The Left Atrium

CMAJ 2001;164(10):1471-4

Michael A. MacKenzie
Family Physician
Antigonish, NS

Gert H. Brieger
William H. Welch Professor
of the History of Medicine
Johns Hopkins University
Baltimore, Md.

For the third consecutive year, medical students at Dalhousie University have pooled their artistic talents in an exhibition of works that reflect on a medical theme. This year's show explores issues surrounding attention deficit hyperactivity disorder.

"This [exhibition] allows us to speak to the public and provoke thought. That's one reason ADHD was chosen. This disease is often misunderstood," says Jonah Samson, a third-year medical student who originally launched the idea for an annual exhibition with an email to his classmates asking if they were interested in transforming their medical insights into works of art.

This year 38 students accepted the challenge and created installations, photographs, sound pieces, quilts, stained glass and even a diorama for Focus: Zero In, Zoom In, which ran for two weeks in April at the Dalhousie Medical School.

Although the original intent was to nudge viewers into thinking about a particular medical issue and to provide a creative outlet for medical students, the annual exhibit has become a means "for students to learn about medicine in a different way," notes Samson.

Pat Feltmate, The Methylphenidate Machine. Digital image, 2001

In his paper collage, 1280 Right Angles, Samson tried to put himself (and the viewer) in the shoes of a child with ADHD by deliberately making concentration difficult. Brightly coloured squares within squares prevent the eye from resting on any one spot for more than a second. "The overall effect is that you can't focus on any one colour," says Samson, adding that compiling the collage was painstaking and labour intensive.

First-year student Madeline Morris looked at how ADHD affects a child's sense of self. She used wool to show how self-worth unravels as the disease distances a child from classmates and family. "I came across the analogy of weaving a blanket as a representation for building self-esteem. Each thread or colour represents a theme," she writes in the exhibition catalogue.

For second-year student Pat Feltmate, the discordance between familiar images of a carefree childhood and a life tied to medication is expressed in a digital image entitled The Methylphenidate Machine. It is a realistic depiction of a candy dispenser brimming with Ritalin. The reaction it evokes is eerie discomfort.

"It is often said that Ritalin is given out like candy these days," Feltmate writes. "While this served as the inspiration for the image itself, the message I intend to convey is a reminder that long-term medication and childhood do not fit together."

Donalee Moulton
Halifax, NS

July 1st, my first day of McGill residency, I leave the Douglas Hospital at five. The Douglas is a sprawling mental hospital set among spacious parks in southwest Montreal. There are locked wards with depressed, violent patients; there are wards with ill geriatric and child patients.

In August I will be on call for the entire hospital of 2000 patients.

At noon, to relax, I wander the hospital perimeter, past the road where the St. Lawrence rushes by in dark currents, then north to the rear of the hospital by the children's section, where the fenced Lachine Canal flows. Between the waterways the hospital is remote from the world.

Inside, patients sit in corridors and move slowly. Some tremble, others stare, most eat lunch. I attend an afternoon orientation for new residents, then take a tunnel to the children's section. I emerge at "F" Pavilion, where I will work with preadolescents. Then I leave.

Outside, a few adult patients move in the July heat.

In the distance I see the man in white climb the fence.

The man in the johnny shirt slips one leg over the fence, then the other. He climbs down to the water.

I wake from my torpor, run across the road, scramble up the fence and, with a passerby, seize him as he disappears.

He fights us. Between gasps, he swears we should let him go. We pull him out from the water, kicking.

He punches me.

By the canal we lay him on wet long grass and order him to be still. We flag a car to call the police. The man in the johnny shirt rises to his knees and makes a move to run back to the water. I grab him and push his face into the grass.

"Say there," I say. "Don't move."

"Fuck you."

The two of us are strong. He is thin. His skin is pale and covered with fuzzy brown hair. The water of the Lachine Canal is cool.

He trembles under our hands.

Spluttering, clearing his throat, he lies on his side. His damp johnny shirt slips up, exposing his body, which glistens in the sunlight like a flounder. I keep both hands on him, to guard him from fleeing. When he stops coughing I ask what happened that he wants to die.

"Fuck you."

An ambulance, followed by a squad car, takes him away.

After, I ask myself: What if he had been a large man? What if I had been alone?

Two years pass.

I am in my fourth year as chief resident in psychiatry at St. Mary's Hospital, Montreal. One night in the inpatient unit I am dictating overdue charts when Céline, the head nurse, pops into my cubicle.

"Dr. Ruskin. You have to see a patient. Now."

"I'm doing a dictation ..."

"I can't get the on-call. The man in 633 looks weird."

"Weird?"

"Bleu," Céline says. "Dusk blue. That colour." She points to the mauve wall of the nursing station.

In medicine we are taught that the signs of disease are calor, rubor, dolor, tumor. Warmth, redness, pain, swelling.

Céline stops outside 633. "He isn't right. I checked his breathing," she says. "His pulse is up. He says nothing is wrong. No pain. No shortness of breath. He's reading Time in bed."

"What was his colour when you first looked?"

"At 19:00 hours, pink. At 20:00 hours, a bit blue."

"Blue?"

"If you wouldn't mind," Céline says. "Look."

Céline introduces me. I sit at his bedside.

"You don't look so good," I say.

"You don't look so good yourself."

"I'm fine," I say. I turn on the night-light."

"I'm fine too," he says. "What's your problem?"

I take his pulse. I listen to his chest. His lips are pale. His nail beds are pale. There is a half-empty Coke on his night-table. He stares at the bottle.

"So?" he says. "Can't make up your mind?"

"Your pulse is not so good," I say.

"You're not a real doctor."

He wants to be alone. I stare at him. He isn't blue. He isn't pink. His face is an Impressionist painting. Flecks of grey and green. His eyes are small moist prunes.

In medical school my teachers have told me there are two things a doctor must know: the disease, the patient. Signs and symptoms of disease are important. Knowing the patient is crucial.

This man says nothing.

I sprint to the nursing station, open his chart, flip pages. He is 58, depressed, taking antidepressants. Nothing unusual. The chart indicates he is hostile to staff but has improved in the past week. Soon he will go home.

"Something's missing," I tell Céline.

"What?"

"If he's better, why isn't he talking?"

"Un misanthrope," Céline says. "He looks ill."

"You checked his room?" I asked. "His locker."

"Partout. There's a Coke beside his bed. He says he's fine. It's a lie."

I scan the chart. His workplace is buried in the notes.

"Imperial Chemical, Montreal," says Céline.

"What does he do?"

"A chemist."

My eyes scan pages and return: he has lost a year to depression.

"A chemist?" I think aloud. "He's taken poison."

We check his room. I sniff the Coke. It has a bitter almond smell. His chest rises quickly.

"You are very sick," Céline says.

"Leave me alone."

He gulps air.

"It's cyanide, isn't it?"

He looks away. I turn to Céline.

"Call a code," I say. "Tell them cyanide."

"Have you ever seen cyanide poisoning?"

"No," I say.

"So you are not sure?"

"No. But cyanide will hurry them up."

A senior ICU resident, an anesthetist and a junior intern pushing a cardiac tray fly in with IVs, drugs and a defibrillator. The ICU resident is a broad, bearded, spectacled man in greens who runs like a wrestler. "Sure he took cyanide?" he asks. "Him?"

"He looked away when I asked him."

"Shrink logic," the ICU resident grunts. He examines the man, who looks moribund. "Try sodium thiosulphate. Can't hurt."

The man gasps every second breath. They find a vein, insert an IV and rush him to ICU.

Two hours later, I finish my dictations and visit the ICU resident. We are buddies now.

"Amazing diagnosis."

"He's okay?"

"Pissed as hell." The ICU resident leans back, sips coffee, his lab coat filled with pins, pens, memos. "How did you guess?"

"The nurse."

"My book says cyanide turns skin pink. This guy went sort of blue. She's psychic." I walk over and look into the chemist's pruney eyes. They are tinged with regret. He blinks and is still.

"Why didn't you tell me about the cyanide?"

He stares away, then meets my eyes. "I put it in the Coke. There was a concentration problem," he says. "Dumb mistake. I should've put cyanide on my tongue."

"Maybe it wasn't a dumb mistake," I say.

"What do you mean?"

"Maybe you wanted to live."

Like other psych residents I go through the trenches. Inpatient wards, crisis clinics, emergency units, outpatient departments. Working in emergency at the Royal Vic gives me the creeps. Too many patients. Too little time.

Nights I can't sleep, worrying. I send depressives home from emergency. I read newspapers and listen to the radio for deaths. Each time I finish a history and mental status I talk to my patients. I look at their eyes and search their soul. I look for ways to save them. To stop their suffering. To stop my anguish.

Somewhere, the man in the johnny shirt waits for me.

Ron Ruskin
Department of Psychiatry
University of Toronto

Send us your regrets

"Experience," Oscar Wilde wrote, "is the name everyone gives to their mistakes." So let us have the benefit. Why not write about the things you've learned the hard way in medicine? How would you replay the scenes that weren't in the script? We welcome submissions of unpublished poetry, memoir and fiction for The Left Atrium. The writing should be candid, but patient confidentiality must be respected. A sense of humour never hurts, and anonymity is optional. In general, prose manuscripts should be limited to 1000 words and poems to 75 lines. We won't launder the truth, but neither will we hang you out to dry. Send us your regrets at todkia@cma.ca

Copyright 2001 Canadian Medical Association or its licensors