.”

  I notice that her shirt dress has a hole in it.

  “There’s a hole in your dress.”

  “It’s part of the design.”

  She wrinkles up her nose. Is that an evil smile? What is that mean thing she just did with her face?

  Mick rings a bell. Wait a minute, Mick. I don’t want to talk to this girl for the next hour of my life. She’s glowering at me from beneath a pierced eyebrow—and I’m sorry, Ikiru, but as a surgeon you should know that an eyebrow is not meant to have a hole in it. I think I detect the slightest upward curl of her lip. She hates me. Maybe I’m too geriatric for her. My boots are real leather, not vegan. My hair dye isn’t environmentally fri
endly.

  Is this her judging me or me judging me? Well, it doesn’t matter. I’m not opening up to this girl.

  There’s silence, between us, not particularly pleasant, a weak current of uncertain energy. The silence of a stand-off.

  “I’ll talk first,” she says finally, reluctantly. She shimmies on her cushion so we’re a few inches closer to each other.

  Mick asks us to sit in silence for a moment. To notice what’s present before we begin to speak. I notice my irritation, the drama unfolding in my mind, the tension I’m writing between me and this stranger. It isn’t her fault, any of it, what happened to me at the school. Most of my students were good kids, and maybe she’s good too. Maybe she’s blaming me right now for an internist who yelled at her on the phone some night when she was trying to decide whether to anti-coagulate a post-operative patient with chest pain. I’m noticing you, anger. Where have I read that anger is a response to helplessness? All the rage we can’t express, or feel powerless to express? Wallpapering a water-stained wall, ignoring the leak.

  The bell rings. Everyone waits until the note is gone, the long tail of its decay over. Ikiru takes a sharp breath. She puts a hand over her tattoo.

  “So this is about a man with a nasogastric tube.” Her hand moves to the hole in her sweater. She traces its outline, probing it the way I imagine she might search a wound for foreign bodies.

  “It was on the surgical ward, and I was an intern. I was on with a fellow who told me not to call him for anything unless I thought a patient had to go to the OR.” She takes in another tight breath. “The patient was around eighty. He was really dignified; he had been a college professor or something. Just a really nice man. Like a bookish grandpa. He had a mass in his stomach, and we were trying to fatten him up a bit with feeding before we removed it. There wasn’t much else wrong with him. So, one night on call, I had to put the tube in through his nose, and it was really difficult. I don’t know why. He kept gagging, and then he was spitting up a lot of blood, and after five tries, the nurses were rolling their eyes and telling me to call the senior. But I couldn’t. This senior, I don’t even think he would have come, and if he did, he would have ripped me to shreds in front of the whole ward.” She looks down at her lap. “I mean, as I tell you this story, I guess I could have, but the thing is I felt like I couldn’t.”

  Silence. The words Mick left on the screen: pause, relax, open. I’m not relaxed. I’m with Ikiru, on the ward, trying to slide that tube into the right nostril while the patient gags and convulses, while the exasperated nurse rolls her eyes at my uselessness.

  “So, finally, I’m able to advance it, and we tape it into place. He settles, the nurse cleans him up, we get an X-ray. And I look at this X-ray, and there’s a nasogastric tube right where it should be, in the tip of the stomach. So I order his feeds. At a low rate. Just twenty an hour. A trickle, right? It’s after midnight. I don’t think I’ve eaten since lunch, but now at least one of us is getting fed.”

  Pause, relax, open. As she’s telling me the story, I feel myself opening to her. Inhabiting the exhaustion. The stifling uncertainty, the chronic anxiety about what could happen next.

  “I went to do something else. Write orders, see somebody with post-op pain, I don’t remember. But I got a page after a couple of hours that the patient with the NG tube was in respiratory distress. I go see him, and his lips are blue. Fingertips are blue. He’s working really hard to breathe. His O2 sat is 70, and he wasn’t even on oxygen before. That same nurse who was looking at me like I was a pile of garbage, she has her stethoscope over the right lung and says it’s all crackles. So I call for an X-ray, and I try giving him some diuretic in case he’s in heart failure. I have this feeling of total panic. Like, is he having a heart attack? His blood pressure’s good. It doesn’t make any sense. So I get another X-ray, right, and I go to look at it.”

  Ikiru pauses. She folds her hands behind her neck, the way you are supposed to if the police tell you to come out with your hands up.

  “His right lung is full of fluid. Can you guess what else is in his right lung?”

  I pause, trying to follow what went wrong. “How could it be the nasogastric tube? You looked at the X-ray.”

  “No, I looked at an X-ray.” Her hands release, slide down the front of her chest, as if she’s wiping off residue. “I looked at another patient’s X-ray. A patient with the same last name, five rooms over. And that patient’s NG tube was correctly placed in his stomach. Unlike my patient, whose NG tube was positioned pretty much in his right middle lobe. And we filled that lobe with 20 millilitres of feeds an hour. And he proceeded to develop respiratory failure, and we couldn’t get his oxygen levels up, and within an hour he was intubated on a ventilator in the ICU, and a couple days later he went into cardiac arrest and died.”

  I watch her face carefully. There’s something about the tone of her voice, as if she’s testifying in front of a jury. A faraway quality, narrating while she watches these events unfolding on a little TV screen in her mind. Her testimony doesn’t matter. Whatever the jury finds, Ikiru will always think she’s guilty.

  Something similar happened to me once, and the memory of total helplessness washes over me. One mishap after another: a sudden, unexpected movement during a procedure, a needle gone slightly astray, a lung punctured instead of a vessel, a chest tube inserted with complications. A meeting, with an elderly man and his three children, a painful discussion about what to do next for their mother, his wife. That man, holding my hand at the end of the meeting, squeezing it with both of his, looking at me squarely, his cloudy eyes filling with tears. “I know you did your best, dear.” Holding me with so much grace. How could he do that when my best at that moment had been inept? That kindness, so undeserved, so lacking in understanding of my transgressions. That unbearable kindness, alcohol on an open wound. He gave forgiveness. Total and complete forgiveness. Did I deserve it?

  Do I deserve it?

  But it’s not the time to share my own war stories. I pause, relax, open, listen deeply. I don’t interrupt Ikiru, the way I normally would at this point in the conversation, turning the spotlight back from her to me, the way most of us do. I sit with her, just listening, nodding my head. Meeting her gaze.

  “And the thing is,” she says, and now her voice thickens, her words becoming slow and deliberate. “My mother had just died. It was my first week back after her funeral, and nobody even knew.”

  My mouth opens. My hand flutters to my sternum, her words hurting my heart.

  “Oh, Ikiru! I’m so sorry.”

  “It’s okay. This is almost five years ago now, right?”

  “Oh, I know. But your mother.” Suddenly I see it all differently. Her eyebrow piercing, her weird sweater dress, her air of indifference, all gestures of uncertainty. Manifestations of rage cloaked as indifference, a grief that fills your own lungs with something as heavy as concrete until you’re sure you can’t live another minute. This is a girl who lost her mother. A girl who is still grieving, who will be grieving intermittently for the rest of her life.

  “How did she die?”

  “She was sick for a long time.” Her breathing is slower now, her voice calm. “She had a brain tumour, actually.”

  A brain tumour. Words that slice me along an invisible plane, words that seem to trace back to my own mythology, the meaning of my life.

  “That’s a strange coincidence,” I tell her, circumventing pause/relax/open, emotion drawing out each of my words. “My sister had a brain tumour.”

  “Oh, wow.” Ikiru meets my gaze now. She pauses, without relaxing. Then she says, with trepidation, “Is she okay?”

  “No, she’s dead too.”

  “Oh, wow,” she says again. “How old was she?”

  “She was fifty-two.”

  “Did she have kids?”

  “No. She had the tumour when she was a child. It kind of wrecked everything. Like, our entire lives. It’s your turn to talk, though. I need to be listeni
ng.”

  “Obviously you are listening,” she says, with the slightest note of annoyance. “I’m talking like this because you’re listening.”

  “So what happened to your mom?”

  “She had a seizure. This was, like, when I was in med school. Then she had surgery when they found the tumour. It completely wrecked her personality.”

  “What kind of tumour?”

  “Anaplastic astrocytoma.”

  “That’s what my sister had.”

  “That’s weird.”

  “Yeah.”

  I pause. I have one of those moments where you become suspicious of a series of too-perfect coincidences and think maybe everything around you is a screenplay. People you’re meeting for the first time suddenly seem like extras from an earlier act. The whole thing so coincidental, it could just be a clever Netflix pilot.

  “It’s funny, because my sister was on my mind this morning, in the Zendo.”

  Ikiru is staring at me now. “I was having the same experience. It was just as if my mom died yesterday.”

  “Like she was there in the darkness.”

  “Exactly what was happening to me.”

  “My sister used to wear this brace on her leg. Did you notice that guy, Steve, wears one?

  He was sitting right in front of me.”

  “I didn’t notice.”

  “I was thinking to myself”—here my voice catches, and the words pile up in my throat and I don’t know if I’ll be able to extract them—“I was just thinking, what was the point of that brace anyway?”

  “Which one?”