Thinking, thinking

2009
Scholtens, Martina

I expected death to feel more commonplace, more benign, the longer I practiced medicine, but every patient death is still a novelty. The surprised start my heart does each time hasn't changed since my first, in medical school. I can recall the details of everyone of my patients' deaths. But the one I think of most often wasn't from disease.

She was one of hundreds of Myanmar refugees seen at our clinic over the past three years, a group who had relocated to Vancouver after living for up to twenty years in remote camps along the Thai/Myanmar border. Her name was Yulay, one name, but immigration officials insisted on two, and her name was cut down the middle. Surname: Yu. Given name: Lay. And so the chart identified my patient as Ms. Lay Yu, and the name I called into the waiting room was unrecognizable to her. Her birthdate was January 1, the default date for those who slip into the world unnoticed by registrars.

She sat in the waiting room with a scarf wound around her bare legs. The interpreter explained, "She had to pee on the SkyTrain. She didn't know where the toilet was. She wet her skirt." I was dismayed for her, but she didn't seem embarrassed, just another small indignity endured while adjusting to Canadian life. I explained that the trains didn't have toilets, but some of the stations did, and failing that, she could seek out a McDonalds or an Esso. Even to me, it sounded complicated.

In the exam room she sat directly across from me, a gentle and slight forty-five-year-old, and looked at me with friendly curiosity.

Susu, the interpreter, sat to my left. She had come to Canada as a Myanmar refugee herself ten years ago. She interpreted at clinics and hospitals across the city, sometimes disregarding the rules and transporting patients to appointments in her own car. She interpreted the sermon on Sundays at the church the Myanmars attended. She wouldn't call me by my first name, but surreptiously paid for my lunch one day when we found ourselves at the same neighbourhood restaurant.

How are you? I asked.

"Say, 'Fine, Doctor'." coached Susu. The patient looked shy, embarrassed. "Say it! 'Fine, Doctor'." Susu insisted.

"Fine, Doctor," whispered the patient. Susu sat back, satisfied.

What has happened since your last visit? She had seen the nurses for a screening visit a month before.

Through Susu: "Everything is good."

My Myanmar patients rarely divulged details spontaneously. I looked for something to be curious about. I knew that other newly arrived Myanmars lived in her apartment complex.

Do you spend time with your new neighbours?

"Yes!"

What do you do with them?

"We have tea every day. Lots of talking."

Do you talk about life in Canada, or the old days in the camp?

She looked shocked at the suggestion. "We talk about life in Canada. Everyone knows to talk only about our new life."

I looked over the nurse's screening form at the front of the chart. Under Mental Health - Do you feel sad or worried or cry a lot? the nurse had written: Patient cried as she said no.

I used my most proven access point to mental health assessment: What time do you go to bed? "Eleven o'clock."

How long does it take you to fall asleep? "One or two hours."

What are you doing during that time? I knew the answer; I'd heard it a thousand times. "Thinking, thinking."

Do you think about what happened in the past, what's happening in your life now, or what might happen in the future?

"Always thinking about the past."

Did bad things happen in the past?

Susu sat on the edge of her seat as she interpreted. She told these stories like they were her own. Every sentence started with an earnest exclamation or a sharp intake of breath. "Oh! Years ago, in the camp, there was a flood. Many people died. Doctor! She saw bodies floating in the streets. She remembers that a lot. Another time, a group of men came to her house. They surrounded it, shouting for her husband. He wasnt home. Doctor, she was so afraid. she thought they would rape her. But they only beat her. Soon after, her husband disappeared. She never saw him again." The patient recounted further experiences and Susu tenderly passed them to me.

I didn't write anything down. I listened, let myself be moved.

Over the years at the refugee clinic, I'd cycled through various responses to patients' stories of trauma. Voyeuristic fascination with the horrific details. Avoidance of patients' pasts when I became overwhelmed by my powerlessness to change them. Feelings of deep shame over being human. Detachment, where I could hear a story of torture while noting that it was lunch time. Eventually, I simply focused on absorbing patients' stories. I came to believe in the healing power of bearing witness to suffering, a belief borne partly out of results, partly out of resignation.

I asked about symptoms of PTSD and depression.

"She wants to know, Doctor, can she injure herself by crying?" inquired Susu. "Because sometimes, when she cries so hard, it feels like something might break inside."

I offered her counseling, wrote a prescription for sertraline and trazodone, booked her to see me again in four weeks.

Over the next six months, she responded well to treatment. I adjusted her medications, did her first pap test, treated her for H. pylori. I praised her English. She found a job picking potatoes. Her teenaged sons became my patients as well, wearing low-slung jeans, hoodies and carefully tousled hair like they'd done so all their lives.

One day, she gave me a brilliantly pink, handwoven skirt wrapped in a plastic bag. I tried it on over my pants. It was a perfect fit. Later, I pulled Susu aside and asked if it was appropriate for me to accept the gift. It was so generous, so unnecessary, when all I had done was provide routine care, perhaps offered a little kindness which was effortless and cost me nothing. She shook her head before I had finished explaining my hesitation. "You must accept it!" she said emphatically. She gripped my arm, said quietly and firmly, "The Myanmar give gifts to people who they feel in their hearts are looking out for them."

For everyone of my patients who have died, I remember how I learned of the death: a faxed ICU report, seeing a name erased from the ward white board, handover from the on-call team. This time, I was dipping a urine, interpreting the row of coloured cubes, when Susu passed by and asked, "Oh! Doctor! Did you know that Yulay died?" What did I miss? I thought. What got by me, got her? An MI, maybe, or a stroke, or (and this is what I feared most) suicide. Susu told me the story in a sentence. I didn't fail my patient; it was worse than that.

She was crossing the street on a dark November morning, umbrella held against the rain, hurrying to get to English class, when she was struck by a bus.

Theme: Patients | Patients
Theme: Death and Dying | Décès et le mourir
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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