Saturday, October 24, 2015

"How are you able to continue working after witnessing a death like that?"

I had a great question from a very insightful medical student after the first case of our day was to Code Blue that did not get any better. The code was on a young patient in my primary care. She was very unwell, and I'm sure nothing would that have changed the outcome. Tragic, true, circle of life type stuff. 
Initially, I felt really upset with myself. How could I just move on? I know this woman and her family quite well. Should not I be more upset with what just happened?
With every death, every code, I ask my team to do a quick debrief with me (longer if needed) to ensure that we did all that we could, and needed to do. I go over everything in my head as well. Where could I improve next time? Were we all wearing PPE? Did I speak with the family in a respectful, clear manner ?
This time around, the police were with us. We're a small town, so all tragedies involve them. It's great, because they call victim services if needed, get in contact with distant relatives, chase after teens who "can not take it" and run off. They are a really good bunch. They surrounded me and checked in on how I was doing. Asking if I would talk to someone if things went poorly. I am telling me I was a rock star in the trauma bay, That the family completely trusted me and was incredibly relieved to know that I would be the one working on their loved one. Basically making sure I do not get PTSD from the event - something I try to do for them all the time but was not used to having it in return. 
I was a bit upset, but felt like I was not upset enough. That I was a big faker pretending to care. 
It was not until yesterday that I was able to figure out why it is that I can just pick up and go on. This was the third patient that description fit that died in front of me this year that I was able to continue working after their pronouncement. 
I have a therapist. Everyone should. She helps me figure out things like this that niggle in the back of my head but that I do not take the time to work through. She helps me figure out when the culture of medicine is nutso and I'm right to ignore the culture and do what is right. 
Here is the answer, finally, med student of mine. I have an incredible resilience built around patient deaths. 
When I first got into med school, I knew that someone like me with a soft hear t might have a hard time with death so I sought out situations where I would be challenged. I thought about each deat h as an unavoidable event and looked for the way that I could make it the MOST comfortable for the patient and their family and (even when the patient is a baby). I learned that I could cry with family in a respectful manner. 
Each of those links is a blog post I've done during my training and practice to reflect on death and my part in it. I see myself as separate from the patient and their family. I love them in a way that is not family or friend, but caregiver. My role in their life is just a step in their journey through this world. They hold the same role in mine. While our lives intersect, my goal is to make our lives both better for the experience. I learn my lesson, then a go to intersect with another life. The lessons I've learned stay with me forever, but they are not necessarily emotional. 
Sometimes they are. A patient died of malnutrition at a young age, and you bet your ass I got angry and looked to make change. But, because I want the rest of my patients to be healthy, because i was not dwelling on his passing. 
So, my thought process goes like this; reflect on the death changeable and my role in it, reflect on the interaction with family and colleagues, move on to the next patient who needs to see me. This might happen many times during the day following that death. I still wonder if I could have done more for my patient before she died, but that use as a way to be a better doctor, not to dwell on the past. 
Death is part of life. My job is to keep moving forward. I see my getting back to work and helping other people as a way of respecting my patients' lessons to me. 

Saturday, October 17, 2015

Pregnancy in Medical School

"Remember people, well except medical students, typically reproduce before the age of 30."
MD, cardiologist
I’ve had this in my drafts for a while. It still pisses me off a bit. Not that it necessarily should, the cardiologist isn’t saying that no med students have kids before 30 but it’s atypical. 
What pisses me off, is that those who recognize that their life starts NOW, not after residency, or fellowship, or any other magical time, and want to have children are treated as wackos by most of our community. I know I rail on about medical culture and why it is not reflective of reality, but I’m going to do it again. This is another example of thinking that we need to change. 
There is research on just about everything that med students do. You’re the easiest population for medical researchers to bug, so they do.
However, I can’t find much research on being a parent in medical school.  This focuses on mothers (wall free article). It’s the only paper I could find (lots for residents by the way, probably because they are also leading a lot of the research). A lot of the young women I’ve spoken with felt they were treated poorly by the fellow students because they were getting “so many” allowances for time. The new dads in my class felt like they were expected to carry on as if there wasn’t a new sprog at home.  
Back to the paper, “Medical School-Mothers” in the Rhode Island Medical Journal. I’ve never heard of this paper, or this journal and I’m pretty damn excited about all things undergrad medical education and feminism. That’s disappointing. (Have you heard of it and I was just under a rock?)
They don’t tell us how many medical students were interviewed. I want to know what several means - is it 4? Is it 34? Help a sister in research out.
They also don’t discuss fathers. I get that women in medicine is new and all, but I want my colleagues to be good dads. I don’t want any of my colleagues to be fondly remembered by their grandchildren because their own children never saw them. 
As part of universal precautions, all female medical students who are sexually active with men should be mindful of potential pregnancy.” BARF. Shouldn’t our male medical colleagues also be mindful? This reminds me of the episode in 2014 where a female medical student was at risk of losing her funding to study in Cuba because she “fell pregnant”, while her XY partner was not reprimanded. BARF I say. IUSs, condoms, and access to family doctors for all med students who want them!!
This article is mostly focused on what Student Affairs type people need to know (which is fantastic). 
But. 
What I would like to see is something that talks to many more students to provide curious students with help making decisions, something that gets more into the pros and cons of an educated choice. No one knows when the time is right to have children. Everyone has an opinion on it though. 
I’d also like to see a nation wide mentorship program - to be paired with an attending, hopefully in your chosen field, who also was a parent in med school. Knowing you have someone who has been there and survived. 
I’d like a handbook for parents in med school. Tips tricks and downfalls to avoid. I’d like this to be an open topic of discussion that starts in Year one. I want the parental leave policy to be pointed out to all students during orientation week. 
I want to know how much post partum depression and anxiety are present in the learners having children. We are all pretty crappy at taking care of our mental health, and how many of us have med studentitis? (Pregnant med studentitis is like that on freaking crack - everything that could possibly go wrong, will and you will blame yourself, even though you would tell your patients to think better of themselves. My friend had 10/10 stress through the last 4 months of her pregnancy. Uncool.) 
I want there to be scheduled check ins with Student Affairs during pregnancy and post partum to ensure this isn’t an issue. My suspicion is that the numbers of sufferers in the medical community are high. 
I want to get rid of the shame associated with wanting to be a good parent when you are ready to be one. Seriously. If we don’t stop acting like families in medicine are bizarre while we’re in first year medical school, how can we expect attendings to respect their colleagues and learners’ choices?
One of my colleagues is pregnant. I’m over the moon for her and her MD husband. The amount of stress they underwent preparing to tell the rest of the team about the (wanted, expected) pregnancy was overwhelming to ME. I’m not having a baby. Jeepers. They felt they needed to make it very clear that they do not want to stop practicing for more than 2 months each (like it’s not bad enough that they don’t get parental leave from our governing body). They were shamed into divulging the information much sooner than they wanted due to morning sickness. Our colleagues (all XY but me), have children with stay at home moms and incredibly twisted senses of what parenthood should look like with a physician parent. 
This has got to stop guys. We need to treat each other better and watch each others’ backs. 
What would you add to my list to make it happen?

Sunday, September 27, 2015

Just get over it

During my first year of practice, I was told over and over again that I should "just get over it”, that things get better in 5 years, that what I was experiencing was normal.

 When I noticed that I was diagnosising at least 5 cases of cancer per week, I confessed to a friend that I was concerned and a bit freaked out. She told me to get over it. That's what family doctors see and do all day. (It's not, especially not in a small rural practice, but I guess surgical residency makes you cynical). I was also told by a colleague that I should expect lots of cancer in my first few years because I will be seeing people who haven't been reviewed in years. But then he walked away.

 I missed a few cancers because I was so far behind on my paper work. They came to light and the patients will survive despite me. This concerned the hell out of me. I asked for extra staff to help me stay on top. I was told to make my staff I already have work faster. My staff that is already overworked with the difficult set of patients we have. There are parables about beating overworked animals, I definitely wasn't going to add to my staff's excess burden.

 When I received my second death threat in 8 months, I told my colleagues. They laughed and told me that I was a real doctor now. (Apparently two of them had received one threat in the past 15 or so years. The rest had received nothing.)

 There was a tragic, horrible, incident on my watch. Then, my colleagues surrounded me and offered help. Looking back, I do wonder how much was because they were worried I'd get the yips and need to stop working the ER. They did do a good job though.

 Seeing patients with more mental health concerns than years in their lives, listening to stories of horrific childhood trauma, being manipulated by personality disorders and drug users was exhausting. When I brought it up I was told to fire these patients, to not ask them questions (I didn't, they offered me their horrific stories on their own), to not let them speak. This advice suggests that I completely ignore my values and put my license in jeopardy.

 I burned out very early in my first year of practice. Looking back, reflecting on the times I asked for help and the lack of actual help I received, it's fairly obvious to me why. I expected my fellow family physicians to care about people enough to care about me. Now I see that I was making a mistake. Everyone has been working for themselves and doing what they can to keep their heads above water, even my good friend. No one is able to help someone else when they aren't able to handle themselves. This is why I now have a therapist. It's also why every new doc needs a dedicated mentor. Someone who has time carved into their schedule just to help the new doc and answer all their questions, let them know what is reasonable and what is not. Knowing at least one person will listen and not tell you to just learn to deal with it is vital to keeping your new docs in practice.

Wednesday, September 16, 2015

Screw it

I’m just so tired of having to be persistently pleasant while at work, in the grocery store, on email. If I’m not, I’m seen as a bitch. Other (read male) physicians are allowed to be as moody, rude, blunt, cruel as they want to be. If I’m not smiling constantly and holding peoples’ hands I’m the bitchy doctor. 
Screw this. Screw gossipy nurses who still treat me like I’m not a physician. Screw the backwoods attitude that men are held to a lower standard and that women are supposed to be soft, pink, and fluffy 24/7. Screw “business feminists” who write crappy leadership literature that perpetuates these ideals. Screw jackass patients that don’t like hearing the truth. Screw the parts of my professional life that are unprofessional and make me lose my temper. 

Saturday, September 12, 2015

Fluids are Magical

Everybody feels better after fluids. When I'm working ER I call them my fairy dust. Everyone who looks bad gets 'em. 

Kid who is pale and crying and sleepy? Enough Advil that she can latch and get all the breast milk needed to get her up and dancing. 

Lightheaded and falling down? Litre of saline and his blood pressure is stabilized and he's ready to go home. 

Head splitting in half, vomiting, pneumonia, and fever of almost 40'? 2 litres, some metoclopramide and she's ready to go home with antibiotics. 

And yet, I'm just starting to drink something myself 13 hours into my shift.

Friday, September 4, 2015

Soft skills

I’ve become part of the medical culture that minimizes the “soft skills”. Before the brainwashing cult of medical school, I almost worshipped those soft skills. The culture I’m embedded in has made me loathe much of what makes me a good doctor. In general, the men I’ve been working with have little respect for the areas I excel in - palliative, psychiatry, geriatrics, and pain management. They think that patient centred methods are not something any physician should aspire to.

 This has rubbed off on me. Now I think that the areas that I am strong in are not worthy of being considered real medicine. It’s something I’ve been struggling with since clerkship. On all my evaluations, I was lauded for excellent communication and advocacy skills. I never took these seriously because the hidden curriculum taught me that my soft skills aren’t real medicine. I wished that someone would say that my cardiology skills were amazing, or that my physical exam skills are exemplary.

 If these skills are so soft then why do so many physicians have a hard time with them? Maybe there needs to be another name for them. Making a list of possible alternatives, I think about collaboration, organizational, conversational skills, but I imagine these as also being diminished as being too “pink” to be considered real medicine. Could try something like supratentorial skills but given how frequently we use that as code for somatization, that also wouldn’t be treated seriously. Even people skills are “pink” - something we expect those who work in retail to have to learn by watching videos in a break room.

 These “soft skills” are not gained that easily though. Yes, we can learn them through videos and work, but the best of them are learned by experience. By watching what our mentors do well and emulate the people skills they display. We learn them through collaborating with our allied providers and seeing how they advocate for patients. There are no textbooks to show us how to be the best at advocating, listening, collaborating, communicating, organizing, and generally being patient centred. We need to shed tears, sweat, blood, to get to that point.

 These skills are not obvious and difficult to describe, maybe the opposite of concrete skills? Abstract skills? That might work.

 But then again, what is so wrong with calling them soft skills? As long as we start to acknowledge the efforts made to learn them. There shouldn’t be anything wrong with the pink skills that are associated within the soft skills. All physicians should strive to be the best doctors they can. That means practicing their concrete skills, (clinical skills, rote learning, anatomy) as well as their abstract or soft skills. To be a fantastic doctor, one shouldn’t have to hire another MD to provide bedside manner. We should expect it of each other to want to be a complete physician who is able to provide all a patient needs from their specialist or primary care provider.

 If female providers are better at the abstract skills, we should be congratulating them rather than acting like they have done something wrong. I’ve been told several times that I care too much, that I am too passionate. This is ridiculous.

 I want a doctor who is passionate about their job. I want a doctor who cares. No, I don’t want my doc taking their work home with them, spending their night going through all the coulda’ woulda’ shoulda’s. They shouldn’t cross boundaries to make my experience better. But, that doesn’t mean that they shouldn’t cry when they feel like, argue with specialists who refuse to take my care, give 100% during office hours.

 If you think my passion and caring is the problem, I think it’s safe to say that you are the problem. The concrete thinking physicians with a limited view of medicine should really just get the hell out of the way of the physicians who flex both soft and hard skills and are kicking ass. Those are the physicians who are asking the questions in research, are pushing the boundaries of what we are able to do to make our patients’ lives better. We need to repair our culture to catch up with what patients expect from their physicians, and what we expect from our colleagues. The concrete thinking docs need to be called out for being the dinosaurs that they are.

Sunday, August 30, 2015

How could I be mad?

When at the end of my 24 hour shift my patient’s epigastric pain changed to a STEMI? As I explained to him and his wife what was going on and how dire the situation was given his prostate cancer? As I told them the high risk of bleeding to death on our way to the city to see the cardiologist? As he kept sneaking his thumb over to touch my hand that was on his leg while I talked to him? Tough old coot was scared at the odds I gave him, worried about his wife, worried about his chest pain, worried. 
These are patients who are used to the doctor just telling them what to do. I won’t do that. I’ll present the options as I see them, and likely bias the discussion one way or the other, but I ask them to make the decision. Sometimes the decision is to let me decide, then I check if they are relieved or distressed with that decision and adjust accordingly. Not by the book med school ethics, but patient centred. Luckily my patient’s wife was able to decide for all of us. 
I’m worried too. I hate sending my patients to the city with another doc but I’m not safe to still be caring for him. Very happy I kept doing serial ECGs though and trust my gut when I think something is wrong. 

Wednesday, August 26, 2015

Sexism in Clerkship

I’m going to point out that frequently during your clerkship, you will experience sexism. Sometimes these moments will be not too bad, a patient thinking you’re a nurse (are you kidding? I wish I knew that much in clerkship!)

Most times, it will be subtle. It will be everyone ignoring the suggestions made by the female clerk. It will be judging her outfit or flirting with anyone. It will be interrupting her, presenting her ideas as their own. It happens. It becomes common. Everyone will act like this is just how it is. Your job, male or female, is to make sure this is no longer common. Your job is to make sure that clerk feels supported. This is your team, you all need to be strong.

Here’s how to do it without waving a flag and making everyone on the team afraid of you.

When she is interrupted or ignored, wait until the interrupter is finished speaking, then say “I think that Meredith was making a good point, did everyone get to hear it?” When derogatory comments are made, ignore them and change the topic to whichever patient was being discussed prior to the comment. If someone is presenting Meredith’s ideas as their own, be subtle, this one is tricky. Something along the lines of “It’s a great idea, I thought as much when Meredith said it this morning at rounds. Maybe you two should work on it together!”

Everyone on your clerkship team deserves to feel supported. Everyone deserves to be able to show what they know and learn. When your colleagues thrive they bring you with them.

Be the colleague you want to have.

Monday, August 24, 2015

Not gone. Dead.

I love when I’m working emerg and my next patient is someone I already know. It makes it so easy to get to the bottom of what’s happening and get them feeling better.
Unless they come in VSA. Then it just sucks.
Especially when they are young and their kids aren’t ready to be an orphan in high school.
Especially when they’re your own patient.
Especially when the family thinks, because of a diagnosis you magically pulled out of your ass that you walk on water.
Especially when no matter how many of the Hs you cross off the PEA list, he just doesn’t come back. His pulse never returns. He doesn’t have another joke, or jab, or hug. He’s just purple and bloaty and looking nothing like you’re guy anymore. His brain stem hasn’t caught up to his heart and doesn’t realize he is dead so keeps telling his lungs to breath horrific, agonal breathes and you have to explain to his children that he is dead.
Not gone. Not done. Dead. Without those words his kids can’t move on.
But they need answers. Why? How? What did I do wrong?? Who can I blame? Maybe I didn’t love him enough? I just want to hide and cry. Because I have the same questions and no answers.
It’s an honour to say that I fought valiantly to save his life. But would be a greater honour to say I had actually won.

Sunday, August 23, 2015

My current patronus is Lewis Black

I am furious. So angry. Yelling at people angry. I never yell at people.
The group of middle aged men I work with has described my work as less than medicine. They are suggesting that as someone who practices patient centred medicine, I am not a real doctor.
I work my ass off all day every day, and their interpretation of my work is that a middle aged man could easy double the patients seen just by not being nice.
Protecting these men’s reputation is more important than caring for patients. Slagging patients is ok as long as I don’t question a man’s clinical judgement. As of Hallowe'en I am done here. Until then I will try to avoid hurting anyone. And destroying my reputation.

Friday, June 26, 2015

Monday, May 18, 2015

Bad patient outcomes

They happen. But I hate them. 


I'll spend the next 72 hours straight second guessing every minute of every interaction with the patient. Even though I know I did the best I could, with the resources I had, I will still blame myself for his death. I'm not sure if or when this step in losing a patient goes away. 


Until then, the best I can do is try to be a better doctor and do what I can to keep the dark and twisties at bay. 

Saturday, May 16, 2015

The Rural to Urban Transfer, a Primer for Urban Docs

1. If the report starts with "...is a horse and buggy Mennonite, and called an ambulance to arrive here at...", know that whatever comes after means this patient needs to be transferred out ASAP. These patients will do everything they know how to do at home, waiting until the very last minute to come to hospital. If they are willing to splash out on an ambulance, there is something very wrong. Same goes for any Mennonite that shows up the ER on a Sunday. Just seeing them there on a Sunday makes my pulse race.

2. Don't assume that we have the same resources that you do. For example, I have an RT that comes in some Wednesday mornings. There is an anesthesiologist who comes in a few days a month. I do the difficult airways. I figure out the ventilator settings. When I show up to the ICU, you have more people waiting in that room to receive us than we have in our entire hospital, usually at least 3x as many. Please ask what resources we have before repatriating a patient who requires more than we can give, or assuming we can handle the case that is being consulted on.

3. We work 24+ hour shifts. I am acutely aware of the time that I am calling you at 4 in the morning. If I say that I need to discuss a case, please be sure that I really do. I've either exhausted all my internet and paper resources and need help, never seen what is in front of me, or am having a hard time organizing my thoughts after a particularly stressful day. Rural docs are proud. If we are asking for help, assume it's legit.

4. During that 24+ hour shift, for the most part, we are it. Any and all codes are run by us. I've run several in the same day plus delivered babies, saw 30+ sore throats in the ER, and talked down psychotic patients. Not every day is like that, but give us credit for being able to handle all of that and keep going. We do this because we love our communities and are dedicated to keeping our hospitals open, we love medicine, and we are masochistic idiots.

5. Nothing makes me feel more validated than having staff ready when we show up. If I tell you it's a difficult airway and you have an anesthetist and RT waiting for us when we arrive in the city, it seriously makes me feel incredibly relieved. I know that you believe us and will treat my patient well.

6. We get attached to our patients. We see them again and again in our hospital, and in truth, I may be the family doc of the patient I am transferring. I will do everything I can to keep them in our tiny hospital. When it's time for them to go somewhere else, I will fight like a dog to advocate for their proper care. You would too.

7. Rural docs are "real docs". We are generalists who are constantly studying and upgrading. After every code, every transfer, every good and bad event, we talk to each other to learn about what went well and how we can make things go better in the future. Consult notes that belittle us and derogatory comments on the phone are entirely unnecessary. We are counting on your expertise to help us in our practice, but also on your civility.

In case I forget to thank you because I've been hand ventilating a patient for 3+ hours when I finally see you during my 27th hour on call, please assume I do. I am incredibly grateful that you have chosen to work in the city in ICUs, surgery, high risk obstetrics, etc. Without you, I couldn't have the brilliant job I do.

Saturday, May 2, 2015

Benefits of being a rural doc

Include stopping at Dairy Queen after a rough transfer. 

Saturday, April 4, 2015

Professionalism, continued...

Powers That Be (the PTBs) want their medical students to be able to play well with their future colleagues.

I've talked about professionalism before.

There was too much to cover in one post, so I'm adding some more thoughts here.

1. Conferences: Students should really go to as many conferences as they can. These are fantastic places to learn how your (potential) colleagues perform in the future. To see what is actually important to them and what daily practice can be like. They are also where you can learn what is important in research if the specialty isn't all about the Twitterverse. But they should be. Talk them into making that happen while you are at the conference. Also, look around. What do you think about this group of people? Can you see yourself working with them in the future? Going out for a few beers? Is this the specialty for you?

2. Business Cards: Get business cards made. Hand them out. You want to give them to people you want to do research with, want to have elective time with, etc. Seriously. Get it done. They're dead cheap. Put your photo on it to ensure the peeps you share them with will remember who you are.

3. Committees: Sometimes annoying, sometimes difficult to deal with, but so important to learn how to deal with this kind of interaction with colleagues. Sitting on committees will teach you how to follow Robert's Rules that you will need to follow as you move through your career. It also allows you to stand up for what you think is right while you are still protected as being "just a student". Learning how to make a point so that others understand is not something that comes easily. It's worth having some practice. These skills work when you are talking to other specialties, asking administration for resources for your patients. It also teaches you when to shut up and trust your colleagues to do what's right.

4. Counselling: Everyone in medicine needs a counsellor. Trust me. Get one.

Friday, March 20, 2015

Waiting...

Little tiny hospital, almost 50% of our beds being used by patients waiting for mental health or long term care beds. 

Saturday, March 14, 2015

Colleague support

When I divulge to a colleague that I'm struggling, and their answer is "just get it done, that's ridiculous", I may not have found my new home yet. 

Friday, March 6, 2015

Confidence

My frail patient sat at her dining room table as I came in to see her on house call day. 

She wears a bib like the ones we use in hospital, brown, ugly plaid. Her husband calls it her cape. I imagine her as a super hero, bib flowing behind her as she flies through the air. 

Her hands tremble as she works on her bun. She accidentally drops her finger in the butter and acts as though it didn't happen, discreetly licking her hand when I'm looking down. 

She is as frail as I would expect for someone who spent so many months in hospital and came close to dying more than once. Hunched over, looking up at me though our faces are on the same level. In her youth she was an independent, vibrant school teacher. What a change this must be for her when she looks in the mirror. 

After our check in and a brief physical exam, I ask the question I always ask, "is there anything else I can do to make things better for you?"

My patient surprised me by whispering, "give me my confidence back?"

I wish I could bottle up confidence and sprinkle it over my patients like holy water. That's precisely the intervention so many of them could use but the CDC doesn't have it available yet. 

We discuss how far she's come since her release from hospital. How difficult it is to be in a new home in a new town. How as her strength comes back with physiotherapy, so will her confidence. 

I stop and consider the last time I was truly confident. I think of when I was 5 years old and able to do absolutely anything. With my new shoes I could run faster than Superman. My body was perfect and I was the strongest person I knew. How does one prescribe "be a 5 year old" to an octogenarian?

Then I remember the art group run locally. They laugh and play and generally enjoy themselves. Everyone leaves the group feeling like they can take on the world. Their pain diminishes. They make friends of all ages and diagnoses. They heal. They help each other. 

As I talk about the art group, I see my patient's back straighten, just a tiny amount as she imagines making a giant colourful mess like she did when she was 5. 


Friday, January 16, 2015

Miss Kitty is Gone


We spent 18 wonderful years together. She got me through my undergrad studies, medical school and residency. She has snuggled me when I felt like the world was an evil place, or maybe just the emerg department. 

She's been unwell for a year and needing extra care. I hope that I gave her what she needed. There is so much guilt associated with every death of a loved one. I shouldn't be surprised there is with the loss of Miss Kitty too. 

I was stoic during her euthanasia. Quietly crying and kissing her. My partner was devastated, so loudly mourning. 

Is it that I've seen so many patients die that I'm getting cold? Or that I'm too focused on the intellectual aspects of death of someone we love? But my body is grieving even if my brain isn't. My stomach feels empty and sore. I'm craving sushi and grilled cheese. I've had a migraine for days. I keep walking past her basket to give her a quick snuggle and make sure she's not in pain. My feet are lying to my brain, Kitty isn't there. 

I miss her.