Wednesday, January 26, 2005

Privilege

A mantra that I have heard over and over again these last three years has been to always remember the privilege it is to be a physician because of the role you will play in people's lives, and to never take it for granted.
I had seen glimpses of the true meaning of this over the past years, particularly in the past eight months. I have been present at the births of babies, mine being the first hands to ever hold them as they enter the world. I have had patient's tell me things that they have never dared tell another human being, placing trust in me despite only knowing for a few minutes. I have looked into orifices, I have dealt with secretions, I have breathed in odors.
In the past week, though, this idea of privilege has become truly ingrained, and as I spend my last few days here in McPherson, I am feeling a new weight.
This entry is a compilation of several stories, so it is pretty long.

Mrs. S
Last Friday, we took one of our patients to the operating room to perform what is know as a split-thickness skin graft. This patient is dying of metastatic colon cancer. The doctor I am working with said that when he first met her, he would have given her six months to live, and that was nearly three years ago. She is married to a real cowboy: a man who gets on a horse and drives cattle across the range. She has had rheumatoid arthritis for several years, which has twisted nearly every joint in her body to a form that looks barely usable. She has managed to continue her life as a cowboy's wife, though, raising a garden, canning vegetables and fruits, baking pies, tending to children. In December, her husband noticed a small sore on her ankle, at a spot where a shoe or boot rubbed against her skin. Quickly, what began as a pindot progressed to a 3 inch round ulceration, clear through to the tendons and bone beneath her skin.
She was admitted to the hospital for management of this ghastly wound the first week I was here. We were attempting to get the wound to heal with aid from various bandages, ointments, cleansings, and the like, even as the cancer in her body sequesters every nuttient for its own deadly growth.
Last week, it became clear that this wound was not going to heal on its own, and she and her family have realized that what remaining functional time she has left should not be spent in the hospital nursing a leg wound.
Fortunately, we have been able to encourage a certain amount of recovery in the would, enough to creat a bed of blood and soft tissue that could support a skin graft. So, Monday, we took her to the operating room for the procedure. It involved using what I can only describe as the world's most high tech cheese slicer to slice a millimeters thin section of skin from the front of her thigh to be transplanted and sewn into place over the wound on her ankle.
Since the procedure, she cannot stop talking about how much better she feels, how much better she is sleeping, and how much she is looking forward to going home again. What has touched me most, though, is the way she has welcomed me into the circle of her care. She has learned my name. She greets me every time I see her, and thanks me every time I leave her room. I am touched to my core that in the limited time she has left, she has allowed me into her life and treats me as someone she cares about seeing.

KP
Last Thursday we were asked to see a patient about a 1 or 2 inch mass growing on his outer thigh. This man admitted himself to the hospital for alcohol detox, and his doctor thought it might make sense to have this mass taken care of while he was here drying out.
On Friday, after we were relatively certain he had reached a steady level of sobriety, we had KP come over the clinic, which is a part of the hospital, se we could remove the mass and send it for biopsy.
For most people, the weird lumps and bumps we feel floating beneath our skin are about as dangerous as a tulip. There are some oddly occuring cancers, though, that can show up as just another odd lump that just keeps growing.
The doctor told me that I would be doing most of the work of this procedure, and that he would be talking and guiding me through it. I was extremely excited, as anyone who knows how much I love to extract ingrowns hairs can certainly imagine.
We has him lay down on his side, and once the area was nicely numbed, I proceeded to cut into his flesh until the skin opened enough and the nature of the mass revealed itself. It was gray or blue, enclosed in layers of clear, tough fascia. It sat just atop his muscle, and took anly a few minutes to fully remove. Even with my limited experience, I could tell it wasn't going to be one of those innocent little lumps. It had a sinister look to it, but I kept the thought to myself and only later asked the docotr what he thought it might be. "I think it's a sarcoma," he said.
Sarcoma is a nasty kind of cancer that likes to invade and proliferate and use a body like its personal playground. Treatment can sometimes require amputation of the entire limb.
When the pathology report was faxed to us on Monday, it confirmed that this was, indeed, a sarcoma.
The problem for KP is more than just this sarcoma, though. KP is homeless. KP is an alcoholic. KP has no phone number, no address. KP has no medical insurance.
When closing his incision, we purposely used non-absorbable sutures so that he would have to return to the office to have them removed, so we knew we would be seeing him again (unless he decided to remove them himself). This way, the doctor knew he would be able to let him know the results of the biopsy, and try to make some kind of plans for KP to receive treatment.
Sarcomas are difficult and costly to treat. In general, there will be one oncologic orthopedic surgeon in a multiple state are who specializes in the treatment of these kinds of cancers. For KP, this will Dr. Kim Templeton at KU Medical Center in Kansas City, an amazing physician whom I have gotten to know and whom I deeply admire.
Today, KP showed up to clinic. It wasn't time to take his sutures out yet, and he didn't have an appointment, but the doctor knew this may be a key moment in KP's treatment.
Until today, I have never witnessed anyone being told that they have cancer. I have never observed the way the news seems to travel like a wave from the doctor's mouth, to the patient's ears; the way it takes time for the wave to settle into the mind and be understood; the way it eventually runs down to the heart, and then as tears from the eyes.
He heard the news, but it took several minutes for it to really be felt, and then his soulders began to shudder, his hands went to his face, and he cried.
To think of dealing with a deadly disease is one thing, but to consider the obstacles KP faces in getting the treatment he needs to, very literally, save his life, almost seems to much to face.

Mr. E
On Friday, an 82 year old gentlemen came to the ER by ambulance because he could hardly breathe and was having terrible chest pain. This had been going on for over 24 hours, and Mr. E though he would be able to tough it out, but finally let his wife call the ambulance.
He was suffering from a partial collapse of the right lung, because he had essentially blown a hole in the bottom of the lung, allowing air to leak out into the space between his lung and his ribcage, which then compressed that lung to only half its normal size.
You'd have a hard time, breathing, too.
So, the doctor placed a very small tube between two of the ribs, into this now air-filled space, to get the air out and allow the lung to re expand. We admitted the patient to the hospital to make sure recovered okay and that the air leak in the lung healed. This meant that I was going to see him at least two or three times a day, and it somehow happens that everytime I go see him, he has just started a meal. It has become a bit of a joke with us, and the two of us have hit it off quite well.
Over the weekend and beginning of the week, it was starting to look as if the tube we placed in the chest just wasn't doing the job of sucking all that leaked air out, and this morning it was decided that we would put in a bigger tube with more suction power.
Obviously, this can be very painful (imagine sticking a garden hose between two ribs), so we were going to give him some sedation so he could fall asleep and not have to be aware of what was going on.
Once he was snoring away and in the right position, the doctor directed me to a site and told me to make a half-inch incision. He then had me pick up an instrument that I would insert into the incision, and use to begin separating the muscle tissue beneath it. I was essentially making a tunnel through the muscle between the ribs to gain access to the lung cavity. I would insert the instrument with its prings together, and then open it like a scissors, stretching and prying apart muscle fibers as it opened. I did this for several minutes, with the doctor assuring me that I was making progress. I inserted the instrument as I had before, prying it open with all my hand's might, when I suddenly felt a total loss of resistance and a gush of air. I nearly jumped onto the ceiling, thiking I had done something gravely wrong. "Oh my God!" I yelled, my eyes three times their normal size and my heart skipping a beat. I thought for certain this was a huge mistake and that it would lead to his death. "You're okay," the doctor said, "You did exactly what you need to do."
"Holy crap," was all I could say, and everyone started laughing.
"Now put your finger in and feel the space, you can even feel the lung," the doctor instructed.
I took my finger and placed in the tunnel I had created, which was still whistling like a punctured balloon. I out my finger in a little farther, and then, sliding over my fingertip, was his actual, breathing lung. With each breath, it slid smoothly over my glove, up and down, up and down.
I looked at the doctor again and uttered, "Oh my God! That is too awesome."
Once I collected myself, we finished up by inserting the tube into the cavity, allowing it to suck out the leaking air, placed a few sutures to keep it stable, and added lots of gauzed and tape to keep it secure.
All I could think was "I touched his lung." When we went to see him this evening for rounds, I wanted to say, "Guess what, Mr. E, I touched your lung today!"
Instead, when we went to see him, and he was, of course, just starting to eat his dinner, he asked if he could change from his "sexy hospital gown," into his own pajamas.











1 comment:

fiat124girl said...

Emily,

Your writing is amazing. I am so proud of you and of what you are doing.

Keep up the good work! You are going to make a great doctor.

Jennifer

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