Blast | August 19, 2022
“ICU” by Samuel Freeman
BLAST, TMR’s online-only prose anthology, features prose too vibrant to be confined between the covers of a print journal. In “ICU,” physician Samuel Freeman writes about the complicated challenge of providing medical care to indigenous communities in Northern Quebec, a challenge that led him to reckon honestly with his calling and motivations. “ICU” was a nonfiction finalist in our 2022 Perkoff Prize competition for writing about health and medicine.
By Samuel Freeman
Author’s note: The essay is based on true events. However, out of concern for patient confidentiality and to preserve anonymity, certain identifying features and circumstantial details have been fictionalized.
The boy had finally made it through bad weather by air ambulance to our ICU, and now his body was shutting down. Each organ’s failure brought on the other’s, a gruesome domino effect. The machinery of modern medicine was humming along, keeping him alive: expertly trained staff cared for him, a ventilator breathed for him, IV drips kept his heart beating, an artificial kidney filtered his blood. All of it was meticulously recorded, analyzed, and calibrated. Still, his prognosis was grim.
He was in critical condition from a suicide attempt, after ingesting a number of toxic substances: lubricants, solvents, detergents. He was from an isolated Inuit community in Northern Quebec, which was accessible only by plane, or, in the summer months, by boat. Aside from a small local hospital with limited resources, the nearest facility for acutely ill children to get care was our hospital in Montreal, a thousand miles to the south.
I approached the room where he lay sedated and unconscious and sat at a small desk facing the floor-to-ceiling pane of glass that was the room’s inner wall. That partition, a feature of the state-of-the-art ICU, turned the room into an aquarium. I could see in while the space remained sealed off from outside contaminants: unwanted germs, people, and sounds.
I looked through that aquarium glass at the patient and his nurse, devices twinkling and pulsating around them. Inside the room, several relatives, including the boy’s mother, sat by him. I stared: the room was a diorama, a silent film.
It had been almost a year since my first trip North, as the only pediatrician for a handful of Inuit villages, artificial settlements of five hundred to two thousand inhabitants created by the Canadian government to force the Inuit into a “civilized” way of life. They dot the Quebec coast of Hudson and Ungava Bays, tiny outposts on an inconceivably vast expanse of tundra.
Once a month, I packed a bag, a cooler of provisions (groceries in the villages are expensive and usually less than fresh), and my stethoscope, and flew North on a propeller plane with the feel of a Greyhound bus. I spent the week running pediatric clinics in the villages, seeing patients with chronic conditions, or doing specialized consultation for the rotating cadre of general practitioners who worked in the villages. In Montreal, I checked up weekly on children from those communities who were admitted to hospital, which is what had brought me to the ICU.
As I sat outside the boy’s room I sensed activity behind me. A teenage girl was being pushed down the hall in a wheelchair, surrounded by an escort of hospital staff and family members. She was from the same community as the boy and was also on my list of patients to see. She had been transferred to Montreal a few days before him, after shooting herself with a hunting rifle. During a night of drinking, she had become upset about a recent death in her family and decided to kill herself. She had taken the rifle into her room, propped it under her chin, and fired.
When she’d arrived at the village nursing station a large piece of her cheek and jaw were missing. Despite all the blood and mangled flesh, the two village doctors had managed to insert a breathing tube into her trachea, a daunting technical feat that had probably saved her life.
One of those doctors told me subsequently that three things had struck him during the adrenaline-fuelled night he and his partner had worked to save the girl: the shocking nature of her injuries, the fact that she never once complained of pain, and the moment when, still conscious as the small medical team labored frantically to save her, she had raised up her hands and joined them together in the shape of a heart.
The girl had asked to visit the boy, a friend from home, where everyone knows everyone. As she was wheeled down the hall toward his room, the lower part of her face deformed by her injuries and the first, crude stages of reconstructive surgery, she let out a voiceless cry. Her body crumpled onto itself with grief.
Suicide among Indigenous children and youth in Canada is an epidemic, with rates severalfold higher than the national average. The situation is even worse for Canada’s Inuit, whose suicide rates are some of the highest in the world. After a year working in Inuit communities, I had seen how this reality manifested through self-inflicted hangings, shootings, and medication overdoses.
I had also learned that suicides were often carried out impulsively, without premeditation, in reaction to seemingly trivial conflicts or moments of intense emotion: a fight with a friend or parent, a break-up, an insult launched over social media.
That made the approach to suicide prevention and screening I’d been taught during my medical training nearly useless, based as it was on the expectation that suicide was preceded by depressive symptoms and thoughts of death, and that patients without a concrete, practical plan for killing themselves were at relatively low risk. Many suicides I’d heard of in Inuit youth had come out of the blue, blindsiding even those who knew the victims best.
The girl was wheeled to the boy’s bedside, where her body spasmed from the force of her crying. Her chin dropped to her chest, and she wept, I imagined, at the realization that her unconscious friend did not have long to live, while she was severely wounded but very much alive. Members of both youths’ families stood in a circle, held one another, and prayed.
As I watched the scene unfold through the glass, I felt ashamed. In the year since I’d started working in the North, I’d done little more than what I was doing in the ICU: watching, documenting, collating.
It had been a difficult year. The work itself was routine, but the context was a challenge. I was a white man in my midthirties who didn’t know the North and spoke not a word of Inuktitut, the local language. The communities I worked in were close-knit and had good reason to be wary of outsiders, given a long history of colonialism, forced relocations, and abuse by the medical establishment. Most people providing government services in the North—nurses, doctors, teachers, child protection workers, and police—were white and from down South.
My clinics were not a big hit. Many families didn’t show up for their appointments, and when they did, they often seemed dissatisfied. I couldn’t tell what wasn’t working, but I was sure it was my fault. Was I was being unwittingly offensive or, since English was a second language for most families, simply incomprehensible? Did parents see me as the instrument of a state bent on breaking up their families, probing for a reason to report them to child protective services? With my Western ideas and medical background was that, in fact, what I was? Or was I simply entitled, expecting warm smiles and gratitude as advance payment when in reality they had to be earned?
With no sense of what I could do to make things better, I dragged myself along, replicating the rituals of medical care I’d been trained to perform: poring over thick paper charts filled with all manner of handwritten scrawl, peppering families with questions, examining ears, throat, heart, lungs, belly, concluding appointments with a flurry of recommendations I seemed to be reciting mainly for my own benefit. My consultations felt like a wooden performance, a pantomime of care and healing.
That day in the ICU, I was struck by the strange voyeurism of medicine, by the desire I’d seen in myself and in other physicians to be close to the action, the damage, and the efforts to repair it. While that desire enabled extraordinary acts, it often resulted in far less: a meaningless note added to the medical chart, a story to tell your colleagues over drinks, the self-satisfaction that comes with witnessing the hidden violence of human experience, of being able to say, I was there, I saw it happen.
Naturally, doctors want to feel useful and necessary, to test their skills and themselves. But that noble calling has a morbid underbelly: to be useful, essential, and challenged means someone else is sick or injured or on the brink of death.
The voyeuristic impulse could be intense, a form of bloodlust. When the village doctor told me about caring for the girl in the aftermath of her gunshot wound, I was sickened to notice an uncanny pang of emotion arise in me: envy. If only I’d been there too, my distorted logic went, I could have done something vital, something real. I should have been devastated by what had happened to the girl, but instead I coveted my colleague’s moment of heroism, decisive and noble next to my own insipid, bureaucratic contributions.
In truth, my desire to work in the North—a demanding, in many ways undesirable job (all that travel, that isolation, that weather)—had stemmed from a twisted curiosity. I had wanted to see the hardship faced by Inuit communities, to be the young, energetic doctor who was undaunted by the harsh climate, the difficult living conditions, and the cultural differences. I had wanted to return home with my own stories to tell.
Instead, there I was in a Montreal ICU, watching two young people from a village I worked in who had done themselves horrible harm. Although those circumstances had nothing to do with me, I couldn’t help but experience them as a reproach, a message about what I represented as a physician: inadequacy, lack, absence.
I had gone North chasing my own sense of challenge, accomplishment and catharsis, so on that day in the ICU, I should have felt some satisfaction at seeing a wrenching, intimate scene up close. Instead, I thought only of how I had witnessed it all from behind soundproof glass, partly present and partly absent, a spectral figure. I was observing without affecting the outcome, watching without making meaningful connections. I was a ghost.
I stood up abruptly, flushed with the sense of my presence as a transgression, feeling I’d stayed too long in a place I didn’t belong. Soon after that, I would stop working in Inuit villages, a decision that felt necessary but also like an admission of guilt: my confession. It was impossible for me to continue doing work that left me feeling like an intruder and an aggressor, presuming to help people without even understanding what help they needed or if they wanted help at all. Yet I also had to own up to the fact that I wasn’t above what I was repudiating; I had been part of it.
As I walked hurriedly down the antiseptic hallway out of the ICU, I thought about how confession was an implicit demand for absolution, and so was also an act of entitlement, putting my own conscience at the center of a human drama in which I had no role to play. Wallowing in guilt was as self-indulgent as basking in the release of forgiveness. But if neither guilt nor its resolution was my due, what was?
That anguished moment felt nearly like an ending for me, for my career, but as I stepped out of the hospital into the midday light, it opened ever so slightly onto the possibility of my playing another role in medicine, one in which I could stop being a ghost and become a person.
Of course events are impervious to such musings; the boy died that night, while the girl continued to heal.
Samuel Freeman, MD is a pediatrician, writer, and creator and host of Practicing, an interview podcast about the work and lives of healthcare providers. He has published over twenty opinion articles for a general audience, in English and French, in outlets including the Washington Post, STAT, Huffington Post, the Montreal Gazette, and La Presse. This is his first published nonfiction essay. He lives in Montreal.
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