Puella cum Cultello

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

Tag: loneliness

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.


Heartbreak Hotel

Residency can be lonely, with long hours that make isolation from friends and family inevitable.  Often, during that separation from our own social supports, we’re left to care for people in terrible situations.  This piece was written several years ago, while I was working nights in the ICU, right around Thanksgiving.  Reading it again has brought back a flood of emotions.


Over the last few weeks, I’ve been taking care of a very sick woman, D.  She had 2 prior bouts of cancer, and then developed a third, more malignant form in her upper esophagus this year.  Her tumor grew so large, so rapidly, that she could no longer swallow her saliva.  Our attending agreed to remove the cancer and reconnect her esophagus, with the understanding that this would be a palliative procedure, not a curative one.

She underwent a technically challenging but successful procedure involving two surgeons, and several residents.  Unfortunately, when D woke up, she couldn’t move one side of her body – she’d suffered a stroke during the operation.  We couldn’t treat the stroke because it was caused by a blood clot deep in her brain – using a clot busting drug would turn it into a bleeding stroke, one that we’d be unable to control.

By the following day, D had another blood clot, this time in her leg.  Because we couldn’t use any clot busting medications, she went back to the operating room to remove this blockage.  Most of the blood clot was removed, but the smaller blood vessels below her knee remained closed off.  She was left with considerable pain from both surgeries and her mottled leg.  Further testing showed that she had a disorder of excess clotting, one that was quite rare and not routinely tested for.

During all of this, the blood supply to D’s new esophageal connection was also compromised, damaging the delicate tissue that had been so painstakingly re-attached.  We had no way of knowing this until foul smelling liquid began to ooze from her incision.  Upon further investigation, we found a gangrenous esophagus.  From a medical perspective, this was essentially irreparable.  There was nothing we could do to significantly prolong her life.  Her underlying condition was incurable, and in her current state she wouldn’t survive long.

Our attending tried, in the best way he knew how, to convey that to D’s twin sister, the only family member still alive.  He repeated it over and over… D had a clotting disorder that no one could have known about before the operation.  The same process that happened in her head and in her leg had happened in her neck and damaged the esophagus.

To our medical minds, this meant that the graft was dead, well beyond repair, just like her brain and leg.  To her twin, it meant that there was still hope.  After all, she also had clots to the brain and leg – those were damaged but still alive.  She could survive this too, right?

Everyday, the attending would repeat the same phrases.  And everyday, the well twin would nod and smile bravely and tell us that D was a fighter.  We soon began to wonder when she’d finally put her sister in hospice, end this futility.  As the time dragged on, I slowly realized that it wasn’t false hope – this woman wasn’t in denial, she simply didn’t understand what we were trying to tell her.

Finally, the night before Thanksgiving, the well twin approached me in the hall.  I was in the middle of transfusing blood for another patient who was bleeding it out almost as quickly as I was putting it in.

Doctor, that graft… is it ever going to work?

Oh no, I cringed internally.  Not this question, not now.  But as I looked at her, I couldn’t just walk away.  She needed to know, to understand.

So, I answered her truthfully.  As I spoke, I could see the hope in her eyes fading.  The esophageal tissue was dead.  In the best of circumstances, we might have been able to perform an even more complex salvage operation.  In this case, with D’s body already so badly compromised, the salvage operation would likely kill her faster.  I tried to be as plain as possible and as gentle as I could be.  The words sunk in and her tears welled up.  All I could do was put my arm around her shoulders and wait for her questions.

But I just didn’t have time to comfort her.  I had to leave, my pager calling me to other tasks, other patients, other disasters.  I spent the next couple of hours distracted as I worked, hoping I hadn’t just destroyed the well twin too.  When I finally saw her again, she thanked me, for telling the whole truth, helping her understand.  But it didn’t feel like I had done much, certainly not enough to deserve thanks.  Then she told me her plan for D.

They would spend Thanksgiving, the next day, together – just as they had for over 60 years, as a family, as they only family they each had left.  The decisions would come after that.  I think we both knew the decision had already been made.  And all I could do was hug her again.

Later that night, a photograph on the bulletin board caught my eye.  It was part of a display explaining the benefits of an “open” ICU.  The well twin was shown asleep, in a chair beside her sister’s bed.  All you could see of D was a hand, extended over the side of the bed.  Even in the middle of the night, sleeping in an ICU room hundreds of miles from home, the twins were inseparable, hand in hand.  Yesterday, they went home together, to allow D to die at home.

And I stood there again tonight, alone, staring at that picture.