Surgery: The Enemy

In the last few weeks, one question has been pressing against my consciousness with insistent force: since when did our patients become the Enemy?

It's an attitude I encounter almost daily-- when my residents use phrases like "OTL" ("Off the List," or more colorfully, "OTFL"-- or when in a particularly irate mood "OTMFL") to express their joy at finally having gotten rid of an especially troublesome patient. Or when they call patients "crazy" (or "fucking crazy"). Or when they make fun of an extensive list of psychotropic medications. Or when they make a beeline out of a patient's room before the patient has finished speaking, the sentences trailing off behind them without even a goodbye to punctuate.

I saw Ms. F this morning, a spunky woman who has a malrotation of the gut (a congenital defect that can cause bowel to twist up on itself and obstruct). She underwent CABG (coronary artery bypass grafting) 3 weeks ago, but her hospital stay has been complicated by small bowel obstruction and consequently a second surgery. When I entered the room at 5:30 AM, she was beside herself. Yesterday she had been able to eat clear liquids! And she had been walking all up and down the halls. She was so looking forward to finally being able to eat again, and to going home, but last night, in her sleep, she had palpitations. Her heart rate was in the 140's; the cardiology resident was called to manage her and she was set back, yet again.

I only had 15 minutes to spend with her, but by the time she was done telling me everything, I had been with her for 30 minutes. Honestly, what could I do to help her anyway? But I bet there was no one else in this whole damn hospital who could do what I did this morning for her-- spend a whole extra 15 minutes listening to how she felt horrible that she hadn't asked the nurse to call her husband in the middle of the night because what if something was critically wrong and she was about to die? He would be so upset! But she didn't want to wake him up, especially with his congestive heart failure, in the middle of this 5 degree winter night to come out in the cold to watch her sleep in the hospital. And she was so tired of being in the hospital, can you imagine being in a hospital for three whole weeks? And her left arm IV had infiltrated so it was moved to the right arm, but one of the IV lines had a long catheter that kinked when she bent her elbow, so her right arm had to be splinted to keep it extended, and now she couldn't even knit anymore to pass the time. And how she missed doing her hobbies, and having the freedom to do what she liked! I bet you're getting tired of reading this bullshit, aren't you?

By the time I got back to my team to make rounds, I was late, but I figured my residents would understand. After all, how horrible must it be to be a patient in a hospital! Can you imagine not being able to eat for a week? After all, we go around making patients NPO (nil per os, nothing by mouth) left and right all day long on a surgical service. Obstruction? NPO! Diverticulitis? NPO! Cholecystitis? NPO! Pancreatitis? NPO! We bandy NPO around like it's a free-for-all. But do we ever stop and think about what that means, physically and emotionally, for the people to whom we're doing it?

And blood draws. How about we come and poke you with a needle at 5 AM every morning for the next 2 weeks? Forget the hospital bed, we'll even do it in your home, see how that feels for you.

And resident rounds. Try waking up with a start to a crowd of 3 residents and 2 medical students arranged around your bed, talking about you. Because they were in too much of a rush to knock on the door before entering the room. That actually happens.

And those horrible plastic beds. Try sleeping in those for 2 weeks. Woken up every 4 hours to have a blood pressure measurement. Add a little bit of intractable pain to the mix.

I explained and apologized that I was late and hadn't written my note because my pre-round with one of my patients had taken much longer than anticipated. My senior resident nodded, understanding my plight. Ms. F was really not feeling well--

"Oh... Ms. F? She's fucking crazy!" He rolled his eyes with the air of an old soul sharing a dirty secret. The junior resident cackled, sycophantically. I had to pick my jaw up off the floor. She's crazy, I tried to reason. She's crazy because she can't shut up, can't stop complaining about not being able to eat. She's crazy because she's depressed about not being able to do what she loves. She's crazy because she feels guilty about worrying her husband! She's crazy because she can't stand incessant blood draws, being bed-bound, and not being able to eat. She's crazy because she's afraid. Try as I might, I couldn't make 2 and 2 equal 4. Flailing in the deep end, I cast about for any purchase I could find, and managed to lock eyes with the other medical student on my team. Together, we cringed; at once, I felt human again.

Patients are human beings too. Perhaps we forget it, in the sleep deprivation, the desensitization to how incredibly frightening and uncomfortable it actually is to be in a hospital. Perhaps we are dead to the mortality our patients are facing daily, because we see it every day without even a blink of sleep to break things up. I don't know what the cause is, but this is my greatest fear: that I will become like that someday, that I will forget how to empathize with suffering; that, caught up in my own tasks and troubles, I will have no energy left to be compassionate-- and worst of all, that I will be OK with it, laughing along with everyone else, cracking jokes at my patients' expense, any avenue to break up the tension inside me. I am afraid that in this struggle to become a surgeon-- superhuman-- I may somehow end up less than human.

Surgery: Baptism

"So you want to go into Surgery?" asked Dr. H, elbows deep in a patient's abdomen. We were standing in the OR at 7:30 on a Sunday morning, and I imagined the rest of the world still gently asleep in their beds, early sunlight filtering quietly in through the windowshades. I had already been awake for three hours, and was in the process of being awarded for my diligence with the first of three emergency operations of the day. I had visited my patients in their beds in the dark morning, listened to their concerns, and created their plans for the day's work of healing. I had stood in my place at the end of the queue as the ritual of morning rounds wound its way around the hospital. I had participated in the flurry of action as a trauma patient (alcohol, car collision, rollover) was rushed to the OR, STAT! Changed into my green scrubs, I stood, flummoxed and breathless, as the attending and senior resident performed the magic of swashbuckling into a man's abdomen in a matter of minutes, a process that they called "controlled chaos," to get to the secret inside: a lacerated spleen that was rapidly hemorrhaging his life away.

Within minutes, the comment "spleen out" was followed by a maroon object which emerged from the depths of the abdomen to attend its own open-casket viewing in a blue, kidney-shaped basin. What a sad remnant of man's body, separated from him forever! The spleen had been slashed liberally across the face by the patient's own traitorous 10th, 11th, and 12th ribs, set free by fractures to wreak their havoc inside his abdomen.

"Get up here." Flustered, I moved my hands to where Dr. H was investigating loops of small bowel for injury.

"No, take my place. Now follow Paul as he works the bowel. Get your hands in there! You're responsible if he misses something!" Dr. H stepped away as I touched the bowel gingerly, several inches behind Paul, who was nonchalantly proceeding along the intestinal tract, smoothing, feeling, inspecting for signs of trauma.

"You move along, checking every inch of the bowel for damage; that's a standard procedure for trauma. You see where the bowel changes caliber here?" Indeed, the bowel changed perceptibly but indescribably at the point Paul was indicating to me. No amount of description in an anatomy textbook had ever revealed that secret to me so openly as this patient's body. "That's where the jejunum becomes ileum." We continued in this fashion for a time, companionably.

"You're still missing something," said Dr. H from the corner. He moved closer to me. Thrusting his hand into the bloody abdomen, he soaked my left hand and arm with the ooze.

"So you want to go into Surgery? There. Now, you're baptized."

Surgery: Today Has Just Been One of Those Days...

Today has just been one of those days. You know, one of those days where you come in the morning all studied up and ready to scrub in on a radical cholecystectomy with liver resection and lymph node dissection (and ready to impress, having memorized all the staging systems and appropriate treatments and prognoses for gallbladder carcinoma), but end up getting diverted to a colorectal resection which starts out laparascopically but turns into an exploratory laparotomy (open surgery), and then the anastamosed (reconnected) colon somehow loses its blood supply and starts to die and you have to do it all over again with another piece of colon and now the patient has an ileostomy too and it was supposed to take 3 hours but it took 8... and then the second patient of the day who was supposed to go at 11 ends up going at 6 and has a carcinoma of the pancreas which has decided to wrap itself around the superior mesenteric artery thereby making it unresectable (read: we opened him up and couldn't take the tumor out anyway). And when it's all finally over at 11 PM you just want to shoot yourself so you don't have to come in at 5:30 AM again tomorrow morning.

You know... one of those days.