ER: Hitting It

This time, I hit it on the first try. I was sure and steady and my technique was flawless. As the blood whooshed into my syringe and hit the heparin pad, I felt a sense of triumph and a new calm. I know that I am not going to hurt patients doing ABG's any more.

ER: Love

There's no better way to show your love for someone on Valentine's day than by accompanying them to the hospital, then sitting in a hard plastic chair for 4... 5... 6... 10... hours with them while they puke, get poked with needles, go through a CT scanner... etc. Forget candy hearts. Be mine! Have a blood pressure pill!

ER: Losing It

I've volunteered thousands of hours in the past five years on an ambulance. It began as a "prelude to med school"-- something that many pre-meds do to boost their resumes and dip their toes into the water of patient care. Most quit after they make it into med school, the utility of the operation spent. I loved it and kept going. There's nothing quite like the family at the first aid squad: a group of community members crazy enough to spend sleepless nights each week working with sick people for free. There's also nothing quite like the thrill of rushing to an emergency with lights and sirens, the fulfillment of recognizing my competence (EMT's often joke: "Somebody call 911! Oh wait-- I am 911!"), the reward of a fellow community member's gratefulness. A lot of people ask me if I want to go into emergency medicine.

I hate the ER.

I worked my first overnight (11PM-7AM) shift on a Friday. Second years had just finished exams and were out getting drunk on the street (good for them). I showed up and stood mutely at the nurse's station, unsure of what to do with myself. I was quickly asked to dance.

"You wanna go get an ABG (arterial blood gas) on this patient?"

I jumped into action! Every medical student must meet a required number of procedures before graduation, and I had yet to collect all three of my ABG's. Inside my body, catecholamines rushed to prepare me for the exploit; endorphins signaled my excitement at getting to perform a procedure. You gotta love it! I know exactly how to do an ABG. You feel for the pulse, then you stick the needle in. It's really simple. I was totally going to show my stuff.

It wasn't until I walked into the patient's cubicle that I recoiled at myself. I didn't even know who this patient was, or what she was here for; I couldn't have known, since I just started the shift. I was about to stick her without knowing her. And what gave me the right to draw her blood, anyway? If I were her, I would have kicked me out, had I known how little experience I really had with this procedure. I felt disgusted. I was using the patient.

I tried to make things a little better. I introduced myself. I acted very confident.

I missed.

I returned to the nurse's station, troubled. The tech student looked at me with pity and said, "Don't worry, you'll get it with practice," and proceeded to discuss a few helpful tips on needle placement with me. That's the truth; these things do require practice (on real people), and I will eventually become competent at them. But I felt unable to reconcile that rational argument with the feeling that I had just toed some ethical line. I stood there, inwardly searching for some source of moral solace. I didn't find it.

Instead, I got a friendly nurse:

"Hi! I'm Steve. How are you doing? Do you want to come help me take off this woman's pants?"

The woman he was referring to was a hilariously drunk woman in her forties who had just soiled herself; Steve needed a female chaperone. Taking off her pants? That's one way to meet a patient for the first time. There was also a tube top which Steve, in his male ignorance of feminine fashion, tried to remove by pulling down past the patient's hips (guys, don't try this at home; the top comes off over the head). This resulted in a lot of wiggling of the hips and peals of laughter all around. When I say hilariously drunk, I mean we all had so much fun, it should have been illegal. She's not gonna remember any of it, though.

The next seven hours continued in the same vein. I did painful stuff to people I didn't know. I met patients with bullshit complaints that I treated in 30 minutes and dispatched; I'll never see them again. I met patients with real, serious complaints that were admitted to some lucky medicine or surgery team who will get to diagnose, treat, and build a relationship with the patient over the next few days in the hospital; I'll never see them again, either. I felt like I was losing it. I felt detached, dehumanized, and demoralized. A trauma alert came in; the woman was screaming "Fuck you, bitches!! Fuck you all!!!!" and jerking all over the damn place as the trauma team was trying to assess her injuries, so they all said "fuck it" and sedated and intubated her to end the abuse.

I'm not knocking the ER for people who want to work there; it's an incredibly important job and a vital part of a hospital-- and it's not an easy job, either. But I want to spend more than 30 minutes with my patients and have time to clarify my moral boundaries. That, in a long-winded way, is why I don't belong in emergency medicine.

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.

OB/GYN: Bringing Forth Life

In real life, the uterus looks just like it does in picture books. Springing forth from behind a curtain of fat and abdominal muscles in the depths of an incised abdomen, it's a strange, almost whimsical shape which is easily recognized as "uterus!"-- even by the unseasoned medical student. On the inside, the uterus looks just like a blood-soaked sponge, and it's easy to imagine that if you were just to rinse and wring it out, it might be ready for another go on the kitchen counter.

These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.

It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.

The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.

From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.

The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.

Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.

I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.