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Pits and Promise

The ongoing grind of COVID medicine is starting to wear, although the promise of reopening is tantalizingly just out of reach. The everyday aggravation of life in pandemic times feels like we are all walking around with nerves exposed, as if a protective layer of resilience has rubbed off over the past year and a half. Yet, sometimes something good happens.

First-year medical students at McGill have a course where they follow around a family doctor for ten half-days. This gives them some perspective of what family medicine is and how we fit into the healthcare system. During this academic year, it is one of the few times that the students leave their Zoom rooms and interact with real health professionals and, more importantly, patients.

In Quebec, people can start medical school at age twenty. Many of these students are brilliant, passionate and committed but often come from sheltered backgrounds and are not worldly. My student this semester very much fits this mould. Arshia is a child of South Asian immigrants. She chose my clinic because we serve that population. As an extra added bonus, she speaks Punjabi and Hindi.

Today, I pair her with one of the residents I am supervising. I am in the teaching room watching three residents as they work. Last week I taught one of these first-year residents, David, a single father who had to work from home because his kids’ school was closed with a COVID outbreak.  That week he saw a patient who was off work because of an accident on the job. We need to examine him today so he can go back to work. David also wants to see him in person because he is worried about the patient’s mental health.

This young man left India for the usual reasons we see in our clinic: political strife, police brutality, and poverty. He came to Montreal to claim refugee status in Canada about two years ago. He brought his wife and son with him. Because he had to leave precipitously and did not have enough money for all the tickets, he left his two young daughters in India with his parents. He has been working eighteen-hour days, six days a week, saving money to get them here, but now they are trapped. With COVID devastating the subcontinent, he is terrified that he has condemned his children to death. His refugee claim is still unsettled, and he cannot travel. The borders are closed. There is no way he can get home; no way can he bring them here. Last week when David spoke to him, he seemed upset and depressed.

Interpreters are the connective tissue of our clinic. Because so many of our patients speak neither French nor English we have always had interpreters working closely with us. Often, they serve as cultural brokers as much as translators. Now with COVID, however, they are not coming into the clinic and are usually on the phone. Sometimes we use a telephone interpreting service that is centred in Ontario. This makes things so much more challenging than having one of our trusted people in the room.

I am watching David on the video. The student, Arshia, is in a room with a different resident. When the patient comes in, he is visibly upset and wound up. David tries to call the online service. He is on hold for what seems to be a long time.

I have a moment of inspiration. I unhook myself from my earphones and trip down the hall to where Arshia is. “Do you feel comfortable doing translation for a patient?” I ask her. “This may be an upsetting case.”

“Please, yes, if I can help!” she replies. We go down to the room where David is still struggling to get an interpreter on the line.

“I have some help for you,” I say, bringing Arshia into the room.

Once Arshia introduces herself and the patient is free to speak in his own language to a compassionate and comforting presence, the whole story spills out. While it is evident that he has a bond with his treating resident, being able to express himself freely opens the floodgates. He speaks about his fear, his guilt, his inability to sleep, eat or concentrate. He tells the two listeners that he is hopeless and that he wants to die but will not because he needs to save his family. He weeps uncontrollably, shaking and sweating. David tries to comfort him. Arshia is there, she is totally engaged, but I can see her shock and stress. Then he says that he had a cold this week, with a fever, but did not mention it when he was called for his appointment. There is a McGill policy that we must do our best to protect our students from COVID. So we remove Arshia from the room – and she must phone in. Just another gift from the pandemic!

When David reviews the case, we discuss our plans and the logistics of getting psychiatric help for this poor man. Last week we referred him to the psychiatric service for refugees, but we did not specify that he was a unilingual Punjabi speaker on our consult. When they called, he did not understand them. He does not want to go to the agency where there are refugee lawyers because he already has legal help. I worry that he has fallen into the hands of the predatory immigration consultants who exploit people in our area. If Rani or Sue, our usual translators, were available, they would ask, but for legal reasons, we cannot.

We decide we will try him on an antidepressant. I am worried that he is so despairing, and I just want to help him sleep a little until I can get him assessed. We then get into intense negotiations. “Nothing can help me,” he says. “I will just have to pray.” I know that on some level he is right, and that antidepressants are like a Band-Aid on a gaping wound. Yet, I go into the room to lend my grey-haired gravitas to this suggestion. I tell him that using an antidepressant is like putting on a cast for a broken leg, that he has been under so much stress it is like his heart is in a deep pit and that the medication is like a ladder to help him out. I tell him anyone in his circumstances would be distraught. Arshia, now on the phone from the supervision room, is translating with concentration and attention. Her voice is tense with pent-up emotions. The patient reluctantly agrees to try this medication. David assures him that he will call him in a week to make sure that he is OK and give him a few more weeks off work.

Luckily this is the last case of the day because we feel as if we have been steamrollered. The three of us debrief in the teaching room. David is concerned that Arshia may have been traumatized. I am worried that he has been. “I’m a father too,” David says. “I don’t know what I would do if these were my kids!”

Arshia is shaken, but I can see her pride in having been of use at this crucial juncture. “It was terrible to see him so upset and shaken,” she says. “I can see that he is a strong man, a proud man. I just wanted to help him!”

I call her again the next day, just to check on her. “You know,” she says, “this is why I went into medicine. It is so important to me that who I am and where I come from helps me to help. I know for sure that choosing to be a doctor is the right thing for me.”

At the other end of the phone line, I smile.