I was finishing off the evening charts. The small country hospital had that quiet feeling that comes when the night calms.

Outside the winter wind whipped across the prairies. Inside, though, all was serene.

Down the hall came the sound of the outside doors sliding open.

From the snowy night emerged two figures. It was Annette and her mother, Marie. The girl trailed behind, dragging her feet as one does when weary of struggle. She was wearing bulky mukluks with undone laces caked by snow. They made a hollow clunking on the polished tiles.

Annette’s face was swollen, and she was obviously having difficulty breathing.

Before I had even greeted them properly, before I had any idea what could be going on, Marie spoke, her voice a near snarl.

“No way she’s going back to the city. Not this time.”

She was fierce, shoulders squared, as if threatening to charge.

“Exams are coming. She’s not missing again this year.”

And with that, another round of negotiations began. In front of us, a child gasping, her small chest rising and falling too fast.

This dance, the intricate footwork, the twists, grim and dark and desperate, all while death drifted through the room.

I tried to sound soothing. “Let’s see what we can do.” Annette’s tired eyes stared at the wall. I risked a joke. “You don’t wanna skip out on exams, Annette?”

A smile teased her face. There was, I think—through the fear and exhaustion—some pity, as if to say, You are trying hard, aren’t you?

* * *

A year ago, soon after I moved to this remote community, I received a refill request. It was for a 13-year-old girl, but the medications were far from routine: names like sirolimus, Myfortic, metoprolol, and so on.

It was the kind of med profile found in faceless city hospitals. Not some shack standing sentinel over that liminal strand where the plains meet the endless spruce stretching northward.

I searched out her old records. They were encyclopedic. Thousands of pages with seemingly no end.

They read like an academic physician’s dream, the kind where the actual person is absent.

Viral illness in infancy, requiring a heart transplant at 3 months; renal failure secondary to nephrotoxic anti-rejection medication, necessitating dialysis and then a kidney transplant. Chronic lung injury from countless infections. And on and on.

I called Marie and asked her to bring Annette in so I could meet them and discuss her complex picture.

“Don’t worry, you’ll meet her soon and come to know her plenty good,” was her casual reply. “Look, she sees enough of you doctors already. She doesn’t need to come in when she’s feeling good.”

And that was it.

But there must have been a change of heart because a couple weeks later Annette and Marie appeared. Marie wore a buckskin with tassels and Annette sported a Harley-Davidson hoodie.

Our first meeting was pleasant enough. Annette ignored me and Marie was flippant. A few minutes in, prior to any physical exam, Marie got up.

“She’s got class. We gotta run.”

“Just a few more minutes,” I pleaded.

Marie looked me in the eye.

“Listen, you folks send her to Children’s the minute she gets a runny nose. It happens every time.” She started to leave.

I tried a last Hail Mary. “But maybe we can avoid that by getting to know each other.”

She turned. “You just got to know us.”

* * *

Since that first meeting, I came to learn the reality of Annette’s existence. The Damoclean sword was forever hanging over her by a thread, rocking gently in the northern breeze.

I had to put her through procedures I would never want performed on myself. During a bout of meningitis, I needed to perform a lumbar puncture. “You’re gonna stick a needle in my back?” she had said incredulously. Later that night as we were losing her, I put a large line into the jugular vein in her neck.

It had been a night of suffering, one of many in her short life.

Marie came up to the nursing station at one point. She looked at me. “You got this,” was all she said. “Get it done.”

* * *

Over time Annette slowly let me in.

And somehow through that old set of negotiations, that dance kept unfolding until, on a level so deep and full of anguish, I learned her moves, and—I think—she came to know mine.

From a medical perspective, we had reached a sort of détente. I would compromise with Marie—taking risks that some colleagues felt were entirely too reckless—with the trade-off that when I said it was time to ship out, Marie would balk, but ultimately agree.

It would be wrong to mistake Marie’s ferocity for aggression. Aggression implies hostility. Marie’s ferocity was a determination—by any means necessary—to defend her child. A love so powerful, its primordial essence almost unsettling.

And so tonight Annette was once again struggling to breathe. Was her kidney failing? Maybe more pneumonia? Or, the spectre of impending heart failure? (“One of these days …” her cardiologist once told me. “That transplanted heart won’t last forever.”)

Mother and daughter were resolute throughout. They prided themselves on resilience, but on this night their faces read like an open book. It was weariness, I suspect, that eroded the protective wall.

And, the constant struggle against imminence. Death comes for us all someday, but for this kid mortality was a palpable, permanent presence.

I went about starting an intravenous line. Her veins were incredibly scarred after hundreds of starts, and they seemed to hide and reappear randomly. When she was simultaneously dehydrated and overloaded, the task was even harder.

As I searched her body for a good target, Annette silently pointed to a promising vein. As I prepared my attempt, without prompting she shifted the position of her arm, giving me the best angle.

I briefly wondered if I would weep.

* * *

Hours later, I glanced through the window into their room where mother and daughter shared the bed, propped up against each other. Annette settled into the hospital bed as naturally as if it were her own. She had probably spent nearly half her life in such beds.

The bravado of medicine sometimes distills the complexity of life and death into the crass binomial of victory and defeat. But I could not see it this way. The notion of victory itself offends that harmony we all seek.

The tension, that struggle between cold, calculated biomedicine and that awesome urge to be human—for Annette and Marie, and I guess for myself as well—came swirling up and then blew away, dancing across the frozen northern plains.

These in-between spaces remind us that, as the Vedas teach, life—the atman—is itself only the briefest of passages before reunification with the world soul.

A singularly central blessing on the journey are those gentle releases when we feel our breath exhale, reminding us that we are alive, if only for now.

For Annette and Marie, that apparently is enough.

Dr Lodge’s story is the winning story of the 2023 Mimi Divinsky Award for History and Narrative in Family Medicine sponsored by the Foundation for Advancing Family Medicine of the College of Family Physicians of Canada. This award is named in memory of the late Dr Mimi Divinsky for her role as a pioneer in narrative medicine in Canada. It recognizes the best submitted narrative account of experiences in family medicine.

La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro d’avril 2024 à la page e61.