Back in McPherson

I am rounding out my third week back in McPherson, Kansas. This is the small Kansas town where I spent January of this year doing 4 weeks of my surgery rotation. During our 4th year of school, we are required to spend 4 weeks in a rural location for our "Rural Health Month." Knowing this would be a requirement, and knowing how great a time I had in McP earlier this year, I quickly asked to be reassigned to this quiet little town.
I have been with the surgeons again since I got here, but this time we have had quite a bit more action. We have had unscheduled surgeries on the past 14 of 18 days. This has meant being in the operating room well into the evening most nights, even well into the next day on a couple of occasions.
Of note, I got to see my first amputation. It was bloody and bony and physically demanding on everyone involved. My job was holding the thigh up while the surgeon cut off the leg below the knee.
There have, of course, been plenty of colonoscopies. We also had a run on appendicitis and and gallstones, getting to take out at least one of the two every day in the past week.
Yesterday I worked with an Ob-Gyn who comes to McPherson once a week. She was helping out a little old lady whose vagina had decided to fall out, bringing along the uterus and part of the bladder and rectum with it. It was to the point that she had to wear a catheter because she wasn't able to go pee. Since this little old lady was quite frail, it was thought she wouldn't be able to tolerate general anesthesia or a long procedure. So, the ob-gyn did something that is rarely done in the age of hysterectomies...she got an epidural. and then, after tucking everything back into place, the vagina got sewn shut.
This may sound like a great idea for some people...many of the nurses invovled in the case asked when they could have theirs done.
What I thought about, though, was that somewhere in the past, some poor woman had to be the first to endure this. And she probably did it with little in the way of sedation or analgesia.
In fact, when I thought about it, I realized that most surgeries are fairly barbaric, specifically gynecologic surgeries. And what is most frightening is that sometime, someone had to INVENT these procedures.
I have tried to rationalize that most of these things were probably first done on animals in barns and fields in order to meet the demands of necessity.
You have a cow and her vagina is falling out? Well, just stuff it back in there and sew the damn hole shut. Problem solved.
None of these rationalizations give me a great deal of peace, though. It just makes me really grateful to live in a time of really nice drugs that can make us fall asleep and other really nice drugs that can help take away pain.
My time with surgery is drawing to an end, though, for my last week I will be working with a family practice doctor. I don't think we'll sewing any holes shut in her office.

Exit Stage

A thought occurred to me today that I know has been hashed out by cultures, religions, and societies for thousands of years, but that for the first time really made sense on a practical level. Death is almost exactly like birth, but instead is the opposite.
This month on the oncology service has been among the most remarkable thus far. In a way, it has been so remarkable that I have had a difficult time remarking on it. I have seen how precariously life can hang in the balance, how fiercely it can be fought for, and how easily it can be let to fade away. All of the patients I have seen this month are sick. This sounds a bit silly, given that I have been seeing sick people for almost a year now, but this month the patients are sick. They do not simply have a sickness. They, in a sense, are their sickness, because cancer, no matter how valiantly it is fought, will, at a minimum, take over a life, and when fulminant will simply take the life.
The patients that we see range from those who are admitted for "routine" chemotherapy to those whose bodies are losing their last battle. For the most part, every patient we have seen has been nothing but wonderfully kind and thoughtful and a true joy to know. We don't just get to know the patients, we get to know their families, and we get to know their stories. This makes it all the more difficult when they leave the hospital, all of us knowing that they are going home to die. This event of dying is one that I have feared witnessing. Every doctor has their story of their first patient that died. It is just one of those touchstones along our path. I haven't yet made that part of my journey, but today I came very close.
We have a lovely older woman in her late 70s who has widely metastatic breast cancer, including metastases to her liver, lungs, and brain. She came to us having seizures and extreme shortness of breath. For the past two weeks, we have been working on getting her to a point of having her pain managed well enough for her to be able to leave the hospital. Her family has decided that she should receive only comfort care, and that we should not make attempts to resuscitate her or intubate her should her heart stop or should she stop breathing (doctor lingo: do not resuscitate, do not intubate, or DNR/DNI). She has made steady improvement, but there have been several setbacks along the way, including her becoming delirious and needing to be sedated because she was taking swings at every one who came into her room, and a run in with pneumonia. Over the last few days she has seemed to become a bit more coherent, but still confused, and plans were in the works for her to go home with her family on Friday.
This morning the other medical student on service with me commented that this patient seemed a bit more confused and lethargic. Later in the morning, our senior resident rushed into the resident room where we all do our work, asking, "Mrs. E is a DNR/DNI, right?"
"Yes," several of us said in unison.
"Okay. She's dying."
The three of us who were in the room jumped up from our chairs and walked across the hall, following our senior resident into the patient's room. Her nurse and the nurse's aide were with her. Her eyes were closed, she was breathing very rapidly, her heart rate was less than half the normal, and she was unresponsive to us, but seemed to be trying to utter something. The four of us who had just entered the room gathered around her bed, and watched.
The thought kept going through my head, "This is death. This is the last battle for her." It felt like some kind of out of body experience, just too surreal to actually be taking place in front of me, with all of us just standing around watching it happen. There were questions flying around the room about calling her daughters to let them know what was going on, paging our attending and updating him, running checks of her vital signs to see if this would somehow pass, theories about what might be happening other than simply death. At that point, the four of us all had a task to accomplish to make sure things went smoothly and that all the proper people were called.
We left the room, did our tasks, and by the time we got back, she seemed to be improving. Her breathing was slowing, but still irregular. Her heart rate was approaching normal, and her blood oxygen level had started to creep back up from the depths. Then she started whimpering, "It hurts. It hurts." Again, a flurry of activity. When was her last chest x-ray and what did it show? Could she have just had another seizure? Is this something that actually could be easily treated? So again, we left the room.
After a few more gatherings around the bed, we drifted back into our resident room, and waited. We soon realized that she had, indeed, faked us out, and that although her death would likely be soon, it was not imminent.
It all reminded me so much of the nights on the labor and delivery floor, the waiting, the checking, the watching, the progressing of labor and the failure to progress. The knowledge that a life changing event was about to take place, and that it could be neither hurried nor delayed. Life, it seems, comes and goes as it pleases despite our best efforts to command it.
In experiencing these moments, I have noticed the division beginning to develop within me. There is the side that must think, "What do I do now with my knowledge and my skills to help this person medically," and the side that thinks, "Given my lack of real knowledge or experience, what can I do to make up for my lack of skills?" This is the same side that wonders, "Do I pray now?" and "Do I try and say something soothing or calming."
Not exactly being a churchly person, ahem ahem, I find the idea of actually praying a bit awkward, but for some reason, I find myself hardly being able to keep myself from simply thinking, "God please help this person and help us help them." Not having ever been in the position of having my legs in stirrups with all my goods showing while a small human is ejected from my body, I have an equally hard time mustering up the courage to say something as ridiculous as, "Keep pushing." Or even being able to imagine the feeling of hearing that first cry, that first breath.
And, not having ever been in the process of dying, it seems grotesquely inadequate to try and think of anything at all to comfort someone who is about to breathe their last, or to their families watching the last breath be drawn.
In both of these moments, I feel so small.

Four More Weeks

after this week, i will have only four more weeks left of my third year of medical school.
i still do not know what i want to go into after all this is over, and i have really just stopped trying to figure it out.
as has now happened 6 times previous, i am finding that i unexpectedly enjoy this rotation. i had really convinced myself that i would hate everything about internal medicine, from the hours to the patient population to the subject matter. i kept thinking," this rotation is going to make me learn about all that stuff i hate, like the kidneys." when i shared this thought aloud, the reactions i got were along the lines of, "well, i hope a doctor would know something about the kidneys..."
um, true.
so, here i am, finally actually understanding material that has evaded me for so long. i am not sure if it is because i can think, "oh, mr. so and so has kidney failure, and this is what happened to him, let me read about it so i understand more." maybe it is because my brain just needs to read about kidney failure 28 times in three years to finally get it, in which case, i will be about 78 before i am able to understand every organ in the body.
the other thing i feel i need to share right now is actually an answer to a question that has recently been asked of me several times.
the question is, "have you been watching that new show 'grey's anatomy?'"
answer: no.
i was intitally intrigued by it, and i watched a short part of maybe the second episode. it had to do with some guy dying and the interns deciding to try and get his organs or something. what i remember most are things like, " we're doctors, aren't we supposed to save lives?" delivered with such emotion that i nearly gagged on the puke welling up in my throat.
i have been warned that any form of entertainment involoving the medical world would one day be ruined for, and i think it now finally is. the thought, "that could never actually happen," has gone through my head several times, each time annoying me because i do not want to be "that girl" who always says things like, "oh, that would never really happen because blah blah blah," thereby ruining the show or movie for all the other people who are just trying to be entertained. so, i have now started avoiding any medico-fiction-drama in order not to have to see myself as "that girl."
and, since i am married to an attorney who has a very difficult time watching any legal fiction-drama, and since 90% of television shows have something to do with medicine or law, we have no choice BUT to watch intellectually stimulating shows like "America's Next Top Model" and "Showdog Moms and Dads." i suppose the one exception to my rule is "dr. 90210," a show on E! that i fond very amusing because, unfortunately, it is a pretty accurate portrayal of the kinds of personalities that flock to surgery as a career.
thank you for excusing the lack of proper capitalization.

Two Months?

Has it really been two months since I have written anything for this. Yikes.
I do have a lovely set of excuses prepared, though...

1. Upon my return from McPherson, I was assigned to the neurosurgery service at KU Med. Although I enjoyed parts of it, the hours did begin to suck my will to live. Although I often thought about writing about seeing a skull sawed open, or drilling pieces of skull back together, it just never happened.
2. For some reason my computer stopped letting me log into my account, so I wasn't able to post anything even if I'd had the time to sit down and write it. Last night I did some computer wizardry, though, and ta-da, here I am again.
3. Now that I have had a bit of experience with the psychiatry, I have a label for the constant worrying and thinking and talking about what to do with my future. Perseverating. I have been spending all my free time perseverating about what the heck I am going to do for the next 30 years.

So, now that the excuses are all there, and now that I can access my account, and now that I am about to do a 4 week stint on the inpatient psych ward, I ought to have plenty to share. I think.

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.

Lessons Learned: Week Two

I have been trying to recall any of the itneresting or amusing things that took place last week, but, sadly, i have been drawing blanks. I am just going to start typing and see if it can dredge up anything worth while.
Much of the time in procedures last week was tied up with colonoscopy after colonoscopy. The doctor let me actually "run" it a couple of times, which involves holding the control device for the camera and light that are on the end of the tube that has been rammed up the butt. As we watch a television screen to see the inside of the colon, it is similar at times to a video game...a video game gone very wrong. There is one wheel on the control device for moving the camer up and down, and another for moving it left and right. Inevitably, when the doctor directed me to look up, I would look down, and when he would ask to look right, I would look left. Fortunately, he is possibly among the most relaxed and laid back surgeons in the world, and he has quite a bit of patience with me.
Another procedure I have gotten to see several times now is called "hemorrhoid stapling." It is designed to both treat hemorrhoids and also remove about 2 centimeters of the rectum. I am going to try and acquire a pciture of the device used to achive this, but for now imagine a miniature version of Apollo 13. It gets stuck into the blessed behind, and once a few stitches are placed, the device is fired, causing it to clamp down. this simultaneously removes the 2 cm of rectal tissue, while placing miniature staples to hole to newly created ends together. These staples remain there forever. No, I do not know if they set off metal detectors, but in my reading about the procedure, I have learned that the main cause for concern after the procedure is anal sex. Not for the recipient, but for the giver, as he is likely to feel the staples, and may suffer some scraping of his unit.
There was another interesting and disgusting run in with some veritably flying feces. One of the patients had taken the oral enema, but somehow managed to resist all urge to expel due to the severe pain he would expereince. So, when the doctor inserted the anoscope, all hell, literally, broke loose, as all of the fecal matter the guy had held in was subsequently released as a flood of shit. A flood of loose, watery, slimy shit.
What better closing image could there be?

Lessons Learned: Week One

It is now Saturday afternoon of my first week in McPherson. I am on call, so I find myself tied to staying here at the hospital, in case some dire emergency or large disaster necessitates my "assistance." Rather than reading any mroe about the colon, I decided to go ahead and reflect on the lessons I have learned so far.

Lesson One: Do Not Swallow Toothpicks
Tuesday morning brought an interesting case to the Emergency Room. A man was complaining of intense abdominal pain and fever since the night before. An emergency exploratory surgery was arranged, and the list of possible diagnoses was long. It could be appendicitis, diverticulitis, gall stones, and the list went on.
Shortly after opening up the fellow, it became clear that the problem was in his small intestine. This became clear as about half a toothpick was poking through the intestinal wall, into the gut cavity.
The surgeon removed about 5 inches of the small intestine around the toothpick, placed the segment on a tray, and we began to examine it. He made a lengthwise cut, and opened it up, to find the other half of the toothpick. It was perfectly intact, sticking there like some kind of strange cocktail weenie gone bad. There was much speculation as to how this could have happened. Did the guy know he had swallowed a toothpick and was just to embarassed to admit it, even under the threat of major invasive surgery? Had he fallen asleep with it in his mouth and just forgotten?
Turns out, when it was explained to him after the operation, the man was just as puzzled as every one else. He continues to claim that he doesn't even use toothpicks, and that he can't think of anything he might have eaten that could have possibly contained a toothpick. So, the mystery continues as he heals from his incision.

Lesson Two: Stand Clear the Line of Fire
Wednesday morning I got to see the first of what I know will be many colonoscopies. The colonoscopy is that treat that everyone is supposed to have at the age of 50...a 5 foot long hose stuck up your butt to examine the health of your colon.
At this hospital, they very kindly give patients IV sedatives, essentially knocking them out for the procedure.
In order to get a good look at the walls of the colon, the patients have to "prepare" the colon by only taking clear liquids the day before, and also ingesting certain drinks that essentially cause a lot of diarrhea. During the actual colonoscopy, something that I can really only decrsibe as a small hose with a camera on the end of it, is inserted into the anus and advanced the length of the colon. Since it is empty, the colon is kind of like an empty ballon, which we need to slightly inflate. This is done by blowing air from the end of the hose ahead of the camera's path. Needless to say, quite a bit of air get blown up their asses.
Usually after a colonoscopy, the patient is brought to a recovery area, and allowed to deflate.
This patient, though, was also set to have a hemorrhoid removal after the colonoscopy, which made it all the more interesting.
After the camera/hose was removed, the nursing staff got the patient into the proper position for the next procedure. This means having her lay face down on a bed, with pillows beneath her lower abdomen to prop up that part of the body we are again going to invade. The bed is then tilted so the head goes down, which means that the butt goes up. Everything except the patient's butt is covered with sheets and drapes, so there is, essentially, an ass flaoting in the middle of the room.
For our little old lady, this turned out to be the perfect position for deflation.
As soon as she was flipped over, she began expelling large quantities of air, to the effect of someone having sat on a whoopie cushion.
Now, I realize that at my age and with my planned profession, I should not find anything amusing or remotely interesting about farts. Fortunately, I was wearing a surgical mask, so my facial expressions were mostly disguised. Soon, though, even the nursing staff could not hold it together, and we all giggled a bit at the next 30 second expulsion of air.
It was all fun and games until more than air began flying out of the butt. Soon enough, bits of lovely, watery stool began flying with enough propulsion to send them 6 feet from their exit. Everyone was a bit taken aback.
Except, it seems, me. Despite the "warning shots" that were sent in my direction, I did not take it upon myself to move even slightly to the left or right, and at the next expulsion, found it difficult to dodge the barrage headed my way. Despite my efforts, I was hit.
It was a small hit, and it only landed on the outside of my scrub top. It was a hit nonetheless. I was totally grossed out, wondering how I was going to remove the top, which can only come off by being pulled over the head, without getting any of the "material" onto any other parts of my body. Somehow, I managed to squirm out of it though.
I am happy to say that roughly 7 showers with lots of soap later, I am feeling almost clean again.

Hmmm. I thought I had more lessons to share, but my mind has suddenly gone blank.
So, I am going to have to leave everyone with these tales to ponder for a few days while I try to learn a few more lessons and come up with a few more interesting tales.