18 April 2016: Hi everyone,
It always strikes me what a broad church medicine is. In many ways it seems a career full of careers. What a doctor does on any given day can range from dissecting a body to talking to a teenager about what is going on at school. It also varies greatly in the locations it is practiced in, from purpose-built Auckland bunkers where everyone is dressed in green to the lounge room of an old farm house in the far reaches of Southland.
A while ago Dave Galler and I hatched a plan to capture what is similar in what we do in the middle of what is very different. We decided to write to each other every night for one working week and talk about our days. Dave is an intensive care specialist. At the time we wrote he was in his last week of a year away working at Tupua Tamasese Meaole hospital in Samoa. He has since returned to Middlemore. I work as a GP in a youth health clinic in Horowhenua.
When the time came both of us thought we had better things to do but by the time we got to the end of the week it seemed strange not to hear from each other. We wanted to find out how those patients the other was seeing were doing – a testament to the power of narrative to draw us in.
We’ve published the emails below. We’d love to hear something similar from any of you who want to record the cut and thrust of a single day in medicine. It occurs to me the simple record of a working day from doctors throughout the country would be a great way to catch the variety in what we see and do.
Hope you enjoy the yarning.
Glenn and Dave
From: Glenn Colquhoun
Sent: Monday 22 February 2016 10:50 PM NZDT
To: David Galler
Well mate, it’s going on 11.00 pm and I’m sitting down to go through the day. I don’t want to but I promised. And there seems something to be gained by it. It’s been long and varied and is coming back to me in pieces.
The girl who lived on the streets for a while and her smile and her gorgeous baby boy. She can’t believe she might just be safe and warm and worth something.
The young man with fetal alcohol spectrum disorder and the circle of papers and definitions that swirl around him. I’ve promised him a banana cake. Small compensation for the systemic mountain we’ve asked him to climb to prove himself to us. Christ we can be bastards with all our processes sometimes. They are a safe meanness.
Then there is the young man tripping along the edge of renal failure after a lifetime of nephrotic syndrome. What a great soul. At 18. Goodness is a thing man. Palpable at times.
Another young mum struggling. Old ghosts. The usual. Trying to run on a broken leg.
My awesome young guy with dripping ears who only gets his meds half the time and only takes them half the time and never makes an appointment. But he’s on the upward curve, Dave. Life is bursting out of him. You can’t stop it. God I wish him well.
Tonight a peer support meeting and my daughter’s homework. A text about a boy who won’t come out of his room and one with a headache. A girl with a boil.
You might see any one of them at your place on any given day. Fights gone wrong. Drugs gone wrong. Bodies gone wrong. Cars gone wrong. At least three of them have nearly died already.
Oh and by the way … ACC wants me to re-refer a girl with a slice of skull missing after an MVA to a head injury specialist who is seeing her anyway … they know that … but want to make sure I think she still needs to be seen. Are these people mad? YES THEY ARE!
Good to talk brother.
From: Dave Galler
Date: Tuesday 23 February 2016 05:07 AM NZDT
To: Glenn Colquhoun
The air here is still and heavy today – thick with moisture and a heat I can feel as it makes its way down into my chest – I can’t help but think that this is what it must be like to be on CPAP.
The ICU is full, most people getting better apart from one who we could never help – he is a ‘medical outlier,’ youngish but already on his way out.
Junior, a sweet 6 monther, has finally started to absorb his feed – amazing really after four big operations in 10 days, starting with a mean intussusception. He’s lost a major part of his small intestine and dropped his weight from 9 to 7.2kg. Maybe, maybe, he will get better.
The baby in the next bed, Sauscisi, I call him, is the same age but twice the weight. A monster child, with a head round as a football. He is still ventilated, his neck opened from ear to ear to drain a horrible deep tissue infection. He is off his inotropes and his renal failure resolving. He should do well in the short term, but managing that wound will be hard here – maybe a skin graft to start with, then a battle to avoid contractures.
The third kid, I call him Mobutu, has been with us in the ICU six times already and he’s only 11 months old. He’s the last of nine children. Each time he presents the same way, with a worsening of his persistent stridor and then heart failure. Each time he has responded well to being ventilated and diuresed, and then is easily extubated and each time he is sent back to the ward on captopril and spironolactone and then home. It’s hard here, we can’t find the cause and we hope he will soon go to NZ to be properly assessed. He is a resilient little guy – I say little because he is undernourished and perhaps a little syndromic. This morning after being extubated, he did what he always does, sat up in bed and threw a minor tantrum, demanding food. When he does this he reminds me of one of those mad African dictators; all that’s missing is the leopard skin cloak.
Opposite him is Lanu, looking comfortable and serene. She is young and has been in the ICU for 42 days with Guillain Barre. She is in perfect nick thanks largely to her family. They have turned her and massaged her and rubbed her with lotions and potions. Each day I chart that on the daily plan – fofo and massage Q 4H.
That was my morning, Glenn – then I started gathering up things and putting them in boxes – recycled ones, mostly those that did the journey from Auckland to Apia exactly one year ago, nestled in the hold of the Southern Lilly. Those boxes will soon be back on the Lilly for the journey home and with their contents somewhat changed; a range of new shirts, fine mats, wooden weapons, several Tanoa and more.
I did this gathering and sorting and packing all afternoon and into the early evening, then I made okra, drank water and went to bed.
From: Glenn Colquhoun
Sent: Tuesday 23 February 2016 11:34 PM NZDT
To: David Galler
Subject: Re: Malo
I loved reading your cases, Dave. It strikes me bodies are stories in themselves. Every one has its own narrative. Every illness is the same. Doctors and families have them as well and when we practice all these arcs start interweaving and overlapping. Medicine so quickly leaves science behind in its practice and becomes an art … a balancing act.
I had a school clinic this morning. And then helped launch a poetry anthology in the afternoon. I’ve got some pieces in it about Ernst Dieffenbach. Probably the first doctor in New Zealand to write about what he did here. He trained in medicine but came out to NZ on the Tory in 1839 as a scientist. He gave the name greywacke to the rock that forms the backbone of the country and was the first European to climb Taranaki. He wrote a grammar of Te Reo Maori and lent his name to the Chatham Island rail – which is now extinct.
He also kept a pet weka.
He didn’t practice medicine much but got roped into helping the ship’s surgeons at the battle of Kuititanga fought out at the Waikanae rivermouth between Te Ati Awa and Ngati Raukawa in 1839. I came across him when I worked as a GP for Te Ati Awa and ate lunch every day on that beach. I realised he would have tended the ancestors of patients I was looking after at the time.
Remarkable how we tangle. We have looked after the same skin. I had to sing him some songs after that. I’ll warble one for you when I see you next.
Go well brother.
Must be bittersweet packing up.
We’re losing the cricket.
Bring me a shirt!
From: Dave Galler
Date: Wednesday 24 February 2016 5:31 AM NZDT
To: Glenn Colquhoun
Malo soifua hombre.
I will bring you a shirt.
Where is that dude buried?
We should go visit him.
Groundhog day, Glenn!
This morning I was woken early by the rooster in the lime tree out back. That hasn’t happened for a while. When we first got here they drove me mad, so mad I complained to Assi, our landlord and Flori, his Annie-get-your-gun daughter. Things improved after that, Flori shot a few and I started to use the air con to baffle their sound. This morning I did what I did in those early days when I first got here, I got out of bed and pelted the tree where they roost with rock sized limes and sent the bugger flying off to another patch.
I could have done with more sleep but I like the early morning – the sun was not quite up but it was getting light. In the air you could hear but not see the thousands of buzzing insects hovering 30-40 feet above the ground; the sound is amazing.
Not long after I started here, the NHS gave me a truck to use; a green Hilux with bald tires and no mod cons apart from good air-conditioning and a basic radio. I love it, being up high cruising through the back roads from Ululoloa to Moto’otua, past the plantations and through the little villages. At that time of the morning there are more dogs than people on the road but by 0745 the kids start drifting out filling the old buses each with its own name – Heavenly Peace; For the Grace of God; Forever Free; Poetry in Motion; and my favourite, Paradise in Heaven.
The African tyrant went to the ward in the middle of the day.
Lanu did the whole day on a T-piece.
The charge nurse pulled the chublet’s central line out by mistake – it took days to get in. I gave a Homer Simpson ‘Doh’ and we laughed then cried.
I met the Faculty of Medicine people at the University of Samoa in the middle of the day. They want to establish a Masters of Medicine programme and shift the training from Fiji, where currently Samoan post grad docs go for years to be used like the Fijians used the Indians in the sugar cane fields.
Later as the heavens broke I steered my green Hilux through streets that quickly become streams and rivers to see Tifitifi, the boss at the government print office – she’s cool. We’re out of 24 hour charts and needed more.
Just as I was planning to leave TTM (Tupua Tamasese Meaole Hospital) we were called to another sick kid on the ward – more of what we have seen before – and too often presented at mortality meetings. A girl of 12 who had been unwell for over a week – vomiting, diarrhoea, myalgia and joint aches. It’s labeled as Dengue here but to me it’s always staph or strep till proven otherwise and if you think staph it will be MRSA. Now she’s sick as, delirious with a hot swollen arm and elbow and looking dreadful. Hypotensive tachypnoeic, sore everywhere, no murmurs yet … she’s been in two days and if that’s not what she’s got then I’m the Pope.
My crew is good now. They know the routine, they recognise the pattern. Full bore organ support and off to the theatre. They are good and they love it, so we talked it through and I left for home. More packing after that … and a Thai beef salad. I had a whiskey too … then crashed.
Four more sleeps… Talk soon, uh!
Soifua from the sauna.
From: Glenn Colquhoun
Sent: Thursday 25 February 2016 00:45 AM NZDT
To: David Galler
He’s buried somewhere in Geissen, just north of Frankfurt, Dave. I walked the old university graveyard there a few years ago trying to find him. He was the professor of Geology when he died. Of Typhus. Out of the blue … unready and unfinished.
I turned up a blank, but found Roentgen instead – the guy who discovered x-rays.
I’ve been in clinics all day today. And finally found someone to help my boy with fetal alcohol spectrum disorder. I trawled the service directories and made heaps of calls. I had a long conversation by txt with a 16 year old who is due to have a baby soon and has found some peace and kindness with her boyfriend’s parents. Her mum has too many old griefs. My mum is knitting for her.
I put in a jadelle and read some old notes about a patient who has been hypothyroid. I asked the ortho reg about fixed flexion deformities. He wasn’t that interested.
I listened to a young woman who has lost her dad and whose mum yells and whose boyfriend yells. Remarkably she is full of joy. As though despite everything it has been born into her. Her boss loves her. Her customers love her. But she is sad too. Sad and full of joy at the same time.
I listened to another young woman who worries. I don’t think I helped at all. I am still running the consultation over in my head. Did I say too much? Did I say too much? I said too much.
Some kids don’t come so I yak to the nurse. She is a treasure.
I tracked down a kid I think the world of. We have worked with her for a long time. She has been poised between the light and dark for as long as I have known her, but I feel her slipping into the dark now. I think her drug use is escalating. We are supposed to catch up tomorrow but we’ll see. I don’t know what to say to her if she does rock up. ‘Stay in the light,’ perhaps.
Medicine made me grumpy for a long time when I first began to practice it … then once I’d survived long enough it made me kind again. Something had to be broken in me first I think. That’s been one of its gifts. Kindness is underrated in medicine. It is unmistakable in the eyes and in the hands and in the pause and in the voice.
I can see it in you, Dave, and admire it.
I’d love you to meet the kids sometime.
From: Dave Galler
Date: Thursday 25 February 2016 10:31 AM NZDT
To: Glenn Colquhoun
It’s been pissing down here – a deluge of water pouring down streets and turning them into rivers – cars almost surfing down the streets.
I started early today – a quick ward round at 0700 then a series of meetings and lunches and finally a big dinner with the NHS Board and the Minister of Health and his fabulous wife – a dinner to thank me for my work here and a request to my organisation to support me coming back here once a month for a week to carry that on and move into other areas of improvement.
Also a chance for the government and PM to thank me too!
It was a little overwhelming, but really moving and affirming. There is a grace and ease about the people here that is simply beautiful – they are welcoming and they are funny and I can feel their embrace wherever I go. In the supermarket, on the street, people know who I am and they thank me for the work we are doing here.
The patients are doing ok, too. The baby with the intussusception will go to a ward today.
Ana the 11 year old with staph sepsis has osteomyelitis of her L humerus and pus in her L elbow and shoulder – more too in her L hip and gluteal muscle. She will go back to the OR today but she is reasonably stable on a sniff of noradrenaline – on CPAP now despite her CXR still showing lungs full of staph fluff balls.
Lanu with GBS did 10 hours of a T piece and today will be 12. Our plan is to extubate her over the weekend or Monday if all goes well – it’s more a matter of her confidence now than anything else – her skin is still perfect after 45 days!
Saucisi, the chublet might be extubated too – but in theatre. His neck wound will likely need a graft – James Hamill from the SS will be here next week – he might do it.
Three more sleeps; three more evenings of farewells. Tonight at La Manumea with the crew from the ICU – that will be quite special I know and very disconcerting for all of us too. Tomorrow morning Ema’s last and very symbolic sitting in the Supreme Court of Samoa. In the evening the official farewell to her from the Ministry of Justice and Courts Administration.
Saturday at HOME CAFÉ with friends for burgers chips and beer….
It’s momentous Glenn.
Talk tomorrow my friend.
Have a good one.
From: Glenn Colquhoun
Date: Thursday 25 February 2016 11:31 PM NZDT
To: Dave Galler
Oh Dave … That’s fabulous man. You and Ema both deserve the congratulations you are receiving. And I so hope you get to carry on what you’re doing there. I’m glad the tide is coming in again on all those small ones … And it strikes me that they are all small.
Our young people’s demons are very different.
I hardly ever pull out my guns. My job has become so much about talking and listening and liking. I think I say ‘awesome’ more than anything else. And yet that somehow seems pretty important.
The things that bedevil here are broken families and communities. We are poorer I think despite our wealth.
Today we cooked at the alternative education school. We started a class a couple of years back. The kids have been excluded from the high schools in the area and bounce and bounce. Every one of them has a story and everyone of them is at risk. I have long figured I can be of more use beside them than in front of them.
We usually cook a big feed for lunch. They prepare the table and the meal. They are remarkably kind and generous and understand aroha. Which is not to say they can’t snap into blind rage and lash about indiscriminately. We made chow mien and two banana cakes today. One for them and the other for my young man with FASD.
I was worried he didn’t have anything to keep it in but he said he would eat it all tonight and I suspect he might. God, there is such goodness in his grandma. She was with him again today for an appointment at WINZ but they couriered a change of appointment to him this morning which arrived two hours after the new time they had given him – then blamed him for missing it. She was at a loss. Systems are so cruel. They are never a substitute for people.
My girl didn’t show up. She rang impossibly late and asked for everything over the phone. I held out and fitted her in on Monday. I told her I felt like she is slipping away under the water.
Someone wanted to know if a protein shake would interfere with their meds.
I completed an application to the council for some money to buy food for our cooking programme.
I saw a young man with a nasty virus and a young girl down the road with chest pain who wandered over after tea. I’ve watched her grow up.
I’m melancholy tonight. A good space to write poetry in. The weather has been gloomy and the salt is all over the windows again. It is cooler. Autumnal. And the days are wearing out just that bit sooner.
The whole thing is going round again.
Catch you on the other side.
From: Dave Galler
Date: Friday 26 February 2016 11:26 PM NZDT
To: Glenn Colquhoun
It does go round and round. I think you need to be of a certain age to clock that. A year older again, and another year faster than the year before. I am certain of that.
I was woken up again this morning. It was still dark with nothing much to hear apart from a distant rooster. Rude animals eh? Best broiled.
And now I have a headache. An accumulation of late nights as well. A farewell at La Manumea with the ICU crew that was so touching and sad and happy and which made us all cry. A huge photo board of the year with friends at work, patients we’ve treated, families we’ve helped, parties we’ve all been too. They will miss me – and I will miss them.
It’s been a hell of a week – so full of emotion. I feel as though great chunks of me are still in various parts of Samoa, stuck to places and people – in their hearts, and theirs in mine. Aeroplanes and modern technology are cruel and leave little time to adjust – maybe we should have come back in a waka or a slightly bigger ship with more time to grieve.
Today saw my last ward round – hugs and kisses all round and messages of thanks from every person I met. I have been blessed a 1000 times over and I am a happy man for that Glenn.
I left my latest group of patients in a good state.
Lanu had her tracheostmy tube removed and is thrilled – so are we. She is good and still smiles the same beautiful smile. Nothing like getting better to make you feel better.
My 11 year old girl with staph sepsis has been extubated, her fever has settled and her noradrenaline is off.
The chublet, aka Sauscisi, who has Staph as well (but one only sensitive to Chloramphenicol) is also good. He is extubated, feeding and ready for grafting late this week.
Junior, with the short gut and ileostomy, is doing ok but I’m not sure whether he will have enough gut left to survive and grow.
Last Sunday we cruised Upolo in Ema’s Hilux. Sunday is a smoky day as families rise early to prepare the umu for the family lunch. We passed people dressed in white on their way to and from church. They waved and smiled and posed for photographs. We passed open fales with families snoozing in the heat, avoiding pigs and piglets, chickens and their chicks, crossing the road till we got tired and felt like a sleep ourselves.
I love Samoa and I love the people and their culture and tradition.
I love their love of God.
We have been touched my friend, truly touched.
We will cry when we leave – that’s as it should be.
I wish I could sing but I can’t.
I wish I could play an instrument but I can’t.
I march to the beat to my own rhythm – but no-one else does.
I will keep saying uh because it’s Samoan and I am part Samoan now.
Love to you and yours, HOMBRE.
From: Glenn Colquhoun
Sent: Monday 1 March 2016 8:35 PM NZDT
To: David Galler
What a blessed week to share with you man. I read back over where we started from. It helps to feel witnessed – and to witness in some way.
The world has turned by a week but I could start all over again and tell you the same different stories.
Today I listened to a girl tell me about her mother screaming at her all her life and to another tell me about being raped by her friend’s brother. Three boys from the alternative education school made quick work of the lolly jar. How gentle the angry ones are. My lad with FASD has taken the cake. Disability services are still refusing to accept his case and his grandmother continues to drive 100 kms every day to see him. She is my New Zealander of the year. My boy with nephrotic syndrome has a creatinine in the hundreds again and is in hospital.
My girl who doesn’t show up didn’t show up.
It’s been good to think about what we have written to each other. The different fates of the young in Samoa and New Zealand. The horror of infectious disease. The horror of social dislocation.
I keep coming back to the tenderness in what we do. It seems woven throughout. And I am stuck on how to write about this properly. But it feels like I love my kids. And that you love yours. It is palpable to me. And yet as a doctor that seems such a dangerous thing to say – as though it could easily get mixed up or messed up. And I am so extraordinarily cautious because I’m old now and have seen that hurt. And I am keen to avoid the old cliche of it as well … but as much as I try to avoid it that is what it feels like. Aroha. Regard. Care. Sometimes it literally is all I have to offer my patients. Kindness. Their circumstances are so ensnared and they are so socially and psychologically and economically stuck that you can but wish for them. And the care wounds and costs and gives back at the same time so that I feel continually tipped upside down and shaken out every day then filled up to bursting again by the time I leave.
I feel like I have read a novel every time I get home at the end of the day and in a way I have. The thing is I could easily miss all this by just not looking and do much the same medicine. I have after all for years. But when I choose to practice with my eyes open the tenderness is overwhelming.
You are an old robber Dave, I have such respect. And I love it that you are capable of being wounded by what you do and that you are still angry and that above all that you are kind. I’m struck by the fact that we are old outsiders too – Jews and Seventh-day Adventists – Saturday keepers – I suspect that’s important somewhere in the whole scheme of things. The bloody gods. But then again we are all local eventually.
I am buoyed by the fact that Samoa’s loss is once again South Auckland’s gain. She is a mighty old city to come home too – rambling and joyful and lost and found. She is in anguish too. Kindness won’t go astray there.
It will be good to see you.
Thanks for the yarn, brother.
Go well on the great seas.
You with your children.
And me with mine.
Drag them from the water.
By the hair,
by the head,
by the arm and leg.
There, at their ends,
find yourself, bedraggled.
Stand up then.
Suck in the air.
Let it fill up your lungs.
We rescue ourselves.