Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: fear

Words (not) to live by

See one, do one, teach one.

It’s an old phrase in medicine, and it embodies a teaching philosophy that has been passed on for decades – observe, practice, then pass on the skill.  During my third year medicine rotation, that expression was turned on its head once or twice.

Do one, see one, teach one.

I was asked to access a chemotherapy portacath – despite not having seen a port or the needles inserted into them.  The intern dictated a list of supplies and told me the requisite steps, along with a couple of technical tips (namely, “it’s a big-ass needle, don’t stick yourself!”).  I scurried off to the supply closet, eager to get started.

In many institutions, physicians are responsible only for placing central access catheters, which go into the large vessels of the neck and chest.  Specialized nurses will place difficult IVs or peripherally inserted central catheters, and they also access ports.  This allows these nurses to gain experience and develop immense skill in a small range of tasks.  They truly become specialists, and they are far more proficient with those tasks than most physicians.  However, this hospital didn’t have an IV therapy team, union contracts prevented nurses from dealing with most vascular access in a timely fashion, and these issues fell to the already overworked house-staff.

So, here I was, a medical student with less than a year of clinical experience.  I was about to stick a large bore needle into a patient’s chest, aiming for a small device that carried silicone tubing straight into the heart.  I had no frame of reference, no prior experience, for what I was doing.  I had some understanding of the potential complications (infection, thrombosis, air embolism), but the intern didn’t review them formally with me.

Yet no one questioned the appropriateness of this situation.

My intern was happy to have another task checked off his seemingly endless to-do list.  The nurse was glad to have vascular access in her patient without doing it herself.  I was excited to actually be allowed to do something, anything (“I get to touch patients!”), though I definitely had some trepidation about the matter.  And the patient was eager to just have the whole ordeal over with.

Of course, I struggled a little.  I improvised a lot.  I kept hearing a voice in the back of my head – “fake it till you make it”.  And, eventually, both the patient and I survived the procedure relatively unscathed.

But would this situation be acceptable to me as a patient?  Absolutely not.  However, the hierarchy of medicine and my eagerness to be helpful prevented me from insisting on more appropriate conditions.  I was too chicken to refuse, for fear of stirring up trouble, delaying patient care, and losing future opportunities.

Every doctor has to learn, and we all start with very little knowledge.  We slowly gain knowledge and experience under supervision, an apprenticeship if you will, before we’re left to our own devices.  But this should happen in a stepwise fashion, with incremental increases in latitude and responsibility.  Instead, all too often, it’s haphazard, and junior trainees are left to sink or swim – along with their patients.

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Keeping control

You immediately wonder what actually happened.

She came in with increasing abdominal pain after falling down the stairs 3 days ago.  It’s an isolated splenic injury.  The story doesn’t add up.  The mechanism of injury doesn’t fit.

Why wait so long?  What is she hiding?

Her boyfriend seems off-kilter from the start.  Something about his manner – his eyes, his words, his tone – he reminds you of someone you once knew.  Someone you thought you’d never have to see again.

She barely opens her mouth to speak.

He answers for her.  He controls the conversation.  He becomes her voice.

Her ex-husband and son are with her as well.  They ask to speak to your team after rounds.  They don’t believe her.  They’ve seen what she’s become – a shell of herself.  His plaything.  They know.

He did it.  He’s done it before.  He’ll do it again if – when – she goes home with him.

The next day, he knows he’s been exposed.  He’s far too friendly, too obvious, too familiar with all the women in the room.  He gives you an ingratiating smile.  It’s a calculated greeting, intended to give him the same power over you.

Your stomach turns, and your jaw sets.  You can’t – won’t – refuse to – look him in the eye.  He cannot have that.

She finally goes to the OR when the bleeding won’t stop.  You want to shake her when she wakes up, to make her see sense, to give her the courage she needs – before he sees her, before he can bewitch her again.  Your fists clench, and the flames begin to burn inside you again.  Because you know how this story goes.

But in the end, you realize… this is not your battle.  And she’s not the one you’re really angry with.

The children’s ward

I’m not particularly looking forward to my pediatric surgery rotation.

It’s not that I don’t like kids, I actually do (well, when they aren’t behaving like banshees).  I’d even like to have one or two of my own one day.  It’s not that the diseases are uninteresting.  Congenital and childhood diseases are pretty fascinating, because they represent the intersection of nature (genetics) and nurture (development within a given environment).

Kids are like cute, funny, little test tubes.

Honestly though, I couldn’t enjoy outpatient pediatrics.  A waiting room full of sniffling, scared children isn’t very appealing to me.  Well-child visits and routine childhood illnesses are kind of boring.

Inpatient pediatric patients are incredibly complex.  But that’s not the issue I have with them.  No, the problem is that the interesting kids are the heartbreaking ones.

Seeing them stuck in a hospital ward is difficult – you begin to imagine them happily playing at home with their friends and loved ones, where they belong.  Sometimes, they’re too sick even to cry when they’re in pain.  They just look up at you with pleading eyes, hoping you won’t hurt them even more.

But unfortunately, no amount of wishing will restore them to good health immediately.  And sometimes, no amount of care can cure an innocent little munchkin.

So that’s why part of me would almost prefer to sleep-walk through the next few months.

Code Blue

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.
-Emily Dickinson

In medicine, we confront death on a daily basis.  It’s been 8 years since I started medical school, but for me, it remains sad, terrifying, poignant, brutal.

The first code I participated in was all of these and more.  I was on call on a Saturday evening with another 3rd year medical student, W. It had been a slow day, and we were just hanging around, studying, chatting, and waiting for 6pm.  W had taken a short break while I continued reading, but she’d been gone for a while.  I decided to give her a call.

While we’d been separated, she had been drawn into a “code blue” on the fifth floor.  This was was where ventilator-dependent patients, among our sickest, were placed – never a good sign.  I raced up the stairs before W could tell me the room number.  I knew that when I reached the ward, the crowd that assembles at every code would lead me to the correct place.

I no longer remember the patient’s name, or even what she looked like.  But I do remember that she was a young woman, diagnosed with an aggressive cancer while her children were still in need of mothering.  Even though her condition was terminal, her husband had insisted that everything possible be done for her.  Death had been looming for weeks, but he wanted their children to have their mother for every possible second, no matter how incapacitated she might be.  She’d spent the last few days alive but unable to interact with them in any meaningful way.  On this quiet weekend afternoon, with none of her family nearby, her body was finally giving up.

She was one of my first lessons in clinical detachment.  During this code, she wasn’t a wife or a mother anymore, she was just another patient, one we were trying to keep alive at her family’s behest.  We knew that we were fighting a losing battle, even if her husband had refused to accept the limits of our abilities.

A couple of residents were taking turns pumping her veins full of medication and pounding on her chest, the respiratory therapist was trying to keep pushing air through her tracheostomy, and W was standing in a corner, holding up an IV bag and looking as though she hadn’t yet decided whether to cry or vomit.

I caught our resident’s attention and asked what I could do.  I became the designated equipment runner, a task complicated by the fact that I was unfamiliar with this floor and couldn’t get into any of the locked supply rooms.  I proved far more adept at relieving W from her imitation of an IV pole.

The code went from bad to worse.  The patient’s heart wasn’t responding to medications, chest compressions, or electrical shocks.  The pumping of the ambu-bag was frequently interrupted by attempts to clear the secretions which were plugging up her trachea.  Blood-tinged froth bubbled from her mouth and nose.  Her pulse was thready despite the fluid and medications we were giving, and her blood pressure was too low for our monitors to detect.

Finally, after 40 minutes of this, the attending running the code allowed us to admit that we had lost this round: “I’m going to call this one. Everyone agree?”  She named the major team members one-by-one, making sure that there was consensus, that we had done all we could.

As the techs, nurses, and residents filed out, W and I stayed.  The attending taught us the steps of confirming brain death: the patient was totally unresponsive; she didn’t have any brainstem reflexes; there were no breath sounds.  We were instructed to ignore the slight fluttering of eyelids before her dull eyes were hidden – it was merely a sign of residual electrical activity in her peripheral nervous system, not an attempt to show us she was still clinging to this world.

Neither W nor I were sure to say or do next.  We’d seen dead people before, from the cadavers in anatomy lab to the autopsies in pathology.  We’d met hundreds of patients already.  But today, for the first time, we had watched someone die.

No lecture, no group project, no role-playing session prepares you for that moment.

So, we reverted to helpful medical student mode and tried to assist with the clean up, using damp towels to wash the body of a woman we had never known while she was alive.  The nurses would then tidy the rest of the room to allow her family to say their final goodbyes.

After wiping the last of the blood from her face, we covered her limp, broken body with a clean sheet, as though concealing our collective defeat.

She was finally at peace.  We were not.

The dark corners of my mind

Sometimes during residency, you encounter your deepest, darkest feelings in unexpected ways.  Last year, I faced one of my fears in the form of an elderly Asian woman.  Miss N. was a feisty little thing when I met her.  Over 90 years old and in assisted living, she insisted on taking the bus, alone, to all of her appointments.  She had come to us because of pain in her legs when she walked.  An ultrasound had shown that her tiny blood vessels were closing off, and she wanted to know if we could help her surgically.

As we talked, I learned more of her story.  Miss N. had been a skilled seamstress as a young woman but retired decades ago.  She had never married or had children, and though I was curious, I didn’t probe into that any further.  The youngest of eight siblings, she was the only one remaining.  She’d also outlived almost all of her other friends and relatives.   Only two kept in regular touch, a nephew who lived several hours away and a local woman who had known the family for many years.

We didn’t have much to offer Miss N. – she had a chronic vascular condition that wasn’t amenable to surgery.  Accepting our opinion without question, she went on her way.  But she didn’t leave my thoughts completely.  Over the next several months, I remembered her often.

Miss N. was obviously a survivor, but she in doing so, she had become profoundly alone in this world.  She’d managed to outlast everyone she was close to.  When she died, who would be left to miss her?  She had no children or grandchildren to dote on, no family of her own, no one to tell her story after she was gone.  Perhaps that was by choice – had she loved and lost?  Or had she simply never met someone worthy of loving?  At a stage in her life when she most needed to be cared for, she had no one, except people who were paid for their time.

She was the embodiment of my greatest fear – loneliness.

My own parents and two siblings live over a thousand miles away.  The rest of our relatives are half a world away, and I haven’t seen them in several years.  I’ve moved so many times in my life that I’ve never really set down firm roots anywhere.  I knew exactly one friend-of-a-friend when I moved to my current city for residency, and working 80 hours a week hasn’t been especially conducive to making or maintaining a strong social network.  And while I have good relationships with the other residents, they’re co-workers, not close friends.  Many of them have families nearby, and their free time is devoted to those obligations.

Right now, my parents are healthy, but I know that won’t last forever.  They’re getting older and no matter what I do, I know I can’t prevent the inevitable.  My brothers are much younger than I am, and though we do have good relationships, we aren’t very good at staying in touch.  Living near each other would be nice,  but it’s not something that any of us are particularly striving for.

My work can make it difficult enough to be a reliable friend, so I’ve invested even less energy into trying to meet someone and establishing a relationship.  Apart from having to live with me and my quirks, that person would also have to accept my unpredictable schedule, very limited free-time, and the knowledge that sometimes my work would come before my family.  They’d get the brunt of the responsibility of a home life, with little to show for it.  It’s not a deal that I would be eager to take.  And, indeed, the men I’ve met haven’t been thrilled with it either.

I chose my field with open eyes – I knew how disruptive my work would be to my personal life.  But actually living this way for the past few years has been much more difficult than I could have anticipated beforehand.  I wouldn’t want to be responsible for inflicting it on another person as well.

Since meeting her, I’ve often had moments where I wonder if Miss N.’s life is my future.  While I certainly hope it isn’t, I can’t shake the fear that it is.