"You want to write when you get sad." I was chatting with Ant, one of my classmates and, I guess, fellow bloggers. Perhaps that wasn't exactly what she said, but after talking about our writing styles and habits, it was the main message. Writing helps us release stress, thoughts, anxieties.
The inherent challenge, then, was to write about something happy. And, cheesy as it sounds, I found myself wondering about the happiest moments of my clinical training so far. My memories brought back patients I liked and loved, moments where I found pride, funny moments with jokes and shared laughter.
There was one unusual moment that I remember clearly. We were in the operating room, with Dr. Packard, one of my favorite attending physicians. I wasn't even scrubbed in, but I was standing on the side watching the case. The patient had a large melanoma, a type of skin cancer, on his left foot, and required an excision. I found melanoma to be a fascinating disease, perhaps precisely because you could run your finger over the black, irregularly bordered spot. Ugly, your mind thinks. Cancer.
The procedure involved removing the skin containing the cancer, as well as a reasonable border around it to ensure that all of the cancerous cells are removed. The result was a large circular hole, red and gaping even after the bleeding was contained. Then, I watched my attending use a small dermatome-- which reminded me of the ham slicers you'll see at the deli-- and removed a thin strip of skin from his upper leg. He brought this thin strip down to the foot.
Dr. Packard arranged the skin graft, like so, and marked out the sections that will connect with the rest of the foot. Slowly, the strip was stretched and sewn perfectly, covering the previous hole with a new layer of skin. The stitches was perfect, and the graft was round and symmetrical. What was originally an ugly cancer had been turned into an even uglier site of trauma, but was now newly covered. It's difficult to describe, but it was as though looking at a painting, deep and detailed and masterful.
I had never seen anything so beautiful.
Then, the attending cut four small slits in the center of the graft. "It's to relieve pressure if fluids pool underneath," he said. "Like a pie."
The attending then said exactly what was on my mind. "You know, the only thing cooler than the actual procedure is the fact that someone actually figured all of this out."
Perhaps it was the sleep deprivation, or perhaps it was the fact that it was my melanoma case, or maybe it was because I had just managed to answer a bunch of Dr. Packard's tough questions just a few minutes earlier. Maybe it was for stupid reasons, but there were few moments of real elation compared to this one. Although he was not my patient, I had met him clinic when he was dealing with his new diagnosis. At this moment, he began his transition to someone with a former diagnosis in recovery. I found myself reeling with the ramifications of the procedure, but also the simple elegance of the procedure itself. This was medicine, science, technology, art.
A few weeks later, I happened to be working at the clinic when the patient returned for a follow-up visit. I was anxious to see the skin graft, and nervously watched as the nurse removed the dressing. I found myself a bit disappointed; the graft took and now had some color to it, but somehow it wasn't as clean and pure as it looked under the operating room lights. However, there was no doubt that the graft was working and healing well.
After the visit, I saw the nurse struggling with the short sutures left on the compression dressing, and for the first time, I found myself sheepishly offering to give it a try. I immediately regretted it, for I realized that I would be doing a procedure with a patient who was not only awake and watching, but was an elderly retired physician. I later realized that we were both nervous as I picked up the curved forceps, but he visibly relaxed as I worked quickly to secure the dressing.
He eyed my work as I finished. "You tie those knots like you know what you're doing," he said. "Are you training to become a surgeon?"
I smiled. "Honestly? I have no idea."
Thursday, September 17, 2009
Monday, September 14, 2009
September 14, 2009
During my surgery clerkship, I found it important to meet the patient before the surgery. Sometimes it'd be someone completely new, which was always a fun and oddly awkward experience-- I'd have to explain who I was, why I was there, and reassure them that, as much as I'd love to, I wouldn't be doing their operation. At other times, it'd be a patient I knew well from the floor, who I just saw a few hours ago. And we would hang out for a bit, saying hello to the nurses and the anesthesiologists and the overwhelming number of faces you meet right before surgery.
And then a variation of this conversation would occur. "I knew for a long time I'd be having this done and I'm ready," they'd say. "But I'm nervous." Some would smile through it; others would admit this sheepishly, as if ashamed. There was often a lot of humor, I would let the patient talk and often they would joke around, but the underlying message was the same.
"Well," I would say. "I really wish there was something I could say to make you feel better." Sometimes we would talk about the procedure, at others about the experience of the medical team. There was always an odd disconnect, for while the patient was going through the procedure for the first time, from the perspective of the medical team, the patient was only one out of hundreds of faces the team saw a year. The medical team was confident; we had the experience, the science, and, quite frankly, our perception of our track record to support us. This perspective was usually something that the patient couldn't see.
I sometimes found myself reminded of being on a plane, sitting next to people with bad flight anxiety. It's my first time flying, I'm terrified of something going wrong, they would say. They would not only share this with me, but also the crew, who were empathic but I could imagine their reaction. We do this every day, they would say.
"We do this every day," I tell the patient. "Don't worry, you have some very friendly faces around you." I would point out my favorite operating room nurses and techs, ask if there was anything I could get them. I would sit off to the side in the PACU, furiously skimming over the patient chart and cramming for the inevitable pimping in the OR until it was time to push back.
There was always an odd sense of paternalism. "Here we go," I would say. "We're headed for operating room 9. We're going to put on some funny masks now. Are you feeling comfortable? Here are some warm blankets. Can you scoot on over on your butt? I'm going to put some funny stockings around your legs." The banter was almost always the same despite the age of the patient, and even for a pediatric patient, the tone was eerily similar. The exception was the one fourteen year-old who requested rap music, and we did our preparations to Jay-Z and 50 cent.
I would like to tell myself that what I did was important, but the reality is that some of the patients either didn't care or were too drugged up for me to make a difference. And, strangely enough, the cases that bugged me the most were the cases where I felt like my presence was important. They were the ones who were the most thankful that bothered me the most.
It took me a few weeks to figure out why. They had nobody else. I soon learned to ask in the PACU how the patient was getting home. Often, someone was waiting in the lobby. At other times, they had no plan. The majority of my patients were admitted for a few days anyway, but some never seemed to have any visitors, and headed home on the Marta alone.
Dr. Stu, one of my favorite residents of all time, made the same observation one afternoon. "These are people who are about to have a major, major operation, and they don't have a single person who will be there for them. You'd think that out of family, friends, there'd be one person who could come." He shook his head. "It makes me so sad."
Sadly, it happened more often than we would have liked. Surgery is a scary, transformative process. You go in and you fall asleep, crazy things happen, and then you wake up permanently changed in some way. And, out of everyone I asked, the experience was different, harder than they expected. No amount of doctoring or talking before the surgery can concretize what the doctor sees and what the patient hears. For the patient, it's their first time, and for anybody, it's an experience outside of the imagination.
I recently found out that a friend was having surgery this week, and although he asked me, I found myself oddly stubborn, insistent that I will be there on Tuesday. I found myself strangely offended when he suggested that he'd be okay otherwise. I don't want you to go through surgery alone, I think. I don't want you to be one of those people, one of those brave few who are reliant on a medical student that they just met, trusting a naive gaze to monitor the fall of the scalpel's edge.
And then a variation of this conversation would occur. "I knew for a long time I'd be having this done and I'm ready," they'd say. "But I'm nervous." Some would smile through it; others would admit this sheepishly, as if ashamed. There was often a lot of humor, I would let the patient talk and often they would joke around, but the underlying message was the same.
"Well," I would say. "I really wish there was something I could say to make you feel better." Sometimes we would talk about the procedure, at others about the experience of the medical team. There was always an odd disconnect, for while the patient was going through the procedure for the first time, from the perspective of the medical team, the patient was only one out of hundreds of faces the team saw a year. The medical team was confident; we had the experience, the science, and, quite frankly, our perception of our track record to support us. This perspective was usually something that the patient couldn't see.
I sometimes found myself reminded of being on a plane, sitting next to people with bad flight anxiety. It's my first time flying, I'm terrified of something going wrong, they would say. They would not only share this with me, but also the crew, who were empathic but I could imagine their reaction. We do this every day, they would say.
"We do this every day," I tell the patient. "Don't worry, you have some very friendly faces around you." I would point out my favorite operating room nurses and techs, ask if there was anything I could get them. I would sit off to the side in the PACU, furiously skimming over the patient chart and cramming for the inevitable pimping in the OR until it was time to push back.
There was always an odd sense of paternalism. "Here we go," I would say. "We're headed for operating room 9. We're going to put on some funny masks now. Are you feeling comfortable? Here are some warm blankets. Can you scoot on over on your butt? I'm going to put some funny stockings around your legs." The banter was almost always the same despite the age of the patient, and even for a pediatric patient, the tone was eerily similar. The exception was the one fourteen year-old who requested rap music, and we did our preparations to Jay-Z and 50 cent.
I would like to tell myself that what I did was important, but the reality is that some of the patients either didn't care or were too drugged up for me to make a difference. And, strangely enough, the cases that bugged me the most were the cases where I felt like my presence was important. They were the ones who were the most thankful that bothered me the most.
It took me a few weeks to figure out why. They had nobody else. I soon learned to ask in the PACU how the patient was getting home. Often, someone was waiting in the lobby. At other times, they had no plan. The majority of my patients were admitted for a few days anyway, but some never seemed to have any visitors, and headed home on the Marta alone.
Dr. Stu, one of my favorite residents of all time, made the same observation one afternoon. "These are people who are about to have a major, major operation, and they don't have a single person who will be there for them. You'd think that out of family, friends, there'd be one person who could come." He shook his head. "It makes me so sad."
Sadly, it happened more often than we would have liked. Surgery is a scary, transformative process. You go in and you fall asleep, crazy things happen, and then you wake up permanently changed in some way. And, out of everyone I asked, the experience was different, harder than they expected. No amount of doctoring or talking before the surgery can concretize what the doctor sees and what the patient hears. For the patient, it's their first time, and for anybody, it's an experience outside of the imagination.
I recently found out that a friend was having surgery this week, and although he asked me, I found myself oddly stubborn, insistent that I will be there on Tuesday. I found myself strangely offended when he suggested that he'd be okay otherwise. I don't want you to go through surgery alone, I think. I don't want you to be one of those people, one of those brave few who are reliant on a medical student that they just met, trusting a naive gaze to monitor the fall of the scalpel's edge.
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