The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:1457-60

• Urgent alphabet
• A history lesson
• Writing in migraine mode
• All forgiveness
• One thousand words
• The tattered map of childhood

The ABC of the ER (CD and book)
Vincent Hanlon
Night Shift Productions, Lethbridge, Alta; 2000
Within Canada Cdn$20; outside Canada US$20
Order from Box 1582, Lethbridge AB T1J 3K4, or
online at www.abc-er.com (prices include shipping)

In addition to his own voice, Hanlon uses the voices of long-time friends from the media and the drama world. Introducing many of the pieces is a voice familiar to many emergency physicians who follow the Emergency Medical Abstracts tapes: Jerome Hoffman (who is eloquently eulogized in the piece entitled "J is for Jerry, Rick & Tom"). How delightful to hear the same voice that urges caution when using cardiac markers in evaluating chest pain, quoting the Buddha in the sombre "M is for mistake":

I am the owner of my deeds. Whatever I do, good or bad, I shall become heir to it.

The ABC selections come in very different flavours. The first essay confronts the most basic and feared domain in the ER: "A is for airway." The listener is taken to the high stress of a resuscitation scene and invited to take a moment to stand back and reflect on the drama. As the very frontier of life is reached and the ET tube is passed, the searing words of King Lear express the moment of utmost grief:

No, no, no life!
Why should a dog, a horse, a rat, have life
And thou no breath at all?

Word play is everywhere; in this piece, the elusive vocal cords, like heaven itself, have gates of pearly white.

The next scene moves from the sublime to the ribald. A bewildered patient confronts the armamentarium of epistaxis treatment in "B is for bloody nose." The laughter here erupts from the realization that the worlds faced by the patient and staff are very different.

Further down the alphabet, past Falls and Guts, is Headache. As in "D is for dead," "P is for pill" and "X is for x-ray," the role of ritual is played out. Evoking the medieval practice of trephination, Hanlon reminds us that modern medicine, too, has its incantations and spells.

I murmur a quiet benediction. I acknowledge the formidable powers of Life Stress and Vascular Spasm, Lunar Cycle and Rogue Virus. The stream of words defies comprehension.

Hanlon masterfully recreates the ambience of a particular ER moment in "N is for night shift." Anyone who has been there will understand the shiver of cold that greets the 5 a.m. nadir, and smell the odour of alcohol and profanity that taints the darkened air. The predecessor of "Night," "M is for mistake," also sets off a certain feeling — the shadow of self-doubt or potential error that lurks behind every patient encounter. "Q is for ..." captures the apprehension of calamity that can interrupt a slow shift at any moment.

I could go on. Every piece is well crafted and evokes a thought, mood or impression culled from the years of drama that Hanlon has witnessed in the ER. But this punchy work is more than just a collection of images. In all of his writing, Hanlon manages to twist the usual perspective so that common experiences are seen in an unexpected way. Thus, the catastrophe of a fall is carried on a cascade of voices while "Z is for zygoma" shifts from studied medical analysis of facial trauma to the "Biff!" and "Pow!" of comic-book fights.

Who would listen to this CD? I played it for a few friends; the nonmedical people laughed at the ironic or comic sketches, but many of the slower, more sober essays that rely on direct experience of the ER were not fully appreciated. I think, though, that anyone with direct or indirect experience of the emergency room, whether as patient, staff or family member would enjoy this collection. I have listened to it several times over, but henceforth will play it mostly one or two pieces at a time. As in the works of his cited teachers — emergency medicine gurus Jerry Hoffman and Rick Bukata, and the Trappist visionary Thomas Merton, there is much wisdom in Hanlon's irony, humour and reflection. If we take each piece as a short meditation, the human face of the ER might become a little more visible on the next shift.

Brendan E. Hanley
General practitioner / emergency physician
Whitehorse, Yuk.

[Contents]

It was my first week of clerkship, and the first time I would interview a patient without anyone looking over my shoulder. I was primed for it. Earlier that morning at rounds the chief himself had given a mini-lecture on the doctor–patient relationship. He reminded us to put ourselves in our patients' position, with all their fears, anxieties and pain, and to listen with an open mind. He emphasized: "If you listen to your patients carefully, they will tell you what the problem is."

So there I was, half an hour early, feeling quite confident in my newly washed and ironed white lab coat with extra pens in my pocket, just in case. The first patient was Mrs. G, a meticulously dressed and coiffed older lady with a heavy accent. She looked and sounded quite relieved after I introduced myself and sat down with her, ready to take the history.

She said: "Oh dear, I am so glad you are a lady doctor. I don't feel comfortable talking about this thing with a man ... you know how it is."

I didn't really know, but I gave her a friendly smile and reassured her that we were professionals and that she should not feel embarrassed about anything at all. "So what is the problem, Mrs. G?"

She started to fidget with her handbag and said in a low voice: "Well, you know dear, I ... well, how do you say it ... I have been dropping lately."

"You have been dropping lately." I repeated the sentence to buy time while a long list of differential diagnoses raced through my brain: TIA, stroke, seizures, brain tumour, hypoglycemia? Anemia? Cardiovascular something-or-other? What about metabolic disorders? And don't forget cancer ... It could be any of these for an elderly lady with new onset of "droppings." What an unusual way to decribe falling — but I stuck with it for the rest of the interview. This was not the time to correct someone's vocabulary.

"So, how many episodes of dropping have you had, Mrs. G?"

"Oh, I had a few before, but lately I have them everyday."

"Every day? And have you ever injured yourself during any of these droppings? For example, have you hit your head against the furniture or the bathroom sink?"

She looked at me with surprise and said No.

"Has anyone witnessed any of these episodes?"

"God, no," she replied, with a look of horror on her face.

"And are you fully awake and alert during these episodes, remembering everything?"

"Of course."

"Do you ever get chest pain before or during an episode?"

"No, never."

"Headache, dizziness or visual disturbance?"

"No."

"How about weakness or numbness in your limbs?"

"No."

"Do you feel nauseated, sweaty or anxious before you drop?"

"Gosh, no." Although she looked perplexed by this line of questioning I had to get to the bottom of things. And so I continued.

"Have you ever lost bowel or bladder control during an episode?"

"No."

"Do you smoke, Mrs. G?"

"No, dear. My husband used to smoke but I never liked the habit"

"Have you lost any weight lately?"

"No, actually I might be a bit heavier since Christmas ... with the cooking and baking it is hard to stay thin."

"So you are pretty healthy otherwise?"

"Yes, I can't complain. I have a bit of back pain and my ankles swell up here and there but I have no complaints."

"No past history of heart disease?"

"No"

"Stroke or seizures?"

"No."

"Diabetes or high blood pressure?"

"No, dear."

I was getting to the end of my rope. I had absolutely no idea what was wrong with Mrs. G, and her surprised looks didn't help. I decided to try another strategy.

"Mrs. G, do you live alone?"

"Yes, since my husband died four years ago."

"And do you live in a house, or an apartment?"

"A house, dear."

"And is your house well lit?"

Now she looked at me as if I had just stepped out of a spaceship with two antennae sticking out of my head.

"Eh, well I guess it is, yes. Why do you ask?"

"I just want to figure out why you keep dropping like that."

Now she looked at me with her mouth open. She seemed ready to say something, but desisted.

I kept going.

"Do you have carpeting in your home, Mrs. G?"

"Yes."

At last, a yes. I knew I was getting close.

"And have you ever slipped on the loose carpet?"

"No, dear, the carpet is glued to the floor."

"Glued to the floor. I see. What medications do you use, Mrs. G."

"Oh, just the little white pills for the back pain and Metamucil for ... you know ..."

"Yes ..."

But I didn't know. I didn't have a clue what to think. I decided to give up the history and end with the usual, last-resort question.

"Is there anything else I should know before I examine you?"

I had a complete neurological and cardiovascular exam on the menu for her.

"Well ... now that you're asking ... You see, I think I'm getting worse. I ... well, before I used to drop but it would go back in by itself. Now I have to push it back."

I sat there in silence. I must have looked like I'd seen a ghost, for after a moment she leaned over to me and asked, "Are you okay, dear?"

"Eh ... yes ... yes I'm fine ... Please excuse me for a second ..."

I got up and grabbed the chart that had been sitting on the desk the whole time. The first line after the personal information read as follows.

"Reason for referral: RECTAL PROLAPSE."

Roya Etemad-Rezai
Radiology resident
University of Western Ontario
London, Ont.

[Contents]

[Contents]

[Contents]

Ottawa Blind Association, October 1917
Courtesy of William James Topley / National Archives of Canada / PA-042919

[Contents]

"Every child shall have the right to freedom of expression ..."

Freedom of expression might not be the most fundamental need asserted by the UN Convention on the Rights of the Child (1989), but it is the one that opens a window on all the others. This is the premise behind Children of the Wind, an exhibition of 100 works by 10- to 15-year-olds from nine countries currently touring in British Columbia. The exhibition grew out of the Mapping our World Children's Rights Project (www.mappingourworld.org), a multi-agency initiative conceived and coordinated by Linda Dale. Born in Newfoundland and now based in Ottawa, Dale describes herself as "freelance curator" with a background in child psychology and an interest in social justice. She became interested in children's art in the 1980s, when she was asked to create a exhibit of drawings by refugee children in Central America: "In working with these pictures I became very impressed with children's capacity to understand and represent their lives in a way which allowed others to step inside their perspective."

For the Mapping our World project, Dale worked with schools and local support agencies to conduct 5-day workshops over the course of eight months with children in Bangladesh, Canada, Colombia, the Dominican Republic, India, Nicaragua, the Philippines, Uganda and Zambia. She encouraged the participants to use drawings, painting, writing, photography and video to "map out" what was important in their lives. Many of these children live in difficult and hazardous circumstances; some are factory workers; others are agricultural labourers. Some are former child soldiers; some live on the streets; others have been displaced by civil war. Dale notes that the preoccupations of children living in relative security can appear to be universal, but under the pressures of violence and poverty profound differences emerge. Paintings and commentaries by former child soldiers in a rehabilitation project in Uganda express a preoccupation with memory; for brick workers in India, time is a more important theme; for street kids in Bangladesh, the most urgent issue is security. As for the preoccupations of Canadian participants, Dale got the impression that many young adolescents in this country seem to feel "that they don't count for anything" and lack a sense "of connection, of belonging."

Sohel, child of the street, Bangladesh, in a Mapping our World workshop

Acen Paska, child soldier, Uganda. My soldier husband. "This is the man who was my husband. It is the face of death."

Although the project was initially intended to give Canadian children "a first hand view of children's lives in other countries," it soon became a means for local field workers to assess the needs of children and the success of support programs. The workshops also became a form of therapy, especially for children traumatized by war. The exhibition press kit gives UNICEF estimates of the impact of armed conflict in the last ten years on the world's children: approximately two million have been killed, four to five million disabled, one million orphaned and 12 million left homeless. The Save the Children Alliance estimates that 300 000 children world wide under the age of 18 are currently taking part in armed conflict.

Dale hopes that Children of the Wind will convey the diversity of children's lives, allowing a response that is engaged by the particularity of experience rather than dulled by depressing statistics. She gives the example of a Canadian child who asked, when looking at the artwork of former child soldiers, "But how do they go to school?" She takes an optimistic view of such a question: if it reflects a vast gulf in life experience, it also expresses a desire to understand. And this is a valuable beginning.

Children of the Wind continues until May 21 at the Surrey Art Gallery in Surrey, BC, and travels to the Nanaimo Art Gallery in the summer. It will then be on view at the Prince of Wales Heritage Centre in Yellowknife beginning in early October.

Anne Marie Todkill
CMAJ

© 2000 Canadian Medical Association or its licensors