September 19, 2009

"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."