You are always there

Looking back the past 6 months which flew by so quickly, I cannot help but see God's hands throughout my entire stay in Johannesburg, South Africa. I could still remember the palpitations I had on my flight in from Singapore, questioning my decision to do a trauma fellowship here. Had I known what I do know now, I would not have worried one bit! However, hindsight is always 6/6, I believe that I needed to embark on this journey myself to learn the many lessons God has intended for me.

I am particularly thankful for my partner in crime, Susumu Matsushime, a trauma surgeon and intensivist from Japan. We started our fellowships on the exact same day, and it really helps having someone around to figure things out with. On top of working together, we frequently meet up for meals to unwind; we even set up a foodie group to enjoy good food with other fellow international doctors! I will always cherish the many trips we took together to explore the other parts of South Africa, and doing crazy things like climbing 2 mountains in a day! Thank you, brother Susumu.

I am also thankful for God's blood of protection over me throughout my time here. I am thankful that I completed by training safely and without harm. I am also thankful for Dr Alan Peter who runs a hostel for medical students and professionals. He gave me home in a foreign land, and a family and community to lean on. I strongly recommend his accommodation should one ever consider coming to do an elective or fellowship in Johannesburg. Thinking back, the worst experience I had here were the 4 times I was pulled over for traffic related offences, but that is another story for another time...

In 1 Corinthians 10:13, the Bible says: "No temptation has overtaken you that is not common to man. God is faithful, and he will not let you be tempted beyond your ability, but with the temptation he will also provide the way of escape, that you may be able to endure it." I always believed that God will never challenge you beyond that which you can bear, and in my time here I intensely felt that He was in control of my training. 

Let me start off by saying that I have never ever worked so hard before in my life prior to my fellowship in Chris Hani Baragwanath Academic Hospital's trauma unit. My residency training was known to be brutal locally, but it was nothing compared to what I experienced in my first 2 months in Bara! In my first week, I was acutely shocked at the amount of violence there was in this place as the patients who presented to us with their injuries were a direct reflection of what is happening out there. I even found myself questioning whether I was in the middle of a war zone on a few occasions. However, once I got used to the injury patterns, it became like factory work. Whenever a patient presented, we had an efficient system to triage, resuscitate and manage their injuries. As I progressed in my fellowship, I was made to take more responsibility, and with it more operative experience. By the time I was in my last week there, I had ticked off all my checkboxes apart from cardiac stab injuries. I had resuscitated and stabilised them during my time here, but I have never operated on one before.

On my last call, I had Susumu as my registrar. It was so serendipitous that I started and ended this fellowship with him! That night, I remembered telling him that all I lacked in surgical experience here was operating on a stabbed heart, but that I was very appreciative for all the other amazing skills I have picked up, from vascular repairs to thoracotomies. We had 2 stabbed hearts that night, and I did my first and second median sternotomies to repair their cardiac injuries. I believe this is not down to chance, but divine appointment.

I am very grateful to all my mentors and colleagues in CHBAH trauma unit, and I will definitely be back to do calls and learn more from all of you! Thank you, South Africa, for being a part of my life's experiences; this is one that I will hold very dear to my heart forever.

What doesn't kill you makes you stronger

9th April, my second day in Johannesburg. I decided to explore the neighbourhood by running to the nearby Neighbourhood Square which was about 3.5km away. An easy 7km run, or so I thought...

I was barely in to my first 2km when I felt immensely out of breath. My heart was racing, I was gasping. Attributing it to a lack of fitness, I decided to head back. The walk back was sobering; if one does not keep working at something, the decline will begin, and this can make starting again very hard. I have made a promise to my sons that I will use this time away from them to become a healthier version of myself, and I was going to attempt at least 3 runs a week. Therefore, no matter how hard it seemed, I needed to get my first run in.

12th April, post 24hr call, I decided to get that 7km run out of the way. The run was uneventful, and I felt better after it, crashing into a deep sleep until the evening. I then discovered a function on my Garmin app which allowed me to plot out a course and upload it onto my watch for use during my run. I immediately set out to find a 10km course, and uploaded it onto my Garmin Instinct 2 Solar. I was excited about this function, and could not wait to test it out on the run.

16th April, after work. This was the day for me to attempt the 10km course. I started it on my watch and off I went. The GPS guidance was amazing, directing me throughout the entirety of the 10km route. However, I realised the difference in plotting out a course on the app and actually running it. The route was killer with many climbs and descends, the craziest was a sustained 3km uphill segment that killed me. I was reduced to walking up a portion of the route and catching my breath, with my heart threatening to pop out of my chest. It was a very difficult run for me, and as I was approaching the final kilometre, looking out into the horizon, it dawned upon me that I could be way above the sea level!

Similar view as I gazed into the horizon

Reaching home, I immediately checked my suspicion - this returned: Johannesburg is located in the Eastern plateau area of South Africa known as the Highveld, at an elevation of 1,753 metres (5,751 ft). It all made sense now, I was not that unfit to have felt breathless a week ago on my first run, it was just the altitude. Knowing this now, everything became more exciting for me. Not only do I benefit from training myself medically, I can also benefit physically with altitude training! 

19th April, after work. After settling my laundry for the week, I headed out for that same 10km course. This time, the course felt shorter, I felt a little stronger. I did not walk, willing my legs to go one in front of the other, I powered through the course. Phrased succinctly by the German philosopher Friedrich Nietzsche, “Out of life's school of war—what doesn't kill me, makes me stronger." I will overcome this course, it is only a matter of time. 

What am I doing here?

Reality hit me once I was up in the sky on my way to Johannesburg. Up until then, I had been so preoccupied with settling the various tasks for my new home that I hardly had any time to prepare for my trip. The kids were much more attuned to my leaving though. In the weeks leading up to my flight, Ansel has been deliberate in his attempts to spend more time with me. Noah, much more subtle in his approach, has also gone of his comfort zone to express his want for quality time. Earlier tonight, he hung around the living room past his bedtime so that he can be with me. When Olivia noticed it, she nudged me to speak with him. "I don't want papa to leave, I want to cry already." Hearing those words from my firstborn almost made me want to cry too, I just hugged and kissed him, mentioning that it will only be 2-months before we meet again in London.

Then, in mid-flight, a sense of fear gripped me. Why am I travelling to such a dangerous place for my trauma fellowship? I was almost paralysed with fear until sleep gripped me with its hold and I thought no longer. When I arrived, the list of things to do helped distract me: getting a SIM card, collecting my rental car, driving to my accommodation, settling in, video-calling home to speak with the boys, then driving to Chris Hani Baragwanath Academic Hospital to recce the place before starting work the next day, ending with lunch and grocery shopping before heading back to crash into an 11-hour sleep.

 

I guess the answer to my question will only be truly and fully revealed at the end of my sojourn here in Johannesburg. All I know is that God is with me, He will protect and guide me. Amen.

Noah's prayer for me in church

Sunday's recce to CHBAH

Everything will be alright once I start running

75km in 3 days over breathtaking trails in Sweden. I signed up for it without a second thought. What a way to kickstart my 6-week of time off from work! To prepare for it, I ran a total of 3 x 10km trails in MacRitchie reservoir (one time even when I was post-call!).

I packed light for my trip as usual, bringing just 1 running vest, running shorts, dri-fit t-shirt (in case it got cold), arm warmers, gloves, full length compression tights and my Vibram Fivefingers shoes. I will discover how grossly inadequate my packing list was in the days to come...

Friday: Stage 1 (24km)
Everyone was decked in their hydration vests and had windbreakers stashed away. There I was in my 2-Iayers, arm warmers, compressor tights and shorts. I felt sorely under-dressed for the cold and what lay ahead.

The run started off well with my Vibram gripping onto every surface with ease. I felt like a mountain goat skipping across the terrain. Trail running works your mind in a way conventional city running does not. One has to at all times plan one's footing, watch for danger and continuously reassess one's plan of advance. Furthermore, trail running utilises more muscle groups compared to city running and this somehow makes it less tiring (maybe it is just the exposure to nature that excites and invigorates me).

At the finish of stage 1, my feet were so sore that walking was almost unbearable. It was then that I realised I did not have enough mileage on my Vibrams prior to this event; my feet were unprepared for the punishment that was metted out. In order to survive stage 2, I decided against the old adage of not wearing a pair of untested shoes on race day - I borrowed a pair of Icebug Acceleritas 7.

Saturday: Stage 2 (29km)
Sleep does wonders. I woke the next day with renewed vigour and less sore legs. The first 10km was amazing, my legs were firing and the shoes provided excellent grip on various surfaces which made running carefree. Things went downhill after that though. However perfect those shoes were, the fact was that I had never broken them in before; my feet ended up broken by them instead. At the 24km mark, I was in so much pain that I decided to walk the last 5km bearing in mind that there was another day of running in stage 3 the next day.

Sunday: Stage 3 (22km)
I woke to a rude shock that ALL my running paraphernalia was soaked from the rain overnight. I left them out to air, using the same attire for all 3 days (I know, I can be digusting). It was 3hrs to the start, there was still time. I wrung my clothing and started to look for tips online for quick drying. To my surprise, there were many lifehacks available! Placing my semi-dry clothing into a dry towel, i wrapped it up and stepped on it to remove excess moisture. I then left them out to air dry.

By the time it was to get dressed, my clothes were damp but almost fully dried. It is an experience to wear damp clothing and socks on a cold day prior to a race. I was at my lowest in terms of morale. My foot was taped up a various pressure points to prevent blistering in a shoe that I was not used to. It was the worst possible way to start a race.

Once we started running though, all my concerns went out the window. Which brings me to my point: everything will be alright once I start running.

1. The cold sorted itself out once I ran and generated heat.

2. My tired legs went into motion after 4-5km once my muscles warmed up.

3. Blisters and pain somehow disappeared when I ran possibly secondary to the release of endorphins or the scenery that was around me.

I played back the last 3 days of running as I was dragging myself to the finish line. Life parallels trail running: you never know what to expect, and have to adapt to the situation and terrain as needed. Furthermore, there are times when you are too tired to go on, but somehow find it deep within yourself to eke out just that little more, placing one foot before another. Repeatedly. You will get there as long as you keep moving. I find this deeply sobering when extrapolated to life.

I will get there as long as I keep at it and persevere. Until then, keep running as everything will be alright once I start running.

6-monthly reflection 2

This week long annual leave came at a rather apt time. This was my first break in 2019 (not counting the 5 days taken for the exit MCQs). Among the many things jostling for my attention, one stood out the most - my journey in becoming a surgeon.

As to when exactly did I begin to become numb to my work I cannot remember, but I would place the period sometime after my KTPH posting. It was only recently that I realised I do not recognise this person I have become. I was just going through the motion of work, the flame was gone; I was just an outer shell, not unlike a machine.

WHO has now defined burnout in its latest edition of the ICD-11 as “a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed.” The syndrome was characterised by:

1.       Feelings of energy depletion or exhaustion

2.       Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job

3.       Reduced professional efficacy

I came across the above while reading some articles about depersonalisation. Reading it felt like I was reading about myself, every word rang true and it was scary. I have always been a very private person, choosing to sort things out on my own rather than seek help. Understandably, I do not believe in counselling - that process was for people who are weak. I cannot be more wrong.

This time away from work, albeit short, has kickstarted in me a process. I have sought help from a Christian counsellor, met up with a lifecoach and very roughly made plans for the next 6-months of 2019. I believe when you are at your lowest point, the only way is up. I have to alter my trajectory if I wish to continue on my journey to become a surgeon.  

“Do you still want to become a surgeon?”

I recently read Atul Gawande’s Complications, the chapter ‘when good doctors go bad’ stood out especially to me. I am sure that if I do not do something about my situation, I might end up harming patients like Dr Hank Goodman. I appreciate that there is a system in place to address this behaviour before it spirals out of control or before someone gets harmed.

The answer to the question above is: “YES”, and I will and must bring about change that is sustainable which will see me through the rest of my career. I am looking forward with fear of the unknown but filled with hope that something good will come out of this. That I am sure of, in the end, it will be OK.

6-monthly reflection 1

Hearing the news felt surreal. I was not surprised as I had already prepared for the worst. It was also the only obvious outcome when I found out that my meeting was scheduled forward. In that instant, I felt an immense sense of injustice. I had completed all the milestones required for progression but I was held back by those 4-months in KTPH.

That posting coincided with the darkest days in my short life thus far. I only managed to trawl myself out of it a few months after. I did not feel a need to share this with anybody and perhaps that was why it seemed like I was ‘out of sorts’ by many during that period. I am not trying to find myself any excuses to pin all of this to, but perhaps the only shortcoming I had was the way I handled it all. I feel that the assessment that I am perhaps still a little too immature for progression is probably not too far off. I am just disappointed in myself, and this feeling had made me a little sore.

For the next few weeks, I allowed myself to let the gravity of being retained sink in. I refused to reflect on the situation and pondered alternative outcomes based on the various choices I could make. It did not help that one of my fellow colleague shared that he was quitting. I allowed myself to entertain the idea of leaving all this behind and just call it quits. I harboured the thought of taking an extended break from work to ‘rejuvenate’ myself and coming back stronger. I told myself I was jaded from work; I was burnt out. I told myself that I could not push on, not in such circumstance.

One thing that any endurance athlete can tell you is ‘mind over body’. I have had personal experiences participating in Ironman Triathlons to know that it is when you reach a nadir in the race that you experience your second wind. You get into a sort of trance state where just a moment ago you wished you were relaxing on your couch. Your body goes into auto-pilot and you just carry on like you were possessed. The thing is, you have to reach that state of absolute suffering in order to experience such liberation. The mind is a powerful thing.

Thinking back, I was acting like a spoilt brat. My mind was weak and it ended up telling me that it was not possible; that this retention was the end. I allowed myself to believe that this was pervasive and permanent. I just cannot deal with failure. My life up until that moment has been pretty smooth sailing. I do not think that I have ever learnt to fail, to pick myself up and go again, to become stronger. I have been blessed and it has made me take many things for granted. This was my wake up call. This is God giving me a life lesson to learn from.

1 Corinthians 10:13 says: ‘No temptation/testing has overtaken you except what is common to mankind. And God is faithful; he will not let you be tempted/tested beyond what you can bear. But when you are tempted/tested, he will also provide a way out so that you can endure it.’

I now take this in my stride. I will use this opportunity to build myself from the ground up, to gain more experience, to become a better person, doctor, surgeon, son, husband, and father. The one thing that has prevented me from taking the easy way out of this situation is my son. Having grown up without a father, I am still grappling with learning how to be a man, a father. I cannot fathom a day where my son comes to me for advice in life and I would be none the wiser. Passing up this chance for growth will then become a life-long regret.

The race is long and 6-months is nothing much compared to the grand scheme of things. I will focus on the bigger picture and continue on even when it seems so tough and that I cannot possibly go on. Then and only then will I experience my second wind, my breakthrough and see the light at the end of the finish line.

Conversations in the dark

"Thank you for giving me the opportunity to love you."
"I'm glad I did."