Mah-Skall-Ick

letsgetfree.

Free your mind.

Original article here.

How to make UpToDate out of date. 

Putting Wikipedia articles through a medical journal’s traditional process can put free, reliable information into as many hands as possible.

James Maskalyk, MD, is an associate editor at Open Medicine, an emergency physician at St. Michael’s Hospital, Toronto, and an assistant professor in the Department of Medicine at the University of Toronto, Toronto, Ontario.

If you graduated from a medical or nursing school before the turn of the millennium, a single glance in a teaching hospital can tell you how things have changed. Resident and student physicians no longer huddle in groups, listening to their seniors: they lean alone over smartphones or computers, searching for diagnoses and doses. With an Internet connection, you don’t need to talk to the brightest people in the room to get the information you need. With the right access, you are one of them.

Of course, making a sound clinical decision requires more than Wi-Fi. One must accumulate and contextualize disparate bits of knowledge and integrate them into a larger impression shaped by clinical experience, the patient’s evolving clinical trajectory, current evidence, and the limitations of the immediate health care environment. After a consensus has been gathered from other professionals involved in a person’s care about available options, an informed and compassionate discussion makes the process clear and creates the solid ground necessary for a patient’s informed decision.

If the latter points are the “art” of medicine, then the former are its science, and that science moves quickly. New evidence pours in to the tune of 12 systematic reviews per day,1 and accumulating the information and then deciding how to incorporate it into one’s practice is an almost impossible task. A study published in BMJ showed that if one hoped to take account of all that has been published in the relatively small discipline of echocardiography, it would take 5 years of constant reading—by which point the reader would be a year behind.2

Thirty-five years ago, Archie Cochrane remarked that the medical profession could use a critical summary of available evidence to aid in decision-making3 so the echocardiographer could stop reading and do some echocardiography. The Cochrane Collaboration, launched in 1994,4 has led to a better synthesis, but it’s far from convenient or complete. More than half of the articles are out of date, and this situation is getting worse all the time:5 having busy academics decide on what topics are important, reach a consensus about new studies that merit practice change, and then publish a distillation of their analysis, is a losing battle. In 2012, hundreds of thousands of new citations were added to MEDLINE, and the number is increasing each year.6 There have been repeated calls for new ways to aggregate information and translate it to the bedside, including making research articles “living” documents that exist only online and evolve constantly at the hands of many authors7—an approach we have explored in this journal.8 In the age of Wikipedia, even the Cochrane Collaboration admits it needs to change with the times.9

If you type “Archie Cochrane” into a search engine, the first link will be to a Wikipedia article. The same is true if you type in “pneumonia,” “azithromycin,” or “life after death.” Wikipedia is the most heavily used health resource on the Internet—even more than MEDLINE—and is the sixth most popular website in the world.10 In printed form, it would consist of more than a million pages,11 and it grows each day. Anyone with Internet access can connect, provide content, and correct mistakes.

Or make them. Despite its popularity,12,13 in medical circles Wikipedia’s constant evolution has been viewed with skepticism. Although often used to gather information, it is rarely considered accurate or complete enough to guide treatment decisions.14 In the face of this, clinicians and trainees turn to medical resources such as UpToDate with greater frequency15 and confidence,16 because in clinical medicine a small error can make a big difference.

It pays to be certain. Some institutions pay UpToDate hundreds of thousands of dollars per year for that sense of security.17 This has allowed Wolters Kluwer, the owners of UpToDate, to accrue annual revenues of hundreds of millions of dollars and to forecast continued double-digit growth as “market conditions for print journals and books … remain soft.”18 In contrast, the Wikimedia Foundation, the non-profit that operates Wikipedia, a resource with 20 times the numbers of views and wide-ranging articles in 287 languages,19,20 has forecasted revenues of $50 million in the upcoming year.21

As a source of clinical information, how does Wikipedia differ from UpToDate or, for that matter, a textbook or scholarly journal? Wikipedia lacks three main things. First, a single responsible author, typically with a recognized academic affiliation, who acts as guarantor of the integrity of the work. Second, the careful eye of a trained editorial team, attuned to publication ethics, who ensure consistency and accuracy through the many iterations of an article from submission to publication. Third, formal peer review by at least one, and often many, experts who point out conflicts, errors, redundancies, or gaps. These form an accepted ground from which publication decisions can be made with confidence.

In this issue of Open Medicine, we are pleased to publish the first formally peer-reviewed and edited Wikipedia article. The clinical topic is dengue fever.22 It has been submitted by the author who has made the most changes, and who has designated 3 others who contributed most meaningfully. It has been peer reviewed by international experts in infectious disease, and by a series of editors at Open Medicine. It has been copy-edited and proofread; once published, it will be indexed in MEDLINE. Although by the time this editorial is read the Wikipedia article will have changed many times, there will be a link on the Wikipedia page that can take the viewer back to the peer-reviewed and published piece on the Open Medicine website.22 In a year’s time, the most responsible author will submit the changed piece to an indexed journal, so it can move through the same editorial process and continue to function as a valid, reliable, and evolving free and complete reference for everyone in the world. Although there may be a need for shorter, more focused clinical articles published elsewhere as this one expands, it is anticipated that the Wikipedia page on dengue will be a reference against which all others can be compared. While it might be decades before we see an end to dengue, perhaps the time and money saved on exhaustive, expensive, and redundant searches about what yet needs to be done will let us see that end sooner.

There were challenges with this article, as there will be with others. A lack of a single, authorial voice in the Wiki process means not only that strong personal recommendations are unlikely, but also that the style can be inconsistent, and the sentences and transitions between them less smooth, resulting in a paper that might be challenging to read. Some “Wikipedians” have little traditional experience in publishing and the editorial process that accompanies it, which can lead to frustrations about content or format that might fit a journal’s preference. (In Open Medicine’s case, we would have preferred a different structure for the article, but deferred to Wikipedia’s standard flow.) Medical articles that originate from Wikipedia might also lack the traditional “senior” author typical of many clinical reviews, whose role is to provide guidance on when a piece is ready for submission, what editorial changes should be accepted or challenged, which journal’s readership might be the best audience for a clinical topic, and who might write accompanying editorials to contextualize new information or frame controversy. Should the example of the dengue article be copied, this may lead to a number of rejected submissions to formally peer-reviewed journals. Also, as time goes by, the Wikipedia-based articles will lose their brevity as they become truly encyclopedic.

The issue of authorship is particularly controversial. We talked about many possibilities, including listing an author even if she made only a single change, or setting a threshold based on the percentage of total changes contributed, and finally settled on letting the most responsible author, the one who had made the most changes, decide who should share authorship according to widely accepted authorship criteria.23 A single change, though, may be an important contribution, depending on what it is, and a case can be made to include all those who contributed: in this case, 1373 people.24 Since the number of changes made to an article are freely available for everyone to see, what of the “senior” authors mentioned in the previous paragraph, who may suggest small but important revisions, or—too common in traditional academia—are added honorifically, without having changed a comma? If a decision is made by a journal to include every person who made a minor change, or only those who made substantial ones, how will a university determine whom to reward with merit? Will medical journals be as tuned to potential conflicts of interest when there are hundreds of authors? Will pharma companies be keen to exploit this weakness?

The line between editors and authors will become more blurred. In the case of the dengue article, we deliberated over whether editorial changes should be made publicly on the “wiki” or “suggested” to the primary author. If journals were truly “open,” recording every change an editor advised, we might see that some publications require more than a careful eye and attention to conflicts of interest. Some require editors to do research of their own, find relevant citations, communicate with experts in the field, and even interpret data. In this case, we opted for a more traditional, invisible role, although a compelling case could be made that disambiguation, in all spheres, brings valuable change.

A trend toward improvement is not just typical of a Wikipedia page, but so too of medicine. Its progress is determined, and marked, by what appears on the pages of medical journals and textbooks—or, these days, on computer screens. It is our hope, and that of the Wiki Project Med Foundation, that this endeavour will encourage other scholars to refine and improve Wikipedia articles so they might become the world’s most accurate and trusted reference, in addition to the most well read (the Wikipedia page on dengue was accessed more than 10 000 times yesterday).24 Freely open and accessible, Wikipedia can improve clinical care at the bedside for physicians around the world by allowing them access to the latest information, regardless of their ability to pay high fees. Already, Wikipedia’s Zero Project is working with mobile communications providers in developing countries to minimize, or even remove, data costs associated with using the site.25 This might encourage greater numbers of clinicians and scholars to contribute their expe=rience and research to our shared, global knowledge, and begin to repair the enormous publishing bias that exists between the high- and low-income world.26 Further, in a time when newspapers and traditional publishers struggle to explain their relevance, medical journals can more easily describe what we deliver: content you can trust.

At least temporarily. Medicine and science, like the diseases they attend to, move fast—much faster than the systems that are responsible for making medical science known. As this editorial is being written, Ebola continues its surge in West Africa. Since the 2014 epidemic started, there have been 1549 changes to Wikipedia’s Ebola disease page, 10 times as many as the year before.27 Which ones are accurate? Given Wikipedia’s history, one would suspect that most of them are. All of them? Without the attention of dedicated, capable, and responsible eyes, one can’t be sure. What we can be certain of is that the story of the 2014 Ebola epidemic, like the recent dengue outbreak in Japan,28 will be told on Wikipedia and that a determining factor for its final sentences will be how much relevant information about how to treat and control the disease makes its way into capable hands.

References here.

here goes everything.

 

we’ve launched high into the clean, blue air.  below, clouds circle.  i read, that for some, it can take years to fall, that they don’t drop out of the air, splash onto the ground, just like that.

speaking of falling out of the air just like that, i would like to get the customary planefear piece of my travel writing out of the way.   for some reason, i am always seated by the wing, and just stare at them as they quiver like feathers.  not thousands of feathers cushioned by millions of smaller ones jutting at different angles from a hollow frame designed by millions of years of evolution, but two  flimsy feathers bolted ono a metal frame carrying a giga tonne of irish spring soap bars. the main problem is that most plane design takes place on the ground.  to make it better, aeronautical engineers should be seated by the wings and piloted straight into the blackest clouds with scratch pads. it would lead to better solutions like plane parachutes, or more wings.

but i’m not an engineer, i’m just a dj, like everybody else.

and a doctor, but i’m taking time fromthat for a year, at least from toronto’s ERs.  i’m flying to ethiopia to keep working myself out of a job. later this week, i’ll be delivering final exams to six young men and women who, should they pass, will be the second cohort of emergency physicians in the country, some of only a couple dozen in Africa.  there are more than that at my hospital.

next week, with friends from Toronto, we will celebrate them at the second-ever African Federation of Emergency Medicine conference in Addis, the first outside of South Africa.  I make a point of saying that because, South Africa has, in some places, for some people, a robust health system that emergency medicine can fit into.  in Ethiopia, these young men and women will have to grow it.  it’s different.  not only do they struggle for legitimacy, but for the right medicines, the right equipment.   in the meantime, they stand beside the beds of people, and watch them sicken when they know it could be otherwise.

it’s a necessary step, however.  there is always a lag between when you glimpse what’s possible, and the arrival.  only one thing that can shorten it.  it is the world’s only true magic: attention.  in its bright light, the world changes.  the question becomes, what do you pay attention to?  love or war? a place for some or a place for all?  with your decision, a future gets pushed slowly into view.

i’ve been coming back here for five years, and with others, paying attention to this idea: a place in ethiopia, open all day and night, where anyone who is sick or suffering can find what peace the environment can afford, no matter how many others have already sought help that day.  in that place, great teaching, not just on the new types of medicine necessary to make good on such a promise, but on how to take it from black lion, to other parts of ethiopia.  jimma, hawassa.  sudan, liberia, sierra leone.

it’s hard to watch old ways disappear.  day to day, change is almost imperceptible.  those of us who have been watching for years can see the slow turn to something brighter.  worthwhile movements seem incremental, almost glacial.  fear crashes stock markets in a day, threats cancel flights in an afternoon.  true love creeps into open space, timid at first, but then with more courage, and when it does, it becomes lasting,  inexorable, unshakable.

i have taken this flight, many many times, and have never seen it so empty.   my return flight was cancelled because of low numbers.  in a familiar collapse of world geography, there is fear about africa in general. the jaundiced eye knows that as soon as sierra leone is ebola free, attention will swing from it to the iwatch, as certainly as the rubble cleaning from port-au-prince stuttered to a crawl a year after the quake. a few countries away, though, 11 young doctors will be working on developing PPE equipment and protocols that are safe, effective, and sourced locally.  at the third annual AFEM conference, they will share what they know, and the ideas will pour into the gaps left behind, the empty tent pads and land cruiser ruts, like liquid metal, and on them, something that can last.

if you can’t pay attention to helping right now, money will do.  we’ll call it frozen attention.  MSF is sweating hard in those suits.  give here.  and for those of you who want to help these young doctors project, stay tuned.  they’ll need love more than ever.  it’s one thing to teach people how to do emergency medicine, it’s another to ensure they can do it.

almost chemical sleep time.  i’m a ninja at that now.  movie, glass of wine, a dollop of this, smidgen of that, and….soon, suddenly, ethiopia.

 

 

 

Wanderlust.

unslakable.  I got my drivers license the day I turned 16.   found the road, but not the end.   it’s taking me to the wanderlust festivals in whistler and tremblant later this summer.  i look forward to the community of wanderers that gather there.

for now, i’m in ethiopia.  below my window, the sound of the street.  people laughing, taxis buzzing by, a dog in the distance.  it’s dark, and the evening air is cool and fresh. it reminds me of home.

it’s spring there, in Canada.  in northern alberta, my mother is looking at the black patch of earth in her backyard, thinking: soon. my grandfather, 93, even farther north, will be watching edges creep into the ice lake outside his window, wondering whether he’ll till the ground to the sky and watch plants break from it, or whether that time is done.

in addis it’s autumn.  clouds gather in the afternoon, drop some hard, brief showers.  soon, the rain will thunder on the tin all day and night, and swell the rivers until they are angry and full.  i’ll be gone before then.  a team of teachers is arriving, and once they settle in, i’ll leave.  in a few days, i’ll be high above the clouds.

on my walk up the hospital hill today, sun on my neck, i smelled rain.  i looked up.  the sky was bright blue.  to my left, through an iron fence, two men cut into the ground with great swings.  the smell was fresh soil.  stored rain.

i spent the afternoon in the ER of ethiopia’s largest public hospital, teaching, learning in equal measure.  the last hours, i leaned my elbow on the nursing station, and watched blood drip.

drop.  drop.  drop.

i learned to watch in sudan, where the wind was so hot, blood would clot in the tube before it could drain into a person’s arm.   today, it rolled in a line towards a young, shaking man   even with his black skin, he was pale as a ghost.  that’s where the saying comes from, i’m sure.  not some gauzy vision of a spectre at the top of the stairs, but the pale lips of the newly dead.

i tell my students what was once told to me, that you watch the young bleeding man with great care. don’t let your attention wander far.  there is so much vigour inside, so much energy, so much muscle to squeeze blood from, that they hide the loss until the last minute.  i tell them, should he, with a heart rate of 130, say “i’m so c-c-c-cold” you should feel a chill too, for you are a few deft moves away from a suddenly dead person and the black birds of panic that flutter around them.

drop. drop. drooop.

a drip dangled.   i walked to his bed, rolled the tube between my fingers, took a syringe and flushed the iv.  it flowed again.  his mother nodded.

the students and nurses were busy with other things. a little girl, 14, from days away, vibrated at 160 beats per minute. with each throb of her overlarge heart, her whole body quivered. you could see her shake from across the room. a few beds over, a man bitten by a dog one month earlier, foamed.  despite being dry, he gagged when we offered a bottle of water, pushed it away. hydrophobia.  rabies.  fatal.  to my left, a woman sagged in a chair.  she saw me notice her, half-smiled, let her eyes roll back into her head until they were only whites.

a young doctor, an american, in addis for a month to learn how to do this type of medicine, where minutes matter and you’ve none of the stuff, joined me, surveyed the people circling to the sick.

“how the hell do you know when to leave?” she muttered under her breath, then joined me in watching the drips.

the best teaching is not delivering held knowledge to a student for whom it is new.  It is showing her to fall fully into questions that have no bottom, that point at a truth to which you can never fully arrive, that always live just there, forever shifting, beyond your finger.

how do you help others without hurting yourself?

that was her question. mine too. i don’t have the full answer, but i know how to start.  you hurt yourself, and don’t help others.  try to care for people, before you learn to care for yourself, figure you’ll learn it along the way, that if you save someone, maybe you’ll get saved too.   you go through the motions for a couple of years, but in the end, you get beaten down, touch burnout, or worse, bitterness.

then, somehow, grace. you find the right teacher, the right question to ask, and you learn that first, to help others, you must help yourself.  not to the last piece of pie, but on a deeper level.  then you see that helping others and hurting yourself is as flawed an equation as trying to help others while robbing them blind.  you understand that you’re part of a process that wants you, as much as anyone, to be whole.

something gathers us together, repairs us as we are pulled apart, binds us together and to all living things. you can call it soul, or god, or nature, but there’s no separate piece, just infinite, peripheralized shifting shapes spread among the stars and made of them, pushing fearlessly, inexorably towards some new place of previously unfound release, like plants from bright black soil, reaching as far we can.

in the deep questions about how to do that for as many people as possible, we taste freedom.  i’m not sure it’s a law, like gravity, or just a rule that gives me a way to live, but it seems to me that none of us can fully abide in that peace until all of us arrive.

the drips stopped.  the blood was done.  a nurse went to find a second unit.  the ER was quieter.  many of the young doctors had gone home, most of the family members, save for those with the sickest patients.  nurses moved from bed to bed, doing their endless work, patching up the broken, bleeding bits of humanity that wash through places like this.

a second unit came.  i showed a nurse to watch the drops when she could, told the night duty doctor i would call in a couple of hours.

“let’s go,” i said to the american.  together we walked down the hill, quiet, thoughtful, wondering if that boy would live the night, whether staying through the second unit would help, but we needed to eat, and we needed to sleep, because tomorrow would be full too, and the tomorrow after that.

 

 

The Doctor Will Not See You Now – Globe and Mail

 

(original article in Globe and Mail here: bit.ly/1uXBApt)

Outside Addis Ababa’s Black Lion Hospital is a crush of people. Some sit on red plastic chairs, others lie on a cement pad stretching from the emergency room’s metal door. Family members tend to mothers and brothers, or try to reason with the security guard leaning halfway out the door’s missing window. He looks blankly past them, sees me, swings the latch and I pass.

The sicknesses I see in the tin room in Ethiopia are different from the ones I see in the ER at St. Michael’s in downtown Toronto. It’s not just the nature of the illnesses, but the severity: You must be nearly dead, or briskly on your way, to get admittance to the public ER in Addis. While some people in Toronto bypass their family doctor and come to the ER when something “doesn’t feel right,” in Addis people are there because they have no other choice.

When Toronto Life published that St. Mike’s has an “express ER,” my colleagues and I groaned. Only two years ago, we thought 200 patients a day was busy. Now 250 is common. We add shift after shift, and our roster of physicians grows. But unlike Addis Ababa, it’s not to treat those lifted seemingly lifeless from a taxicab. Canadian patients are lined up looking for help with hemorrhoids, insomnia, prescription refills, the common cold – and often to standing room only.

This is one time, in a society that has forgotten how to do it, when waiting is good. If you’re in the ER and you’re not hurried to the front of the line, you’re lucky. If people are rushing you in, well, then you should worry. Just like outside that windowless metal door in Addis, there’s an invisible process at work: The sickest goes next. Not the richest or the most powerful, but he or she who hurts most. This ethic illuminates the best part of our human spirit, as brightly as the red letters do our emergency departments that never close.

In Canada, we’ve got a habit of judging the success of our health-care system by how long we wait. The Fraser Institute, a pro-private-health-care think tank, releases reports on wait times for elective procedures, concluding that people are waiting longer than ever, and citing dollars lost to quantify that adversity. We live in an age where everything that matters is assigned a value to the nearest nickel. Unfortunately, what happens after the person reaches the front of the line is given less attention. Did the knee operation help the person climb stairs more quickly? Did the cataract removal sharpen someone’s sight, or lead to the discovery that the blurriness was from something else?

Our population is aging, and that means more painful knees, more cataracts to cloud an otherwise bright day. As patients turn to the hospital for relief, the strain on the system will grow. Old habits die hard, and treatments known to have limited utility persist. The Internet has replaced one’s family physician as a main source of advice, and people Google their symptoms, and without the benefit of experience, note rare cases and insist on an MRI. An already long line stretches out the door, and into your home.

But there are some encouraging steps that will at least make the wait more efficient. Palliative teams and mental-health workers are visiting people’s homes, moving to the periphery care once found only in hospital. More medical work is being done by non-physicians, with comparable outcomes. And Choosing Wisely, an international endeavour started by the U.S. National Physicians Alliance, asked medical societies to identify five tests or procedures unsupported by sound evidence that should be avoided (such as imaging for non-specific back pain, for instance, or CT scans in minor head injuries).

The best way to manage a wait is to avoid it. To encourage wise choices, a family physician remains a remarkable steward, not just to navigate an increasingly complex health system, but to keep you well. Develop a relationship with one, so you don’t come to the ER to jump the queue to a specialist or MRI. If you do, do not expect to be admitted if you can be investigated or treated safely at home; hospitals can make you sicker. Don’t expect refills of opiate or sedative prescriptions; those medicines have so many side effects, you need an expert to help navigate them. Chronic conditions are difficult to manage in the ER, because we only get to see you once.

Above all, if you’re unsure whether yours is an emergency or not, come to the ER. It has the best logic of any place I know, because we take anybody, any time – the ill, the tired, the afraid, the anxious. But, as in Addis Ababa, the sickest first, then everyone else in the order they come.

Opiates and the Masses – Globe and Mail – Mar 5, 2014.

Addiction to prescription opiates is almost always a symptom of deeper suffering

DR. JAMES MASKALYK

Special to The Globe and Mail

http://fw.to/CJ4QJhO

“And so, just as before, only by occupation in the day, by morphine at night, could she stifle the fearful thought of what would be if he ceased to love her.” – Anna Karenina, Tolstoy.

According to the International Narcotics Control Board, Canada uses more prescription opiates per capita than anyone else save our closest neighbour, by a wide, almost unbelievable, margin. Australia – a country similar to ours in size and population – uses half as much at No. 9 in the world. While heroin overdoses have remained stable, prescription-related opiate deaths have bloomed onto coroner’s tables, more than doubling since 2000, when OxyContin first hit prescription pads. According to a drug-use survey of Ontario youth, high-school students are more likely to use OxyContin than smoke cigarettes. Public-health officials in both Canada and the United States are calling it a crisis, one set to worsen with new approval by the U.S. Food and Drug Administration of a long-acting painkiller that promises to be as addictive as any before it.

On my last shift at the hospital, two men arrived to the ER nearly dead from prescription opiates. How much longer must Canadians turn to these drugs before we understand what they’re turning from?

As a curious young doctor new to the big city, I asked addicts what they chased. I’ve since stopped. There are too many, and new answers became rare. Alcoholics and crack smokers were often too lost to say. Opiate users knew. A man claiming pain in a long-healed elbow admitted to such a huge dependency, he was afraid the withdrawal would kill him. He answered with disdain.

“You know why. They treat pain. But not just physical pain. It gets it all. You return to the womb.” Rough edges disappear, and with them, the drive for another breath.

While Rolling Stone eulogizes another star lost to opiates, less famous Canadians die daily. Some are cursed with unrelenting physical pain that prevents them from feeling free. Others taste freedom in the drug itself, a temporary escape from a deeper suffering, and, looking for deliverance, put another thing in its way. My colleagues and I are anxious to help both groups, but want to cause no harm. As such, each day, people leave the ER angry, their pain unaddressed, others with enough pills to drowse into a deep, and sometimes final, dream.

The truth is, a five-minute encounter with a doctor and a dose of opiates is rarely an abiding solution to a person’s affliction. A lack of honesty about this has led to a lack of options, and combined with the lure of a medicalized, anodyne experience, has created a fine system of dependency. In a strange evolutionary turn, our bodies have natural receptors for pieces of poppy. The compounds are very similar to our body’s painkillers that sift into our blood when our bones are broken and so precious that, when in abundance, our cells make more receptors to grab each piece. When the surplus drops, we ache. What once was enough no longer satisfies.

Each day in the ER, I see people claiming backaches. Abdominal pain only relieved with morphine, headaches that won’t go away, all investigated many times with no sign of disease. I rarely give the drugs they request, except for new injuries. They are dangerous in the large amounts that people need if they take them regularly. Wherever their pain came from, a pinched nerve in the neck or childhood wounds, it will take more than one prescription to get past it.

Drug manufacturers know it’s better business to create dependency than to offer remedy, and there are walk-in clinics in every small town. Give people a dose of fentanyl for a broken elbow, and pills to go home with, and a percentage will eat the pills even after the pain fades, seek more, until eating them is not enough, the delivery to hungry receptors too slow, so they scrape off the coating, crush them between spoons, mix the dust with water and put it straight into their veins. What hurt are we walking around with that sees us seeking relief in such numbers?

Chronic physical pain is a horror, poorly understood and difficult to treat. So too is addiction, and what leads to it. It is marginalized in our society, treated as a weakness, or even worse, a disease from which the patient can never be healed. To enter rehabilitation, we ask them to be drug-free, already better. If they succeed and abstain, we tell them they will never be outside its shadow, forever sick.

This is wrong. Addiction is not a disease, but a symptom of a deeper trouble from which a person can be freed, but never by something as simple as what can be written down on a piece of paper, neither methadone, nor three days in detox. These will never address the deeper distress of a traumatic past that needs to be shed, a difficult present that needs to be transformed, a fear of the future replaced with possibilities.

Both patients and doctors need to understand this ache as one that opiates will only make worse.

James Maskalyk is an emergency physician at St. Michael’s Hospital in Toronto. His second book, Life on the Ground Floor, will be published in 2015 by Doubleday.

graduation speech to Ethiopia’s first emergency doctors.

Biruk, Sofia, Yenalem, Seble…..

You did it.

I feel like there should be 84 million, nine hundred ninety-nine thousand, nine hundred and sixty more people in this room.  In fact, I feel like the whole world should be here, not just to celebrate your graduation as an occasion that marks a safer future for the most vulnerable, or that the means by which you were trained is replicable and available, but to see how people from three different countries can come together in a spirit of peace and make something beautiful.

I came to Addis, for my first time, not from a place of peace, but from one at war. Sudan.  It suffers still. I was working for MSF in a small hospital, overwhelmed by the sick and dying and fighting, the heat and the sand, and when a chance came for me to leave that place, to come to Ethiopia and learn how to care for patients with Tuberculosis, I took it, not just to help them get their breath back, but to find mine again, even if just for a week.

The air that I stepped into, at Bole’s international airport, smelled so sweet.  It still does.

A professor from Addis Ababa University taught me everything I know about TB, with his x-rays and experience, saved dozens of peoples lives, through me.  Because of him, because of Ethiopia, in Addis Ababa in 2007, I touched hope when it seemed far away, and it carried me through my mission, and it has carried me back here, to stand in front of you, the country’s first emergency doctors, and it stretches from this room towards forever. I’m fond of repeating a quote of Vaclav Havel, told to me by my friend James, that hope is not a belief that things will work out regardless of circumstance, but the belief that regardless of circumstance, something makes sense.  That you are experts in the type of medicine where minutes matter in a country with such a surplus of emergencies, makes sense.

I wrote a book about my time in Sudan. I’m writing another now.  Some of it is about Ethiopia. You are all in it.  Don’t worry; I’m generous.

I was talking with a friend of mine about how to focus it. I knew it was going to be on emergency medicine, but was deciding on a larger direction. James, he said, remember in your first book, you wrote about that woman who walked for six days with a baby’s arm reaching from her, unable to be born any further? Yes, I said.  It was blue.

Write about what she was walking towards.

She was walking towards you.

I know you think emergency medicine is about what you know, the skills we’ve helped you learn on resuscitation, ultrasound, reading electrocardiograms.  Maybe you think it is about decision making in times of crisis, or how to manage many things at once with grace and compassion.  Or you might even think it is about research that allows you to do better medicine, or advocate for societal change.

It’s not.  It’s about a room that never closes.  It might be the only room in the city that is open twenty four hours per day, seven days per week, Eid, Timket, Easter too, and anyone can enter it, rich or poor,  no one is turned away, and in that room, they will be asked “how can we help you” by someone who means it, with nothing to sell, someone with no other interest except listening to the answer and working to satisfy it, no matter the difficulty.

I’m not sure there are any other places like that.  Churches?  Are they open 24 hours per day here?  Some.  Ok.

This is my challenge to you: make your ER a church.  Make it the place where you pray towards something that makes sense.  People misunderstand the word prayer. They think it is a conversation with god where one can ask for things; relief, salvation, even material goods.  That is not prayer.  That is wishing.  Praying is an activity, a movement towards a world you want to see.  Prayers like that get answered, wishes, never.  If you pray towards a world that makes sense, with your gestures, even the small ones, it will move into view.  This is the magic of the world, your true power.

There will be struggles, not just to find the right medicines in time, or dialysis for that little girl before she drowns from her own backed up kidneys, but in your spirit.  You might not be able to transform peoples sickness as often as you would like, but in those instances, you can transform their fear of being unheard.  And if you use those encounters as a way to pray towards an easier day for the people who will follow, by working with your nephrologists to get emergency dialysis even though it seems like it will take years and you want it tomorrow, one day it will come, you’ll see, and that day or the day after, a little girl will walk into that room gasping, and a week later, she’ll leave it skipping, and the relief will be so complete, you can almost feel it from here.  In the meantime, if you suffer a lack of means, until they make themselves available, you are able to offer the most important thing: your presence and compassion.  Let it shine.  Teach the juniors well, because they will own that space with you, and the more of us that do, the stronger it is.

As you make that place for the sick and suffering, keep its lights on and door open, you must keep your heart open with it.  That becomes your daily practice.  Practice makes practice, never perfect, only better, but you’ll see as you try to keep it open, the longer it stays that way, and soon  you’ll see that it will be filled as brimming full as your stretchers.  You will not just have a satisfying career, and  a place in the history of your country, but food on your table, the company of fine people, and dare I say it: the true love that is only possible with knowing our one shared heart.

If a goal of life is to create one of possibility, you’ve done it.  Doctor. Teacher. Researcher.  Leader. What will you do with that rooms sacred space?  That place where you make no distinction between man, woman, tribe, country, but see the sickest first, then everyone else in the order they come.  Take it throughout the country, let it put the young men and women who are knocked down firmly back on their feet so they can help pull your entire nation towards easier days?   Maybe take it to Sudan, Somalia, let the peace it promises do its work, and watch that space grow.

Whatever you want is possible.  Nothing can hold you back. Today, you join the company of thousands of men and women around the world who share your same space, your same struggles, who are as committed as you are to being excellent. Lean on them. You will find solid ground.

And you will find me.  I’ve come to know you well over these past years, and I can sincerely say you are up for the task.  It is my pleasure to retire myself from being your teacher, and instead, offer myself as a colleague, and friend.

May the long road ahead rise to meet your steps.

first class.

first class taste, economy budget.

first class taste, economy budget.

on the plane to ethiopia were women wrapped in bright scarves, glass beads glistening.  Africa again.  I’ve made a life for myself here.  during the 17 hours on the plane, before drugging myself into a coma, i transferred my contacts to a new phone.  from ermias: taxi driver, just: “ermias”. my friend.

stepped from the airport into Addis’ high, blue air, and it was like coming home.  on the sloped cement path to my waiting car, a mother and a daughter laughed as their carts wagging wheel lead them astray.  i climbed into a waiting truck with my team of teaching doctors, our eyes heavy with sleep, and we drove down bole road, smooth, full with addis’ blue taxis.

the hospital was a first stop. men and women in white coats circled the sick,  the locus of their murmuration not a shifting delight, but the pain of a person they didn’t know.  we don’t flutter in such numbers around a suffering of the spirit.  I wonder if it’s because we bear it too quietly.  an ankle, though, that is redhot and infected, is plain, and if we fix it, you can hobble on that same trip we’re all making.

between the circles of doctors and nurses, a young man, blood at his mouth and nose, shivering, nails paper-white.  it takes time to learn how to spot the sickest in the crush of so many, but I have a particular eye for them, with it, i saw that man from tigray, blood pouring from his face, stooped slightly forward, trembling, alone, between stretchers of women gesturing to me for help, and knew in a glance that those women had days, maybe even years, but this man, arms drawn in from the sleeves of a blood spattered shirt, holding himself, had only hours.  the tough part is that once you tune into, you see age and suffering everywhere you look, in the faces of your friends, even your own eyes.

i picked that man from the pile, and he  was swept into the eddy of attention that runs behind the emergency department threshold.

it’s been four years since i started coming to Addis Ababa, to make that threshold.  with friends from toronto, doctors, nurses, colleagues, Wisconsin university, and ethiopians who understand that if you don’t make a place like that somewhere, for the poorest people, it doesn’t exist in its true incarnation anywhere.  i’m here to deliver exams for the first class of emergency doctors the country who can make it last.

i remember the minute it all started for me.  i was back from sudan, visions of what i couldn’t do to make that place safe flashing in front of my eyes, peppering my dreams with guns that sit there still. i was on the end of jeff’s dock, my toes just over its rough edge. my phone rang in the pants bunched beside me.  it was toronto’s director for emergency.  he told me that ethiopia wanted emergency medicine.  would i help?

no, my first thought.  nononono.  say no.  say no.  but then:  sudan.  sudansudansudan.

no.

“yes.”

that man who got pulled into the river of attention, who got the platelets that plugged up his hemorrhaging holes, who got back the blood he had lost, gifted from someone else, wasn’t swept into it by me, but from one of the doctors we’ve trained since that phone call on the dock.  i’m here to do give the first four their final exams.  should they pass, we will move with them into a new, safer space where even the sick and poor can continue communion with our same shared heart.

sand.

(found this in the notes for my second book, Life on the Ground Floor)

Don’t worry about finding your place in the world.  The world will place you. It will grind you into sand just like the ocean does rocks, back and forth, ever smaller, ever more perfect, until you’re so smooth you disappear, and if that thought makes you look at mountains and think “ill never outlast them”, you’re wrong, you’re fucking MADE of mountains, and together you last towards forever, then rocks, then sand.

a love thing.

the spot warmed by grace has gone cold.

but just for now.

in my piassa apartment.  sun beams warm through a window, then a cloud.  partly cloudy is the best kind of weather because what’s not to like?

tree outside my window bursts from the ground.  if you were a mountain, you would be, like, whoa, so fast?  this place is out of control! the moon, watching the mountains crash like waves, then smooth, then crash again, would say, slow down, let me get my breath.  the sun…well, she would have better things to do than watch us.

busy at the hospital.  busier and busier all the time.  you build it…

a man had his leg taken off.  it was blue to the knee.   i saw him this morning, the day after, wincing in pain.  he looked better, somehow.  more himself.  he has a fever now.  i’m worried.  his remaining foot is not looking so good.  dusky.

today, as every day, on my way to the hospital, i walked past the coffin sellers that line churchill. i try not to take it personally.   beautiful swoops of gold weave on the red felt that covers people’s final box.  outside of one the shops, a father scooped last night’s injera onto his son’s plate.  father to son, cradle to grave, even these people, one day, in their beautiful boxes.

a shroud, my mom said to me, when i asked her how she wanted to be buried before i left, just a shroud. let the worm’s dig into me, straight away.  good idea, i said, changed my will from “a pine box, buried somewhere beautiful” to “shroud”.  she’s still teaching me, after all these years.

when i went away to cambodia for the first time, to do this kind of wore more than a decade ago, i made a CD on which i wrote “play in case of emergency: funeral mix”.    i like plans, what can i say. it’s a youtube playlist now. don’t get sad: the afterparty is more of a dance thing.  maybe you’ll get a chance to hear it if they can’t fill the part of my will that says “if technology allows, transplant my living head and brain, even temporarily, onto a giraffe’s body”.  i just think the galloping would be INSANE.

this afternoon i walked a group of visitors, ferenjis, foreigners through the emergency.  in the background,  a woman screamed, someone pushed a patient by, shroud over his face.

one of the women who was touring paused, turned to me “what is YOUR self-care plan?”.

work with what comes up, i guess.

the world might not be bad or good, but it does ask you certain questions. like: can you see through the lattice of self reflection straight into the outside where bird song takes up empty space in large gulps?  do you get that the only guarantee is that you are born to die, that it’s a matter of time before the other leg starts to look a little purplish too, and the living that happens between then and now, is in your hands, all of it, so how are you going to do it?  in the absence of answers, you can only live questions and the best one i’ve found, the most sincere and direct path towards disappearing completely, is to ask myself if i can give love, and only it, at all times, in every gesture, to myself, to everyone i encounter on this kaleidoscope merrygoround that i get ride for the time being, and perhaps even for a few glorious days galloping clumsily across the savannah, choking down bitter leaves.

i can’t.  i mean, with the love thing,  but i’m getting better, and there’s no perfect anyway, and even if there was, it would last, just change like everything.

at one point, when my practice was stronger than it is now, when i had done a few retreats  months apart, and sat every day for an hour so, first thing in the morning, after i woke, after I stood up from my cushion and winced at the slow electric  feeling in my leg, i would forget who i was.  it was weird.  i would look for glimpses, but there would just be pieces fluttering, disappearing as i tried to to pull them together. i could not even find where to start looking, so i would just hobble down the stairs.  by mid afternoon, the story of myself that i tell myself would form into a sense of “here” and “there”, but until then, there was no difference between the two.  my sense of suffering, during these months, was as close to zero as it had ever been, because there was no one to do it.

there is now.  i’ve a hangover. they have them here too, i was sad to learn.

the smell of a jubilee, once faint, grows stronger.

first here, then here, then here, then, on june29, toronto, here.   you should come.

as i look back on the last months, it’s tough to say i’m proud of anyone, as I have had nothing to do with making them.  still, daily, i feel something akin to that, when i watch the doctors we’ve trained navigate a floor full of sick and worried people with skill and compassion.  maybe it’s awe.  maybe that’s what pride was supposed to be in the first place: an awe one feels to participate in something beautiful.

here is their facebook page.  i like it.  actually, it’s more of a love thing.

those days.

one of them, anyway.

i’m finding it difficult to write. service seem to compete.  why would i spend my time talking about doing something, when there is so much doing to be done?

this morning, i walked down churchill road’s steep hill, the fine, metal smell of poorly scrubbed gasoline driving itself deeply into my smallest spaces.  beside me, cars honked, buses chugged, people fitted between and moved across the road.  at the bottom, there is a corner where people gather selling tea or fried bread to long lines of ethiopians queued outside the ministry of immigration.  three women pushed past me, smiling, carafes of tea steaming in their hands, and ran towards a busy bus that had stopped up the road. i promised myself, like I often do, that one day i’ll buy all the tea and all the bread, and they can go home early.

i entered the hospital gate, past teams of students in white coats, walking hand in hand, leaning on each other, laughing.  i waved at the ones that i knew, or stopped to do the shoulder bump that ethiopians have been doing since forever.  i drew close to the emergency, and heard the high wail of a woman.  i turned the corner, saw her facedown, in the gravel outside our one window.  she rose to her knees, then threw herself to the ground.  again.  her mother.  her father.  her sister.  her daughter.  who knows.  i was five minutes early, five minutes late.  abat, i said, and tapped the blue jacketed security guard on the shoulder.  he kept his eyes on the woman, and unlatched the emergency’s half door to let me pass. inside, the thick smell of sickness in still air.

we put an ultrasound on a young woman’s chest, and saw her heart swinging wildly in a bag of water. with great care, we guided a needle into it, through her diaphragm.  its metal glinted white on the screen.  when it was next to the collapsing muscle, the one through which all the love passes, we pulled bloody fluid into a syringe. her breathing eased. ours too.

a man died breathless.  his pupils widened into a final, unflinching stare, because there was no more use for the light.   there were no wails.  he was alone, found by the side of the road, bruised, maybe beaten, or hit by a car.  we worked on him for long minutes, hoping to get his heart to beat wildly too.  we could not. we didn’t say , after, that if we had better tools, things might be different, because we already know that. we scattered in separate directions, separate thoughts on the same thing.

better people, though, i can’t imagine.  i am humbled by them.  that is why i end up in places like this.   people think it’s because i am generous, but it’s more selfish than that. i come to be, in equal measures, as two sides of the same paper, humbled and inspired, because i would give my life for the idea, that if we make the world easier, even briefly, for someone, the illusion of our separation from them disappears.  i am giving it.  i have no questions.

well, maybe some.  tomorrow i want to ask these young doctors and nurses: how do you deal with all the dying?  there’s a fine line, you see, a balance that can tip.  when you see a lot of it, and then catch yourself in the mirror, your eye to your eye, you can say to yourself, when you’ve seen a lot of it, have just watched a young man’s electricity shake itself free, blink out just like that, you can think that you too are mostly dying, and forget about all the living.

a week ago, I was in the omo valley, running on a straight, rocky path, jumping over small puddles, edging along larger ones, scratched by brambles, my hands bleeding from the thorns.  on hot flat stretches, swatches of brand new butterflies, perched on some treasure in the soil, opened and and closed their new wings.   I ran through them,  and the rose, pattered against me, swirled and trailed in the wind, weightless,  thousands and thousands and thousands blinking points of light.  so much living.

i left the emergency, late for my lunch, ravenous for my lunch, and a young man stepped in front of me and said “my muzzer….my muzzer…”, and pointed at the building i’d stepped out of.  what about her, i said, and his eyes became wet, and the tears started to fall.  he had no more english.  take me to her, i said.

beside her bed, her breathing fast and shallow, i gently welcomed this man to the end of her days, mourned with him and his sister, then left them behind.

how do you deal with it, and still get on with all the living you have yet to do?  i’ll ask them tomorrow morning.

late for lunch l walked down the street.  people smiled, and held hands.  trees stretched an inch closer to the sun, in as many directions as they could.  a bird flew underneath the eaves of a building and was gone.   the world was clear and wide open.   behind me, somewhere in the building i left, on its upper floors, two people came out, wet and new, crying: how cold, how bright.