Life on the Ground Floor: Letters from the Edge of Emergency Medicine

by James Maskalyk

A celebrated humanitarian doctor's unique perspective on sickness, health and what it is to be alive. In this deeply personal book, humanitarian doctor and activist James Maskalyk, author of the highly acclaimed Six Months in Sudan, draws upon his experience treating patients in the world's emergency rooms. From Toronto to Addis Ababa, Cambodia to Bolivia, he discovers that although the cultures, resources and medical challenges of each hospital may differ, they are linked indelibly by the ground floor: the location of their emergency rooms. Here, on the ground floor, is where Dr. Maskalyk witnesses the story of -human aliveness---our mourning and laughter, tragedies and hopes, the frailty of being and the resilience of the human spirit. And it's here too that he is swept into the story, confronting his fears and doubts and questioning what it is to be a doctor.
Masterfully written and artfully structured, Life on the Ground Floor is more than just an emergency doctor's memoir or travelogue--it's a meditation on health, sickness and the wonder of human life.

Genres: Nonfiction, Memoir, Medicine, Canada, Medical, Biography, Science

272 pages, Hardcover

First published April 11, 2017

About the author

James is a physician and author, both of the international bestseller “Six Months in Sudan” and more recently, “Life on the Ground Floor“. He practices emergency medicine and trauma at St. Michael’s, Toronto’s inner-city hospital and is an award winning teacher at the University of Toronto.

He directs a program that works with Ethiopian partners at Addis Ababa University to train East Africa’s first emergency physicians and is a member of Medecins Sans Frontieres, an organization for which he has worked as both a journalist and a physician. In 2007, he was MSF’s first official blogger, He practices and teaches mindfulness at the Consciousness Explorers Club in Toronto, and is passionate about it’s potential to encourage personal and social change.

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Reviews

[Kathleen · Rating 4 out of 5]

"Masterfully written and artfully structured, Life on the Ground Floor is more than just an emergency doctors memoir – it's a meditation on health and sickness, on when to hang on tight, and when to let go."

LIFE ON THE GROUND FLOOR: LETTERS FROM THE EDGE OF EMERGENCY MEDICINE by James Maskalyk is very interesting and well written.
This memoir reads like a narrative telling about the author's extensive experience in emergency medicine at St. Michael's Hospital, Toronto and Black Lion Hospital, Addis Ababa. A member of Medecins Sans Frontieres, Dr. James Maskalyk splits his time between the two hospitals an ocean apart, one in Canada and one in Ethiopia.
We see the differences in culture, equipment, resources, and medical challenges between the two.
I enjoyed this book and appreciated the glimpses into the author's childhood and the interaction between him and his grandfather.
4 caring stars ⭐️️⭐️️⭐️️⭐️️

[Krista · Rating 4 out of 5]

I sit behind the nursing station, stomach rumbling, humbled, watching white coats flash behind curtains. It's tough to say I'm proud of these people, as I have had nothing to do with making them. Still, daily, I feel something akin to that when I watch these doctors navigate a floor full of sick and worried people. Maybe it's awe. Maybe that's what pride was supposed to be in the first place: the awe one feels at participating in something beautiful.

Like author James Maskalyk does currently, my brother used to work at St. Michael's Hospital in Toronto, and although my brother's stress levels certainly decreased when a transfer to our local hospital left him with fewer staff to supervise and essentially no commute, he still has regrets; misses the feeling of participating in the beautiful project that is St. Mike's, surrounded as it is, in Toronto's inner core, with the mentally unstable and the drug-addled and a mandate to never turn anyone away. Maskalyk captures this St. Mike's vibe beautifully, and as he also spends time mentoring at the Black Lion Hospital's nascent ER in Addis Ababa, Maskalyk is able to contrast what emergency medicine looks like in the two systems; the differences in patient complaints and the resources available to address them; the common goal of all doctors to fix bodies, alleviate pain, and allow people to face end of life with dignity. With many emergency interventions described in detail – less sanitized, and therefore, much more real and interesting than you tend to see on televised medical dramas – and many facts inserted about the state of global medicine (including some necessary criticism of well-meaning NGOs), the medical anecdotes are fascinating. Less interesting to me, however, were the personal stories of Maskalyk visiting with his aging grandfather in Northern Alberta – I could see how the personal was meant to graft onto the universal and bring it all together, but as with some jarringly overwritten passages, it just felt too crafted to me; more writerly than the reporterly tone I enjoyed in the other bits. But, that's a personal complaint, and as Maskalyk won the prestigious Hilary Weston Writers' Trust Prize for Nonfiction for Life on the Ground Floor, mine just might be a minority complaint.

In Toronto, Maskalyk's stories focus on excess: people drinking or eating too much, taking drugs and getting into fights; doctors pouring litre after litre of blood into hopeless patients; ordering expensive tests just because they're an available tool and no one pays out of pocket for them:

As cities pile people downtown, as people live longer on more medicines that make more side effects, have more surgeries and more complications, as specialization breaks bodies into smaller and smaller parts, as our population spends more time on screens than outside and grows ever more anxious, there are more people in our ER every day.

By contrast, when Maskalyk travels to Ethiopia, it's a story of need: the goatherd whose vitamin-deficiency leads to nosebleeds, but there's not enough blood or platelets available to transfuse him; family members run to the local pharmacy with the prescriptions from the ER doctors, hoping to be able to return with what their loved ones need; the cables that go missing from the ER's monitors. Mostly, Maskalyk seems to be addressing the need for an ER at all: in conjunction with his mentoring, we watch as the Black Lion graduates its first cohort of emergency medicine residents; with him, hope that some will stay on and pass their expertise and support onto future doctors; that successful outcomes in the ER will prompt the rest of the hospital to regard it as more than the place where the hopeless cases go to die.

Attrition is high. Nurses, security guards, cleaners, all quit with great frequency. The ER is a place where they are sent as punishment, to think about what mistakes they've made among the grieving. Students pass through, a tour of duty to the front lines, grateful to leave the dying behind when their month is up. At home, emergency medicine is one of the most competitive specialties for medical students, and most who apply won't get in. Here, no one knows why you would do it, because it appears that for the sickest, little can be done.

The subtitle for this book is “Letters from the Edge of Emergency Medicine”, and I thought that meant “letters” as in “epistles”. But it's meant as in “the letters of the alphabet”: In a First Aid course, I had learned the ABCs of first response (check the Airway, Breathing, and Circulation), and Maskalyk uses these as the titles of his first three chapters, and then goes on through the alphabet (i.e., F is for flow, K is for Kind, up until XY is for a man [about his grandfather, again] and Z is for ze end), and I just found that too gimmicky for an otherwise serious book. And as an example of what I found overwritten:

The airway isn't a real thing; it's empty space over which a body pulls in wind as breath, then moves it out, vibrating it into cries and words, truths and lies. The hole there, at the vocal cords, is about the width of your smallest finger. I wonder how few of the strangers we pass on the street know this secret, that their entire life depends upon something so small? When it narrows, though, they know, and silent appeal begins.
Pleasepleasepleaseplease.

Overall, though, this is a very enjoyable read – informative and challenging. It's truly a minor complaint to say that it feels so "crafted" (the doctor dares to write artfully!), and I leave interested to read Maskalyk's first book, Six Months in Sudan, on his time with MSF.

[Maryan · Rating 5 out of 5]

I knew I had to read this book when I heard Dr Maskalyk interviewed on CBC about this memoir. His passion balanced with skill and commitment came through then and throughout the book. The fact that he practices emergency medicine at St Michaels Hospital for part of his life drew me as well because I am a long ago graduate of that hospital's School of Nursing. The values I was trained in are evident in his medical practice whether in Toronto or Ethiopia or when he is assisting his aging and beloved grandfather. The compassion, the respect for personal choice, the importance on the action rather than attachment to outcome, the drive to become more skilled to do the best possible job for the patient - all of these echo through his writing. He is honest about his attraction to the unrelenting pressure in the ER, the adrenalin drive, the joy from competence and the pain of a hangover. The emergency settings in Ethiopia and Toronto although worlds apart are similar. The contrast is the peace he finds of the remote winter bush when spending time with this grandfather. There is nothing phoney in this account. He swept me into his worlds. I look forward to more.

[Jaclyn]

Fascinating glimpses into the world of emergency medicine and some heartwarming moments with his grandfather, but the writing style just gets really confusing. I guess it makes sense given the frenetic pace and all the activity in his work, but he jumps from one topic to another and then another so quickly it feels like a flurry of glimpses of all the various pieces in his life (Toronto ER work, Addis Abba hospital and time with grandfather).

Possibly my brain is just tired or it's not quite the right fit for me. DNF at page 95.

[Hailey Van Dyk · Rating 5 out of 5]

As an ER nurse who has worked in the busiest ER in western Canada... I appreciated this book so much. To read things that I have thought, to take in another perspective of emergency medicine in another country... anyone who plans to seek out care in the ER should read this book. It’s well worth it.

[Fishgirl]

No thanks.

[Judy · Rating 4 out of 5]

In this deeply personal and insightful memoir, Dr Maskalyk penned his experiences of working as a physician in the Emergency Department at both St Michael’s hospital in Toronto and Black Lion Hospital in Addis Ababa, Ethiopia. From life to death, laughter to tears, both the frailty of life and the resiliency of the human spirit were illustrated through his interactions with people from all walks of life. The book also touched upon the reality of foreign aid and offered the readers a glimpse into his personal life through the chapters detailing the moments he spent with his ailing grandfather. Overall, this was a fascinating read that inspired me to reflect on the meaning of health and the role of medicine to preserve it.

[Jo-anne · Rating 5 out of 5]

This book is difficult to label...it's an autobiography, an exploration of emergency medicine, a look at the issues surrounding foreign aid...but most of all it's an eloquent journey through the alphabet.
Absolutely recommend it to anyone interested in medicine today, philosophy, and the meaning of death in all our lives.

[JennieWithTheBooks☮️(◕‿◕✿) · Rating 3 out of 5]

Powerfully written. Enjoyed the a-z chapter organization. Made me reflect on our world and what it means to give, to be mindful. A lot of people talk about being mindful but this author does it every day!

Realistic in the way that it was a true account of what the emergency room doctors and nurses deal with every day. It should be read by all the general public before they complain about the care they receive.

I found the author's relationship with his grandfather endearing and would've preferred reading more about that on its own but it was interesting to see it all tie together.

I am in complete awe and admiration for those in less fortunate countries trying to save lives with the little resources they have. This book opened my eyes to that and for that, I am grateful, humbled and appreciative.

3 Stars on this one.

[Joanne · Rating 4 out of 5]

This is a really inspiring book. The author describes life in the ER in two hugely disparate cities: Toronto and Addis Ababa. The miracles the medical teams perform in Addis are stunning, but he pulls no punches: the work is hugely impeded by the lack of even the most basic resources. At the same time, even with all the wonders of western medicine at hand, sometimes the miracles are elusive in Toronto as well.
My favourite chapters, however, are the ones with his beloved grandfather at his wilderness home in northern Alberta. His love and admiration for his grandpa shine through in every paragraph. It's beautifully written and deeply touching.
This is a lovely book.

[Mateo Farfan · Rating 5 out of 5]

Excellently written memoir of a physician who toes the line between caretaker, educator, and a struggling being. Maskalyk's sharp, and subtle, yet direct prose has a way illuminating some of the bleakest moments anyone in the care professions can experience. Whether your work takes you through the work of a frantic, urban ER, or some other locale, the author's candor and humility, are sure to illuminate and shed light on the reader's own experiences.

[Diana · Rating 5 out of 5]

This book was not what it seems. Not only is it stories from the ER at St. Mike's in TO but it is also stories from ER in Ethiopia and a very poignant telling of his time with his ailing grandfather. For a physician Jim Maskalyk is a very good writer, heck not even for a physician. His writing, at time, almost reads like poetry. Thoroughly enjoyable reading. Hopefully this is a trend for 2018.

[Sam Newhook · Rating 5 out of 5]

Great book, heartwarming.

I devoured this book in a single sitting and am excited to recommend it to everyone I know. Having worked at St Michael's hospital I have seen and met many people like the author and it is always inspiring to learn their stories. The book is fast paced, funny, heart wrenching and all together a worthwhile read.

[Pankaj · Rating 5 out of 5]

Wow! James has eloquently captured the frenetic activity that could result in life-death decisions, the frustration at not having resources at hand to save lives and the drive to push ahead and not allow anything adverse to impair a doctor's judgment. Brilliantly written.

[Adrian Sergiusz · Rating 4 out of 5]

Very humane, full of life and compassion. A well written first hand account of being a physician in the extremes, whether it is in Ethiopia or in a hospital in Toronto. Both worlds are continuously compared and contrasted through first person interactions, showing how the life of being a good doctor living on the extreme can be both immensely rewarding but taxing through all the different types of relationships formed. Sometimes it's hard to keep track of what's happening, the author does jump from situation to situation at times but it can be overlooked by the directness and honesty of the stories happening. Great read for any aspiring physician wishing to pursue medicine and see the future of medicine in the developing world.

[✿✿✿May · Rating 4 out of 5]

This book drifted between the author spending time with his grandfather, with his deteriorating health, his work life at the ER in St. Mike's hospital and Ethiopia training doctors, with limited resources. It must be hard to see so much suffering with his job that it must be even harder to see his own grandfather's failing health.
I quite enjoyed it, as I like medical shows on TV, and St. Mike must see a lot of action with its location in Toronto.

[Katelyn Cairns · Rating 4 out of 5]

Great read! I really enjoyed the writing style, and found it made it easy to picture/experience what he was talking about! Definitely different than his other book, but I think I preferred this one more!

[Jodi Lofchy · Rating 4 out of 5]

Perfect book to read while in Addis Ababa working in the same hospital as the author.

[Patsey]

Always something interesting in these true account books. Dr. Maskalyk writes in an engaging style for the layman. He seems like a wonderful human being. Kudos to you Doctor

[Leah · Rating 3 out of 5]

Had so much potential, and I was super excited for it. The content was disorganized, and the writing fell flat. Disappointed with this one.

[Amanda Munday · Rating 4 out of 5]

A- A fascinating read about hospital life in Toronto
B - Breathtaking details about crisis management and especially trauma.
C - Could have used a bit more information about birthing. Aren't labour and delivery some of the most common reasons to be in hospital? Did this doctor never experience birthing emergencies (they all went up to the 15th floor?)
D - Direct experience with this hospital kept me reading through the night.
E - emergency medicine is its own field and I can't believe this author found the time and energy to complete this book.
F - funny - I appreciate the humour in what sounds like a stressful career and life.
G - gross lack of resources in his international travel
H - hard to read about how some people in his experience are simply are waiting to die.
I - I really enjoyed reading the memoir and would recommend it to others!
J - Jargon and medical speak mostly missing from this book, making it that much more approachable.
K -Kindness. This doctor and his tales of returning to patient files in the name of kindness is what makes me proud to be Canadian.
L - losing the battle - I must imagine that at times working in an ER setting feels like a losing battle, that's what this book paints it to be, anyway.
M - medicine is stressful!
N - not like other medical journals - this is both easy to understand and complex in his delivery of patient experiences.
O - OR - we didn't get as much surgery details or details of what happens after a patient is admitted. I would have liked to read more about the experience of patients after they leave the ER.
P - People - who are the close people in this Doctor's life? The story of the grandfather is certainly moving, but the rest also felt private. Too private maybe?
Q - questioning. I'm questioning how doctors view me and my experiences in hospital now. Am I a legit ill person (at times) or one of the worriers he describes?
R - rest - does this doc ever take the time to rest? I wish he did, he needs it!
S - sound logic - it sounds like more than anything else, doctors look for sound logic in making a diagnosis, but what about the rare cases where history can't define current state?
T - Toronto - loved the theme of a majorly busy hospital in my home city. It's also tough to read about the little girl, and about his international experience and his view of privilege back in Toronto.
U - unique - the alphabet chapter titles stole my heart.
V - very easy to get through. I finished this book in two days!
W- want to hear more - I would love an update from this doctor and whether he will continue his work in emergency medicine.
X - X rays - demonstrating medical proof that determine whether what the patient says is actually the case. The reliance on these tests was so interesting to me.
Y - Y "why" did he collapse XY in the book?
Z -"Zee end". If this author cheated so can I.

[Jan Angus · Rating 4 out of 5]

Engrossing examination of the life of ER professionals by a physician who practices both in Toronto and Ethiopia. Extraordinarily candid and beautifully written, the book is arranged in alphabetical chapters (A is for airway, B is for breathing, C is for circulation . . . Z is for ze end). Maskalyk shifts back and forth between his experiences in a downtown Toronto ER department, his work in Ethiopia, and his visits to his ageing grandfather's remote home in rural Alberta. He manages to convey the urgency and intensity of patient care in a compassionate and self critical voice that can be breathtaking at times. His thoughts on his time in Ethiopia are deeply sensitive to the sociocultural context and make for intriguing reading. I will look for more of his books.

[Nancy Croth · Rating 4 out of 5]

In his latest book, James Maskalyk has provided a fascinating and discouraging account of life in emergency rooms in Toronto and Ethiopia. Mingled throughout are peeks at his relationship with his hunter/trapper grandfather who is in deteriorating health himself since the death of James's Grandmother.
He begins with the basics... the ABC's of medicine and moves throughout the alphabet of ER necessities. A for Airway, B for Breathing, C for Circulation.... if can't get those back in working order, there is not much else to do! Interspersed through the narrative, one picks up interesting facts on how the body operates and how it tries to compensate for lost functions.
But the real story lies in the emergency rooms themselves and the relentless pressure on the medical teams that try to resuscitate, comfort, heal, and repair the broken bodies that unendingly flow through the ER doors. You can feel the frustration, exhaustion and despair whether in the supply starved ER in Addis Ababa or the state of the art trauma centre in Toronto. Maskalyk portrays very well the grinding hopelessness that eventually drives some amazing medical personnel from this kind of work. And yet, in spite of it all, he shows us that there are glimpses of hope and that trying again is what really matters.

[Robert LeBlanc · Rating 5 out of 5]

This book has heavily influenced the way I look at life and suffering

[Abi · Rating 5 out of 5]

A truly amazing book by Dr. Maskalyk - moving and humbling and shocking and important.

[Eric · Rating 5 out of 5]

Fantastic. Anyone wanting to be an ER doctor should read this.

[Stacey · Rating 5 out of 5]

Love this book. The contrast between Canada and Africa, the fast pace in the ER and the slow pace with his grandfather, is beautiful. The almost poetic style - love it.

[Bookworm Adventure Girl · Rating 3 out of 5]

For my full review, please follow the link below:
https://www.bookwormadventuregirl.com...

[Ben Truong · Rating 4 out of 5]

Before reading one word, I was pleasantly surprised by this medical memoir. At first I thought this memoir would be told in letters written – like an epistolary novel, but not a novel, because it's using real letters. I thought it would be a travelogue of sorts. However, I was quite surprised when I looked at the Table of Contents to see each chapter using a letter in the alphabet for the title. It was then I realized how cheeky Dr James Maskalyk might be.

Maskalyk who practices at St. Michael's Hospital in Toronto and Black Lion Hospital in Addis Ababa does not consciously set this up as a comparison between two different hospital, but he finds more similarities than differences in the patients and colleagues and as many strengths and weaknesses in the way care is delivered in these respective facilities and cultures.

Which shouldn't really be surprising, after all, people get sick all over the word and those that rush to emergency rooms tend to be desperate and often dying and the doctors and nurses who had heard the calling are cut from the same cloth. Their mission is the same – giving life to a body for a moment longer, in spite of the resources of the hospital.

Maskalysk writes that all hospitals are built the same way, because seconds matters, the ERs are always on the ground level – hence the book title. He also states, perhaps idealistically so that ERs are also society's great equalizer, it is the sickest that get treated first and nothing else matters. Not only that, but ERs also feels the same, when at full capacity the ERs feel like a war zone. However, despite having the same bodies, having similar hospital, the same quest, the same triage method, and the same feeling, then why is how to treat the body so different?

However, the most emotional parts of the book is not in the emergency room, but in a cabin in Alberta where Maskalyk takes refuge to reflect and write, and care for his grandfather, a proud man preparing to die. It is in this quiet place of reflection that provides the most important context to what takes place in the emergency room, a reminder that what ultimately matters to patients – the human contact and compassion.

All in all, this memoir is beautifully written and gives great insights to how emergency room work all over the world and that in the end we are more similar than different. It's about making connections across continents, cultures, and social classes and to cling to moments of joy that can be found admits the sorrow.

[Rick · Rating 4 out of 5]

Life on the Ground Floor, a fast-paced non-fiction account of life in Hospital Emergency Rooms in Toronto and Ethiopia, follows an ER doctor through his daily routines in two very different hospitals. This book is a natural fit for Dr. Maskalyk, an emergency-room physician, who has written another critically acclaim non-fiction book, Six Months In Sudan.

The book begins with James Masalyk receiving a call from his director in Toronto. James has just returned from a successfully trip to Sudan and he is now asked to go to Ethiopia to help start an emergency department program in hospitals there. Thus begins his hopping between emergency departments in a Toronto Hospital and a tin room attached to a teaching hospital in Addis Ababa. Although the hospitals differ in cultures and resources they share the need for triage and rapid treatment for serious illnesses. As what appears to be a contrast, intertwined with descriptions of the two emergencies are stories about growing up with a grandfather who taught James and his brother to hunt and survive in the bush.

There are many facts and figures in the book that help one understand the challenges these doctors face. We learn about the prescribed drugs we take in Canada that are not as effective and one would think. On the other hand, in less developed countries where there are few doctors and no hospital one must give everyone a pill even if it only a vitamin or they feel you are holding back. Are we any more advanced?

My one criticism of the book would be that it takes frenetic jumps from Addis Ababa, to Toronto, to the cottage and then back again. Often one feels disoriented and not sure where you are.

Death and the stress of trying to avoid it are clearly portrayed in the book. The inability to sleep after a shift is common. Many health practitioners do it for a while and then disappear.

In spite of it all, I think the message that came loud and clear to me was a conversation James has with his dying grandfather.

“Are you happy with my will?”
Yes
Is it OK for me to let go?
It’s OK
Life isn’t just one big funeral, you know Jim.
It Isn’t?
No. It’s full of living too, and for that you don’t have to wait. Do you get it now?

I highly recommend this book to those to who don’t appreciate the work that men and women in the health profession do under high levels of stress, often with little appreciation. That’s probably all of us. I give this book a 4 on 5.