“Steeling Their Courage”

This made me cry a little… and then giggle a lot, when I looked out of a window the other day and spotted Sponge Bob the Construction Crane. I hope that will be true of my future career in pediatrics: a little crying, a lot of giggling, and a very warmed heart.

And check out this insightful take on it from Joe Wright’s Hemodynamics.

 

Medical School, Season Three

I’m happy to announce the publication of my second column for the March 6 issue of Focus newsletter.  Something much more lighthearted than my previous one…  Enjoy!

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“Medical School, Season Three”

Focus

by Miya Bernson

Looking back over my 10 months of third-year clerkships, one pattern emerges. No matter whether I’m flopping on the couch exhausted at the end of a long day, entertaining myself while on the elliptical machine, or trying to get my mind off the frustrating or sometimes heartbreaking experiences I’ve had in the hospital, I do the same thing. I watch medical television shows.

It struck me as odd when I first realized that this had become one of my main uses for the limited time I have outside the hospital. I joked about it with my fellow third-years: there must be some weird psychological explanation for my obsession with Chicago Hope, a mid-1990s drama about surgeons, while I was struggling through the harder parts of my surgery clerkship. After I finished the first season of Chicago Hope, as well as the clerkship, I moved on to my medicine clerkship and the 1994 season of ER. I have seen every episode from all eight seasons of Scrubs, though I quit House M.D. at the end of the fourth season. I can’t say that I have gotten turned on to Grey’s Anatomy yet … but I do still have a few months left in my third year.

What is it about these shows that captivates me? Why do I turn to them even when, one would think, I would want an escape from the hospital and the notoriously all-consuming third-year clerkships?

Certainly, the explanation for the popularity of so many medical shows is that, even (or especially) for the general public, the field of medicine offers situations and relationships that are inherently fascinating. Watching the complicated unveiling of rare syndromes by the masterful diagnostician Dr. Gregory House, the title character of House M.D., has all the addictive qualities of a good Sherlock Holmes story—with reason, since author and physician Sir Arthur Conan Doyle’s works greatly inspire House and were themselves based upon the logic of Conan Doyle’s esteemed colleague Dr. Joseph Bell.

But House lost much of its appeal to me after the first few seasons as the medical conditions became increasingly far-fetched. This happened to coincide with my first two years of medical school; my growing factual knowledge from classes and boards preparation allowed me to recognize House’s medical fallacies as well as its flagrant violations of the diagnostic dictum “when you hear hoofbeats, think horses, not zebras.”

The answer to the question of why my love for House has waned as my love for other medical TV shows has grown is that in the latter, I see truth—truth both personal and professional, which have never before in my life been so intertwined.

As the technically skilled, if emotionally troubled, surgeons on Chicago Hope saved life after life in the span of the swing of an operating room door, I recognized in their successes the fundamental attitude of the surgeons I met during my clerkship: this patient is broken, but we can fix him. And they often do.

ER third-year medical student John Carter’s struggles to balance humanism and clinical efficiency all while pleasing his resident are clearly based on the experiences of another Harvard medical student: the recently deceased Michael Crichton, the show’s prolific creator. His character struck a chord with me during the beginning of my medicine clerkship, as I fumbled to find my role on the team, learn the computer system, memorize antibiotics, present cases clearly but efficiently, and reconcile my idealism with the fact that I rarely got to spend more than 15 minutes a day with each patient.

Even Scrubs to me reflects fundamental realities, despite careening as it does between absurd doctor–patient interactions, soap-opera-worthy romantic entanglements, and even main character Dr. John Dorian’s fantasies about all-staff sing-alongs or curing patients with boxes of kittens. Scrubs’ frenetic pace reflects the fragmented and unpredictable nature of the hospital, where in one room a person is dying while in the next a person is being born, and some patients make miraculous recoveries while others unexpectedly spiral downward.

As for Dr. Dorian’s lapses into fantastical re-imaginings of the situations he confronts, perhaps they reflect the same underlying impulse as my own escape into the imaginative world of medical TV shows. Just as much as they are an escape from the current pressures and hardships of hospital life, they are also ways of making some kind of sense out of the experiences of physicians and physicians-in-training, acknowledging the drama and finding the humor in what we do, in order to return the next morning, ready for another day in the hospital.

 

R.I.P. H.M.

This beautifully written article in the New York Times reports the death this Tuesday of Henry Molaison, a.k.a. H.M., the most famous and influential neurological research subject of recent decades of neuroscience – the Phineas Gage of the 20th century.  I won’t repeat their synopsis of his contributions to the understanding of the science of memory, one of the most inherently fascinating domains of neuroscience.

I do want to point out that H.M.’s life was another example of the uncomfortable truth that sometimes what is worst for patients is what is best for the intellectual endeavors of scientists and physicians.  I hope to write more about this in the future, because it is something that I have seen repeatedly this year, particularly in my very defined role as a student, constantly learning from every patient interaction and every view into the workings of the medical system.  I recently met a young patient with HIV since birth, now uncontrolled (and definable as AIDS) since she refused to take her medicines, who came to us with a lump under her skin that had become painful.  The biopsy results aren’t back yet, but it is almost certainly cancerous.  It was an incredibly tragic situation.  But the flurry of medical activity that sprung up around her was medicine, and education, at its best.  She was supervised by the Adolescent Medicine service, but was well known to the Infectious Disease/Immunocompromised team.  They consulted (personally making attending-to-attending phone calls) to Oncology, Radiology, and Surgery.  In the midst of it all, Psychiatry was trying to make some headway with the girl’s refusal to take her medications and the fear around the biopsy.  All of these teams–each with its attending, a fellow or two, and sometimes another resident or NP–were swirling in and out of our already cramped conference room, where I could listen first hand as they discussed what to do.  I followed them into her room several times to hear how they said what they had to say.  And I was trying my best to help facilitate the interactions of all of these different teams and participate in this exemplary interdisciplinary medical effort.  It was a situation that was painful and terrifying for the patient, and educational and exhilarating for me as a medical student.  The positive view is that she is definitely in good hands, but that doesn’t stop me from feeling uncomfortable that, again and again, whether it is the thrill of making a new diagnosis or the joy of seeing different providers come together to care for particularly complex cases, the events and experiences that are best for me and the medical system may be the worst for the patient.

 

Confronting Pain

Returning from a blogging hiatus with a special announcement: I’m published!

My first piece appeared in the Student Scene column of the November 3 issue of WebWeekly, an online newsletter for the Harvard Medical School community.  The same piece was published in the online and print editions of the November 7 issue of Focus, a newsletter for the Medical, Dental, and Public Health schools, in their Forum section.  I will be writing for both semi-regularly, and I will announce here when my pieces appear.  I am excited and grateful to have this chance for my writing to reach a wider audience and hope this is the first of many such opportunities.

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“Confronting Pain”

WebWeekly and Focus

by Miya Bernson

“I feel my world shrinking, and it terrifies me,” she said. She used to be an athlete and yoga practitioner. Now she was one more patient in the Pain Clinic hoping for an explanation and a cure. As we talked, I felt I was standing on both sides of the divide between patient and doctor. Pain is a universal human experience, and I could easily “feel her pain” as her limitations increased. However, she had come to me and to this clinic for treatment, not just for empathy. And that was not so easy.

In the first year of medical school, we learn how to talk about the symptom of pain, what the patient experiences. Where is it? When did it start? What makes it better or worse? This focus on the patient’s perspective in the Patient–Doctor I course leads to a compassionate but theoretical understanding of pain. We ask them, “On a scale of zero (no pain) to 10 (worst pain imaginable), how would you rate yours?” The answer may say more about the patient than the pain.
In the second year of medical school, we become more objective. Rather than talking about the symptom of pain, we observe the sign of “tenderness,” an experimental variable we can elicit. As we learn the physical exam in Patient–Doctor II, we report that a particular part of the body demonstrates “tenderness to palpation”—that is to say, it hurts when poked.

We learn ways to produce certain kinds of tenderness that are essential to making a diagnosis. We are told to not-so-accidentally bump into the bed to jostle an irritated abdomen and produce the typical signs of peritonitis. This condition can also cause rebound tenderness, a painful sensation when the abdomen bounces back suddenly after being compressed. The classic way to test for it without the patient suspecting is to listen with the stethoscope for bowel sounds, gradually indenting more and more, then suddenly letting go and watching for the patient to wince. Such maneuvers are meant to be clinical, not cruel. But we still apologize for them.

As second-years, we also learn about the Waddell signs, controversial tests and criteria intended to ferret out pain with a psychological cause, conscious or otherwise. These include complaints of pain that do not make anatomical sense, or tenderness that occurs in response to nonpainful stimuli and disappears when the patient is distracted. While our instructors have shied away from teaching us that positive Waddell signs necessarily mean a patient is malingering, discussing them reinforced how problematic pain can be for medical providers. Whose pain is “real,” and does it have to be real for us to treat it?

Now I am five months out of the classroom and into my third year of medical school, and it seems every patient I meet has pain. The humanism and pathophysiology of the first two years have given way to this year’s emphasis on management and treatment, and nowhere else is this transition more apparent than in dealing with pain.

My first-year training in empathizing with patients prepared me to recognize the constant anxiety that gripped the young man with raging ulcerative colitis, and connect it to his apprehension before the colonoscopy that would finally decide whether he would have his colon removed. He had made it through several colonoscopies before without much discomfort, but during this one not even the maximum doses of painkillers and sedatives, much less anything I had to offer, could keep him from crying out in pain and fear.

My second-year pharmacology class helped me understand why the drug addict writhing in his bed complaining of back pain had developed a tolerance to opioid pain medications, so that even massive doses would feed his addiction but not relieve his suffering. But no class taught me how to help someone like him. He had violated his “pain contract” with the outpatient pain clinic by seeking drugs from more than one doctor, so he was no longer welcome there.

As a third-year, I have had many opportunities to hone my skills of interviewing and examining, but for me to advance to the next level of medical training, I will also have to act: to give treatment. Medicine’s capacity to manage pain or any medical condition is imperfect, and the stakes are high. My responsibility now is to master the use of medications from ibuprofen to morphine, and to use them judiciously, balancing skepticism with sympathy as I assess the patients’ pain and attain the physician’s power to relieve it.

—Miya Bernson is a third-year medical student at HMS.

 

Medicine: Portraits

Having trouble even knowing where to begin writing about my experiences with inpatient medicine. Despite knowing how sick you have to be to get admitted to an American hospital in 2008, I was not prepared for the pain I have witnessed. Every patient seems to have so many problems: an acute exacerbation of their emphysema or heart failure on top of their underlying diabetes and vascular disease and drug abuse compounded by a history of heart attack, stroke, and cancer. Either that, or they only have one, but it’s the one that is enough. And I don’t know how to process the experiences I have had even in the span of a week, especially now that I have been able to take somewhat more responsibility for admitting “my own” patients.

One patient, a known drug abuser, writhed in pain in his bed. He was begging for pain medication, but little could be done: so much drug use had dulled his responsiveness to opioids. And he had broken his “pain contract” with the outpatient pain clinic by seeking pain medications from more than one doctor, so he was no longer welcome there.

Down the hall, a man on the cusp between middle and old age sat reading a mystery novel while an IV delivered fluids into his arm to treat his dehydration. “I was in the hospital when my ‘friend’ died,” he said, slightly accenting the word, “and I guess I just stopped taking care of myself after that. We were together for almost forty years.”

One of my patients was a diagnostic challenge from the minute she came in from her nursing home for nausea and vomiting. She was sweetly demented, so she couldn’t say much about what had been going on, and she would tell different members of my team that it hurt at different times in different places. We kept getting excited every time we thought she had a new disease to add to her extensive medical history, hoping she was sick: if those really were enlarged ventricles on the CT scan of her brain and she had normal-pressure hydrocephalus, it meant we could do something for her. Otherwise, she was condemned to her dementia. She sat on a board of trustees only eight months ago, her brother said, and my eyes burned. We still don’t know how to treat her urinary tract infection.

The same patient left me kicking myself when the neurology team gave her the diagnosis of not normal-pressure hydrocephalus, but Parkinson’s disease, a long-standing interest of mine. How could I have missed the tremor in her hands, the rigidity of her limbs, and the classic expressionless face? Easily: I was fitting her symptoms to the diagnosis (NPH), not the other way around, and I never stopped to ask myself the question “what else could this be?” We started her on Sinemet to replace the dopamine her brain has run out of, and I know it’s probably all in my head, but I could swear that overnight she became more animated. Her eyes met mine when I said goodnight to her today, and I realized it was the first time she had smiled at me.

The hardest patient was a middle-aged man with end-stage liver failure and untreated AIDS. His body looked alien, humanoid but not like any other human body I had ever seen. His belly was enormous, perfectly round and stretched with ascites, the fluid seeping into his abdomen because it could not pass through his cirrhotic liver. His arms by contrast were stick-thin, all the muscle melted away. His legs were puffy with fluid, soft swelling over sticks. And his head was so shrunken and wasted I could hardly believe it could contain his skull. He looked out at us through wet brown eyes in an emotionless face, tense and quiet like a scared animal. His breathing became unstable this afternoon and he was moved to the ICU, sedated, and put on a ventilator. I guiltily felt a little better once he was sedated because he didn’t seem quite as much like a conscious soul trapped in a distorted body.

My last patient today was a middle-aged man with metastatic cancer. His cancer was originally diagnosed in another country a year ago. They gave him symptomatic treatment, and he felt better, so he thought he was better. This week he started having pain again, and his CT scan showed the mass had spread to three other organs. It was Stage 4 of 4, inoperable. Not years but months. His son grasped desperately at other explanations – it was an infection, it couldn’t be cancer because his father didn’t look sick enough. He asked me in his own words to help him understand the biology of cancer, seeking answers in mutated DNA bases and cells that lose the ability to stop spreading, eating through walls into other organs. On the first day we thought the patient spoke only Portuguese, so we relied on his adult children and the interpreter. On the second day I found out he speaks some Spanish, and from then on our communication has flowed through a wide-open channel, mixing our “fazers” and our “hacers” and cracking jokes and crying. It wasn’t the first time this year I have been so grateful for my Spanish. Exhausted from having no days off for two weeks, being on-call last night till midnight, finishing my work at home, and then coming in at 6:15 this morning and staying until 8, I still went in to say goodnight to him after I dropped off my note in his chart. And time slowed down for a while as I sat on the edge of his bed and we talked softly. He still feels shocked, and shakes his head at what he understands about what he is facing, but his voice was full of peace. In half-Spanish, half-Portuguese he spoke with deep gratitude of the love and compassion and professionalism he has experienced during his hospitalization. I wound up leaving at the end of this whirlwind day feeling that he had blessed me and my work, and I was uplifted, even though he was so far the patient I have seen who has gone most dramatically from health to illness. Obrigado, senhor.

 

New Year’s (New Clerkship’s) Resolutions

I have now finished my three-month surgery clerkship, and I start medicine tomorrow, meaning I am a quarter of the way through my third year of medical school. I’m not sure I like that idea. I don’t feel a quarter of the way towards being as smart, wise, skilled, or experienced as I hope I am by the end of my third year. Not that there is necessarily a way to gauge the intangible elements, although there is a log students keep of the more tangible elements (see below). It’s hard to tell how much progress I’m making since so many things still feel so new, though it has been fascinating realizing from conversations with my fiancé (also a third-year med student, though he started in July rather than May so I had a two month head start) how much I changed in those first two months at least in terms of language, and perhaps understanding or at least wards-savvy. We’ll see how I feel when I’m on the medicine floors and am hopefully more “in my element”, surgery being a very foreign though welcome experience for me. I hope to have time to reflect on those three months more here on this blog. Anyway, I’m going into my medicine clerkship with an overall feeling of having a lot to learn, both about diseases and about how to be a someday-doctor.

A few mid-year New Year’s resolutions for this transition point:

1) Stay organized and on top of my schedule, no matter what. In my last week on surgery I missed a required class because I both lost track of time and failed to remember that the class was meeting that day rather than its normal time slot. Not a big problem this time around, but in order for me to meet the professionalism standards of medicine, it can never happen again. This is a post for another day, but for better and for worse perfection is the expectation in medicine, at least as far as definable errors go. As fuzzy as my brain can be particularly if I’m low on sleep or busy and disoriented on the wards, I can’t miss appointments with patients, faculty, or my classmates who are now truly colleagues. Fortunately, hope has arrived in the form of my new PDA-and-favorite-toy, an iPod Touch. I wanted something that could handle email, calendar, and contacts with the ease of a traditional PDA, run at least the essential medical software (Epocrates), and also replace my worn-out iPod as a source of entertainment for the walk to the hospital or while at the gym (see below). So far I’m very, very satisfied with my somewhat unconventional choice of a PDA (with thanks to my fiancé, who made the same decision and also helped me realize that it’s exactly what I was looking for). Mine has been dubbed Penny, both short for James Bond’s tireless assistant Moneypenny and named for the behind-the-scenes hero Penny of the Inspector Gadget cartoons. She uses a special computer-book to get instant information and make Gadget’s otherwise hapless schemes possible. So that’s goal number one: obtain and use the information I need to stay on top of things.

2) Get healthy. Seriously. While I try to stay healthy in terms of eating right (but note: chocolate is always right), getting a decent amount of sleep, and keeping stress in check, I have never ever been good about physical activity, and it’s becoming ever more hypocritical of me to be in medicine and not participate in one of the most well-established ways of promoting health and preventing disease. So I joined a gym, and I’m posting about it here so the world is a witness to my goal of working out regularly. I’m excited about the gym’s many group classes, especially yoga, and Penny will help keep me entertained on the elliptical. I don’t expect to ever run a marathon or bench press more than… (you don’t want to know what I can do now) but at least I hope I can be one of those doctors who can empathize with the difficulty patients have in getting enough exercise, but also show them that it’s possible to make positive changes.

3) Reflect every day. I’d like to think that I’m pretty good at reflection in terms of it coming easily to me when I take the time, especially when I sit down to write here or in other forums and the words flow for hours. But I think it would help me grow more as a doctor in both knowledge and empathy if I took a little time more often. While I was on surgery, I felt like all I had the mental capacity for at the end of the day was to come home and flop down on the couch and watch Chicago Hope reruns. (Note: Chicago Hope is a TV show about surgeons. There has to be some interesting psychological observation in there somewhere that I unwound from a day of surgery by watching a surgery show.) But I think I was letting myself off too easy, and I think it would have been better for me if I had taken a couple of minutes to just go back over the cases of the day and what I learned from them, in terms of both hard facts and professional development. We were given two pocket-size booklets at the beginning of our third year to keep track of patients we see, tasks and procedures we do (I finally did a successful intubation! Heck yeah!), and topics we cover. And I have been terrible at keeping up in them. I hope my course directors aren’t reading this – but if they are, I am hereby promising to be better in the future. I think it will be a useful exercise for me to sit down with those books at the end of every day and update them, not just as a record the way the books were assigned, but as a jumping off point to fix in my mind the patients I saw and the topics I learned about.

I know this post wasn’t in my usual reflective vein, and there is so, so much more I could and should say about my experiences so far, and my three goals are neither original nor particularly interesting to anyone but me. But at least they were rooted in reflection and recognition of a few of the many things I have to work on, and if you can’t come clean to your own blog (and its handful of readers), then who can you come clean to? So I’m crossing my fingers as I enter another clerkship, and especially medicine, that I will have come a long way by the end of these next three months.

 

I Don’t Know

“Ms. A.” died recently. She was the first patient that I helped care for to die.

When she first came in as a “stat trauma,” after being run over by a truck, she was a nearly ninety-year-old lady in terrible pain, but I thought she was lucky. She had no damage to her internal organs or to her brain and spinal cord. Her leg was broken, and she had some other bruises, but that seemed to be it. As I helped the trauma team in whatever small ways I could, mainly by trying to stay out of the way of people who could actually do anything for her, I saw something glitter on the floor. It was a gold brooch with a purple stone – I remember thinking that when this was all over, she would be sad to lose it, and I put it on the table with her other things. She was wearing heavy gold earrings, gold necklaces, and a gold ring with turquoise blue stones. She was at the age that wearing all that jewelry looked natural rather than gaudy – a lifetime of accumulated precious mementos.

Ms. A. was from one of the ethnic groups that have immigrated in large numbers to Boston, forming their own tight-knit communities, and she spoke very little English. Once the shock of the trauma was over and her leg had been fixed, she lay in her hospital bed moaning in pain, both the pain of her injuries and the pain of not being able to tell anyone about it. I tried to communicate with her through gestures and the few words she knew, and she would point to her right thigh, but eventually she just responded to my questions by shaking her head despondently and repeating “I don’t know, I don’t know.” I sat with her for a while, waiting for the interpreter, but eventually had to move on to other patients.

What I didn’t realize then was that the extent of the injuries to her legs made them unable to heal, and the tissue began to die. The only hope of saving her life was an above-the-knee amputation. Even that had a poor chance of survival, but the surgeons said they had done it successfully in much sicker patients. She would never walk again, but she would be alive. But before her leg surgery, even before she realized the choice she was truly making, she had managed to communicate to someone that “I would rather die than have an amputation.”

The family chose to respect her wishes, and made her status CMO – “comfort measures only.” We stopped giving antibiotics and all the other interventions modern hospitals are capable of. Once she was CMO but still alive, we stopped copying down her vital signs and fluid intake/output for our team rounds, leaving a big blank space on our daily worksheets. We avoided her room when we rounded on patients. Surely no one chooses to come face to face with the dying process when they don’t have to, and there was little left that we could do for her. But more than that, I think Ms. A’s decision flew in the face of what I’ve perceived in the weeks of my rotation as the ethos of surgery: we’re here because if someone has a problem we can fix it. Even more than other fields of medicine, surgical solutions have a component of immediacy and satisfaction. Once the decision is made to send someone to the OR, there is a life-saving change within a matter of hours or even minutes. The cancer in the colon is gone, taken out with that section of the colon. The terrible heartburn is fixed with an ingenious re-structuring of the stomach and lower esophagus. The fetus in distress becomes a baby with a chance, after a c-section has slipped it out of its mother. I can see the appeal. And when our team was talking about Ms. A, the members of my team acknowledged the odds and the tough recovery she would face, but kept emphasizing “we’ve saved people who are much sicker.” With the potential for a solution within reach, made possible by technically skilled surgeons and rehabilitation medicine, in some ways it was a slap in the face to not even be allowed to try. We accepted the family’s decision of course, but it was hard to each day walk by the room where an old lady was slipping more and more into the oblivion of morphine.

I wasn’t there, but I’m sure she passed peacefully, the drug taking away her hunger for air as it took away the pain. The intern and I were called to pronounce her. She was the first person in the hospital I had interacted with in life and then seen in death. As he felt for the carotid pulse in her neck, the last of the pulses to disappear, I held her wrist and felt for the radial pulse. The carotid pulse was gone, so it would have been impossible for the radial to remain. But I swear I felt a heartbeat, and I think it was my own, the blood pulsating in the tiny capillaries of my living fingertips as they rested against her dead skin.

What do I think and feel about the first death I have witnessed in the hospital? The answer is: I don’t know. It is not yet a language I speak, or a culture I am versed in. I wonder with the surgeons whether anything should have been done, whether more life would have ultimately been worth it for her, even without a leg. I grieve with the family that such a senseless accident that initially seemed survivable would lead to her death. And with the necessary practicality of hospital medicine, I pause for a moment by her bedside to say goodbye to the woman with the pain and the frustration and the gold jewelry, and then I move on to tend to the living.

 

Body Parts and Healing

Just got back from the Boston Ballet performance of “Three Masterpieces”, a trio of pieces by major choreographers that definitely stretched my ballet-experience boundaries, ultimately in a good way. The third piece, Twyla Tharp’s “In the Upper Room”, was a blur of bending arms and legs set to a frenetic Philip Glass score. It highlighted the dancers’ youth and athleticism, and easily earned a standing ovation. The costumes were all black/white or red, and often the female dancers’ feet were highlighted with red so they stood out as they moved through the tangling choreography. The second piece was set to Mahler’s Kindertotenlieder, Songs on the Death of Children, and was as subdued and brooding as the third piece was energetic. The program had the translations of the songs, but the arms of mothers and fathers clasped in prayer or outstretched in supplication needed no translation.

Somehow the two pieces are whirling together in my mind along with the milagros I became fascinated with on my recent trip to New Mexico – the examples below are from an old church in Santa Fe. Milagros are small metal representations of body parts that are placed in the church to ask for healing of a related ailment – a leg for a broken leg, lungs for pneumonia, and so on – and an exhibit case at the International Folk Art Museum in Santa Fe showed examples of similar objects from all over the world. In Santa Fe I also saw an exhibit of related objects, ex-votos, plaques giving thanks for the fulfillment of a prayer or request. Many of them thanked God for the healing of a child’s illness. And in between this weekend’s ballet and my vacation to Santa Fe, I started a rotation in pediatric surgery. I helped cut open a three-year-old child. His parents brought him to us for us to make him better, knowing how we would do it, and instead of “doing no harm” we earned their gratitude. I haven’t yet made sense of this intermingling in my mind of high art and folk art, art and medicine, healthy bodies and sick bodies, the metaphysics of prayer and the physics of surgery… At this point in my education as a medical practitioner, a humanistic doctor, and a human being, I’m just trying to be open to witnessing all the ways I see people make sense of body parts and healing.

 

Angry

In all of medicine, but I think especially in surgery, there is an interesting phenomenon in which individual body parts get anthropomorphized. I have especially heard organs or regions of interest described as “angry,” and it’s often an apt description: red, raw, hot, spreading, distorted, bloody, pulsating, chaotic.

One thing that has struck me on pediatric surgery already is the ability of the surgeons to zoom in and out so readily: to one moment be interacting with the patient’s family, then the next be zeroed in on tiny structures under magnifiers in the OR, without either level of focus interfering with the other. In surgery today the image of the frightened preteen girl faded away as her body stilled under the anesthesia, she was covered with layers and layers of encroaching drapes, and they entered down into her abdomen as if through a rabbit hole. As soon as they pushed aside the rectus abdominis muscles, the entire field was tumor.

And it was angry. One of the transformations that a line of cells undergoes as it turns malignant is the ability to form new blood vessels, angiogenesis. But like everything else tumor cells do, it grows them without organization or control. The smooth surface of the tumor was streaked with dark red vessels winding tortuously across it, big fat vessels stolen from the ovarian blood supply and engorged on the blood vessel equivalent of bodybuilders’ steroids. It looked like the swollen body of a tick after a blood meal, and maybe the simile is an appropriate description of how the tumor feeds off the rest of the body. The smaller vessels were haphazardly scattered and matted, completely unlike the neatly organized fractal lines of normal vessels. I think that, even if I had no medical knowledge or experience, if I saw that tumor I would know it wasn’t right.

Two skilled surgeons worked together slowly, methodically working out where the tumor was attached to the rest of the body, then tying off and severing artery by artery. They expressed no outward worry even as it was obvious they were wary about the unknowability of the exact tumor anatomy, but just stayed absolutely focused, until suddenly it lifted free. One held it aloft a moment as it oozed blood from its distended vessels, then lowered it into a blue tray where it rolled a little, an almost sphere with a few protruding knobs. They later took pictures for their records. It was the size of a grapefruit.

Luckily, the rest of the abdomen looked pretty normal, and time moved much more quickly now that the tumor was out. Rewinding back to the beginning, they closed up the incision layer by layer. A navel popped into view, and suddenly it was a person again on the table. The drapes were removed layer by layer, the anesthesia wore off bit by bit, and the preteen girl whose family I met yesterday was back. Her angry tumor sat glowering, its red blood vessels darkening as it used up the last of its oxygen supply, until Pathology came to take it away.

 

My First Day

My first day of my pediatric surgery elective – my real first day of third year – was exactly what I hoped for as the first day of my “real” medical education.

I rounded on every inpatient on the surgery service – forty-six in all, ages one month to seventeen years, with dozens of different problems or different presentations of similar problems. My feet hurt, and I have a lot of acronyms to decipher.

I got to do two procedures, which is two more than I thought I would get to do on my first day. I inserted a Foley (bladder) catheter, one of the standard “by the end of your third year” procedures, in the OR. So I’m on my way.

I removed a suture. Only one, because the thirteen-year-old boy was very skittish (just old enough to know what to expect from hospitals), and said he was “a bit afraid to have a beginner do it.” After all the sutures were out without any trouble, my one and the intern’s two with four more for later, the boy softly told me, “you can do them all tomorrow.”

And there were children…
A little four-week-old fussed a bit each time we adjusted his abdominal repair, until the nurses dipped his pacifier in sugar solution.
A six-year-old brought Buzz Lightyear into the operating room with him, with plans for Buzz to have a gastrointestinal tube placed as well, so they would both have one.
A previously hostile teenager with an abdominal complaint giggled like a baby when the examining surgeon felt her abdomen, now painless and ticklish.
Kids of all ages rode around the hospital corridors and up and down the elevators in pushed or foot-powered wagons and cars of brightly colored plastic.

And I met a teenager who was dying of cancer. He lay pale and exhausted in his hospital bed, clutching his patient-controlled anesthesia (a button that triggers delivery of pain medicine as needed). He allowed me to examine his abdomen, which I could barely indent: every bit of it was like a layer of skin over rock, all tumor, and thudded dully when I tapped on it. His mother cried quietly as the surgeon discussed what measures would best preserve his quality of life as its quantity ran out. After we left the room, he pulled out the operating room schedule and picked out a few surgeries I should consider seeing, but his voice broke and paused.

So, in my thirteen-and-a-half-hour day in the hospital, I was exposed to the joys and the sorrows of pediatric medicine, I watched and I listened and I even contributed a little bit to patient care, I met a dozen new kind and encouraging teachers, and I feel like I learned more about medicine than I have in months’ worth of my preclinical years. I know it won’t always be this positive or energizing or successful, but I wanted to write down right now as much as I could of my first day as a third year, because I know for certain that by the end of the year my life will have changed dramatically…