Perspective

Growing up I dissected three frogs. The first was in the fifth grade, and it was incredible. I looked forward to it for weeks, and when the moment came the only disappointment was that we had to use scissors and not scalpels to do the cutting. The second came during the sixth grade – I changed schools, and my new school simply worked on a different time-line. I remember one of my classmates saying that his mother told him that today we would get a glimpse of who wants to be a doctor. This time around was even better, because I knew what was coming (like the scissors!) and could be better prepared. And the third time was on my own. I asked my sixth grade science teacher if I could purchase another frog and dissect it at home…he looked at me kind of strange, but obliged. I carried that frog home proudly one Friday afternoon, and set to work on makeshift operating table. I guess, in a sense, I’ve liked operating for a ling time.

As part of learning about frog anatomy for all these dissections, we learned about how their eyes differ from human eyes. In order to focus, a frog’s lens doesn’t change shape (like a human’s) but rather moves closer to the pupil. I remember misunderstanding this concept and assuming that the frog had to move his whole body to focus on something. I had images of all these frogs hopping to and fro in order to clearly see. Those poor frogs!

This month I am doing vascular surgery. For most of our operations we wear loupes – those are those funny glasses with the magnifying lenses on the bottoms. Loupes are custom built, and the focus is set at a distance that is comfortable for your hands to work at. But when I’m assisting during surgery, sometimes my hands are not at an ideal distance from eyes. In other words, sometimes I am working out-of-focus. And the only real way to change that is to move my whole head closer or further from the field, as needed. In my mind, I’m a little like those frogs I used to imagine, hopping forward or backward to better get a clearer view of things.

It’s funny how a change in position can change your focus. A step backward often makes things just seem more clear. And while I’m glad the poor frogs don’t really have to do all that hopping, when things are confusing to me I often try to remind myself that hopping backwards may be all that’s needed.

Today is a beautiful day – sunny, clear, and crisp. And I am at the hospital, on call, with my loupes at the ready. And today, things just seem clear.

Falling

Fall has always been my favorite season. There’s just something about the colors, sounds, and smells of all those leaves that makes me feel very comfortable, and right at home no matter where I am. Something about that sensory experience allows me to travel backwards and nearly re-live every autumn I’ve ever experienced. And when I think of my life, I nearly always picture myself reliving it in the fall. When I remember growing up in DC, in my mind it’s in the fall (many would say it’s the nicest time of year down there). When I think of Maine, it’s the fall (who can resist a New England maple tree whose leaves you swear are on fire?). And even when I think of Philadelphia, I think of the fall. I just do.

And yet while this time of year is supposed to be marked by leaves falling slowly to the ground, today as I look out my window I am amazed to see snow falling. Big, white flakes slowly falling from the sky. Seeing snow on the colored leaves is something I don’t think I have ever seen.

And so maybe this fall is different from every other one I’ve lived before. And it’s been wonderful, because it may actually be the start of something new. It won’t simply be another chapter in the Falls of My Life. Rather, it will bring a new twist; new memories; new love.

For this autumn, in addition to the leaves and the snow, I too am slowly falling.

In Control

The myth about a hockey goalie is that he is always simply reacting to a situation. We always hear about a goalie’s reflexes and speed – tools used for combating the aggression of the shooter. But what an experienced player learns is that it’s the shooter who is reacting to the goalie. It’s the shooter who chooses to shoot or pass based on what the goalie is doing. And a smart goalie uses this to his advantage, to force the shooter into a bad shot or maybe even no shot at all.

The same holds true for a trauma surgeon. While the situation is infinitely more complex than a hockey game, the principles hold true. The good trauma surgeon cannot simply react and rely on trained instincts. He must be proactive, and control the situation as best as he can.

I feel like in life we are often on our heels, cornered into a place where we are on the defensive, and forced to react. It’s only when we realize that we actually do have control that we can take charge and move on.

Moving On

In many ways this blog has fulfilled its purpose. Writing is much less about putting down on paper what we already know and more about putting thoughts down on paper so that we can see exactly what we know and start the process of filling in the gaps. Never in my life have I so needed a space to help me sort out my thoughts and fill in the gaps. To those of you who continually encouraged me to write, I thank you.

I thought long and hard about ending this blog for good, and keeping my thoughts to myself. But then, that seemed like a bad idea. If I can write when I’m sad, surely I can write when I’m happy.

And – I almost want to whisper when I say this – I’m finally happy. Or at least I feel like my old self again. Sure, I have my moments when I think on the past and I’m sad. In many ways I’ve been changed forever, and I’ll never get any of that back. I don’t know if I’m better or worse than I was a year ago, but I am definitely a different person. New and improved? We can only hope.

But if surgery teaches us anything – hell, if being a goalie teaches us anything – we have to move on. There’s no use in dwelling on the last patient when another victim is being wheeled into the trauma bay. And there’s no good worrying about that bad goal when another puck is already on its way. Focus, and move on.

And so I have.

Mission: Honduras

I'm currently on a medical mission trip to Honduras. Please check out our church's blog!
http://www.saintmarksphiladelphia.org/honduras-2011/

Who Are These Like Stars Appearing?

The other night I found myself sitting atop the grand steps of the Philadelphia Museum of Art. It’s a magnificent walk up those steps, as the columns slowly come closer and nearly envelop you as you gain the summit. And the result is a spectacular view of the city, which, from this vantage point, continues to buzz with life but at a much softer decibel. It’s a nice place to sit and take stock of things.

This isn’t the first time I’ve found myself on art museum steps when my mind is heavy. Throughout my college years I often would steal away to the steps of our own art museum for a time to think – steps that, while smaller than the ones in Philadelphia, are equally grand in their own way. The key difference was that instead of a view of a city skyline, the museum steps in Brunswick, Maine, offered a view of the stars. Sufficiently removed from the din of the first-year dorms, and shielded from the cars on Maine St., the steps of the Walker Art Building provided a dark sanctuary perfect for stargazing.

The stars in Maine are, as you might imagine, amazingly brilliant. Some nights there seemed to be more stars than not – as my eyes adjusted, I began to see more and more stars and less and less empty space. It always struck me that, as I looked at those stars, I was really looking back in time. The light I was seeing wasn’t new light, but rather light that had been traveling to Earth for many, many years. And it finally arrived! Their beauty is literally timeless. Shooting stars seemed not uncommon – an exhilarating thrill amidst the tranquility. The universe seemed full, ablaze, and uniquely visible. And while I felt tiny beyond measure, I still felt as though I had a part to play in the grand cosmic design of things. I felt connected, peaceful, and happy.

I would always wish on those stars. In those days I’d often wish for a deeper understand of religion and the universe, or of a way to grasp the cosmos that seemed right in front of me. Sometimes I’d wish for things that more superficial, but at that moment were vitally important to me, like success in a lacrosse game or a good showing at hockey tryouts. Maybe even a good test score. Perhaps I had higher expectations of things back then, but I think my wishes all stemmed from the genuine happiness that used to be a part of me.

On some nights I would share my stargazing with another. Those were the best nights of all, because then the part that I had to play in the universe seemed clearer.

But that was a long time ago. For now the twinkling lights of the Comcast center will have to be my substitute for a starry night in Maine. It may not be ideal, but it’ll have to do – and it has it’s own charm, I suppose.

As I stood to leave I noticed one stubborn star poking through the light haze that is ever-present in a large city. This one little star was just bright enough to be seen, as if it was looking for someone to take notice. And so I did. I noticed! Did it maybe notice me? And though I was alone, I couldn’t help but think that somehow that star was trying to bring me back to another time – maybe even another place – though for what reason I wasn’t quite sure.

I closed my eyes and made my wish. And I wished for happiness.

Door #1

Everyday when I come home from work I get the same anticipatory sensation. I never really realized it until today, but I get progressively more excited as I walk closer to the door, and put the key in the lock and start to slowly turn it. I pause as the lock clicks into place, as if I’m listening for something, or someone, and don’t want to barge in. My eyes close just a little bit, and for a moment I’m back in a happier time, long ago. I can picture the apartment the way it used to be, and I fool myself into thinking that maybe this has all been a terrible dream, and that when I cross the threshold I’ll see for myself that everything really is ok. I hold my breath and hope – I don’t want to go on in case I’m wrong.

I don’t know if this is the best or worst part of my day. Either way, it’s total denial. And it’s totally pathetic.

Of course eventually I open the door and step in. The door closes behind me and I lock it quickly. The apartment is completely different than then one in my head. And empty. Home.

I tell myself that one day I really will be excited to come home, and what’s more that there will be a home that is excited to have me. It’s just not now.

Big day in the OR tomorrow…I’m off to bed.

M & M

Today I had the pleasure of presenting at our weekly “M & M” conference. The “Morbidity and Mortality” conference is held every week in an effort to promote self-examination in the hopes of improving the quality of care. It’s sort of like a condensed version of Lent, only more public. We scrutinize all of our patients’ outcomes, and try to learn from the ones that don’t go right. It’s a noble thought but, especially in the surgery world, it has the tendency to become slightly contentious. In fact – back to the Lent comment for a moment – some have described it as a crucifixion.

It’s a difficult thing to stand up in front of all your peers and say, “I did this, and then that bad thing happened.” Today I told the story of a patient who died. He needed an operation. We gave him one. He had a heart attack and died. The implication is that it’s my fault.

I presented the case in detail, and had every aspect of it questioned. Can you imagine a room full of white coats scrutinizing every detail? Did he really need the OR? Did he need that particular operation? What could have been done differently? He died, after all, so surely SOMETHING could have been done. I did my best. In the end, there really wasn’t anything I could have done.

Still…as miserable as it was to relive that sad sequence, it’s a good exercise to look carefully at the past and evaluate it in the hopes of preventing a bad outcome the next time around. And what better thing can we do after a death than try to use it to the benefit of the next patient?

And they’ll always be a next one. At least I hope so.

Forgotten

In the OR today I happened to notice a sign addressed to the nursing staff. It was a sign explaining a new cross-check system called “forget me notes.” Essentially it was a system of notes that needed to be written at various peri-operative stages to assure nothing was forgotten.

Of course, this is a play on the flowers Forget-me-nots – the small, lovely, baby blue flowers. Googling the flowers I learned that German legend has it that while God was naming all the plants of the earth, a small patch of unnamed ones cried out “forget me not, dear Lord!” – and so that was what He named them.

There is something so terrible about the prospect of being forgotten. Really, what’s worse than thinking someone is remembering you – loving you, taking care of you – and realizing that, in every way, you’ve been forsaken?

When I think of flowers I instantly think of my mother, who has spent many years doing floral arrangements in churches and cathedrals all over the east coast. Decorate God’s house before your own, she’d say, as she’d sketch designs or plan a budget on the kitchen table. She’s decorated the churches for our family’s weddings and funerals for years.

She got her start in the National Cathedral, where I was a boy chorister growing up. Someone recently asked my to describe some of my favorite moments singing in that awesome space. And while there were many, I recall with special fondness the literal transformative process that we underwent while preparing a “Te Deum Laudamus” by Herbert Howells. The piece is sensational – big, gutsy, with pure emotion on every page. And it is unique for the high C in the last stanza – the highest note I ever sang, and the highest I’ve ever seen written for a soprano. When you see something like that – that unusual, that difficult – you have to pay attention the words in the music. Howells was too smart to make something like that happen for an insignificant phrase. The high C comes on the word “never” during the phrase “O Lord, in thee have I trusted; let me never be confounded.”

The sentiment of trusting in the lord and never bring confounded comes from Psalm 31. Different translations ask to never be put to shame, or to never be disgraced, or to never be defeated. I guess if I was translating today, I might try to use “to never be forgotten.”

Hell, look at me – I’m terrified of being forgotten. I’m so terrified that I write this blog so that I’ll feel like my emotions and thoughts will somehow reach one of you, and that you might think of me for a moment longer than you might otherwise today. That, for me, is a perverted form of self-preservation. It’s my way of making you not forget me.

There are lots of things we do, really, to make sure we’re not forgotten. We do some things to assure our legacy after we’re dead and buried – have children, pass on a family name, make a donation in our name. And there are things we do to make sure we don’t get forgotten in this lifetime, in the hectic haze of a crazy, crazy world. Exchanging and wearing wedding rings comes to mind as a way to prevent being forsaken.

But I guess at the end of the day we can do only so much – we can’t force our legacy on one another. Someone has to choose to remember us.

Thank you all for reading.

Separation

The other morning a paramedic crew called into the ER and said they were bringing in a terrible motorcycle accident victim. How terrible? They said they would be bringing in his leg as well.

The 38 year-old man was wheeled in to the horror of everyone who watched. True to their report, he had no right leg – a young EMS student was quietly carrying it. The patient’s right arm was unrecognizable as an arm except that it was where an arm was supposed to be. His left arm was mangled but at least it looked salvageable. His left leg had some terrible gashes on it.

And the worst part? He was perfectly conscious. He gave us his name, address, social security number. He looked terrified.

We quickly intubated him for his own protection and began the process of our trauma evaluation. Amazingly enough, he had no significant internal injury.

There are some things that are supposed to be together – attached for all time. Needless to say one’s legs and arms fall into that category. And there is just something so unnatural about seeing that forced separation. Seeing his leg – the same leg that had helped him climb onto his motorcycle just that morning – felt surreal. That leg – that thing – used to move, and feel, and be alive. Now it’s nothing. In its place is literally nothing. And it will never be the same. Never. No matter what, he will never have his leg back.

What happens when you rip something apart? What happens to the pieces that are left? We wrapped the leg in a red “hazard” bag and sent it to the pathology lab, which is really one step above throwing it in the trash. We put some IVs in the patient, threw some gauze on the wounds, and shipped him to the OR where a trauma surgeon, orthopedic surgeon, and plastic surgeon were waiting for him.

They were able to do amazing work. Our patient is alive, and doing quite well. Of course, he’s short one arm and one leg, but he is alive and in good spirits. And I guess that’s really the important thing. Because as unnatural as it may be to undergo a separation, sometimes these things are just completely out of our control. Nobody wants this sort of trauma, but sometimes traumatic things happen. And when they do, as terrible as they are, we have to choose how to deal with them.

Separation is not death, as this patient taught me. It is not the end. It is an end to some things – some really important things – but not everything. And it may yet be the beginning of something else.

Growing

Sometimes as surgical residents we are asked to be the face of the surgical team. Long after the attending surgeon has left, we alone check the patients we operated on that day, and prepare those whom we will operate on tomorrow. The dialogue is always somewhat stilted – in short, I’m not really the one they’re expecting to see.

I’ll always remember one night from my intern yearn. I was on call at a small hospital, religiously doing my post-op checks. Late that evening I walked into a room of a women who had just undergone gastric bypass surgery, and happily introduced myself as a member of the surgical team. I hadn’t participated in the operation, I was clear to her, but I nonetheless was here just to check in and make sure everything was ok. I did my exam, and left feeling confident that she would be fine for the rest of the evening. The nurse happened to be in the room with me during the whole exchange, and I was writing a note in the chart she came up beside me and said “Your patient must think you’re a little too young for all this; she just asked if your mother knew you were up so late!”

As I’ve grown through the surgical ranks my dialogue with patients has shifted. I started saying things like “surgery requires multiple people, and so I’ll be assisting in the operation.” But this afternoon something different happened. A younger man who has been battling dehydration, renal failure, and a pesky gallbladder will finally be going to surgery tomorrow. I’ve seen him every day the last week or two, and today I finally got his consent for the operation. He signed the papers, and then looked me and said “I realize there are other members of the team, but I’m assuming you’ll have a big part in this operation tomorrow.” That’s correct, I answered. He looked down, said something like “ok, good” and then added, with a big grin and a wink “no drinking tonight, ok? I need you tomorrow.” I laughed. No problem; I promise.

Sadly, the comment hit pretty close to home. The truth is that these past few months I have been drinking more than usual. I’ve never thought it’s ever compromised patient care, but it struck me that I can’t take that chance. This patient needs me. In fact, many patients need me, every day, and they deserve me at my best. Their faith in my depends upon it.

Yesterday in church we heard the parable of the sower and the seed. In this story, Jesus tells his followers how a sower scattered seeds upon the land, and depending on where they fell their fate was determined. Those that fell on the pathway were consumed by birds; those that fell upon rocks perished from the inability to form strong roots; those destined to land in the patches full of thorny weeds were strangled; and those precious ones that fell in the midst of the good soil reaped huge crops.

Jesus doesn’t go into the possibility of seeds migrating, but it strikes me as a very natural possibility. I don’t really know where I used to be, but I think I am finally living in the fertile fields, and am capable of growing roots, and yielding a harvest.

I love being the face of the surgical team. And I love that I am growing in it. Wish me luck tomorrow!

Moving On

The patient was kind and gentle, and looked younger than his medical record might indicate. His cardiac history was immense – heart attacks, bypass surgery, and the resulting compensatory physiology that makes for a weak heart and poor operative candidate. And now he had a bowel obstruction, and though the exact cause was unknown, it seemed that surgery was his only option. His high-risk cardiac status notwithstanding, we took him to the OR. He was nervous but upbeat, and the night before the big day looked me in the eye and told me that he had all the confidence in the world that we would do right by him.

The surgery itself went fine, but it took an unusually long time. His intestines were worse than we imagined – abdominal surgery from many years ago had caused massive scarring that pulled his distal bowel into a knot of obstruction. Painstakingly we relieved every adhesion, and resected what we needed to.

As I said, the surgery itself went fine. By that I mean that there was no excessive bleeding or injury or anything like that. But it took too long. And his heart couldn’t handle it. Later that night he had a heart attack and died.

Oftentimes in surgery we are dealt a bad hand, insofar as the patients are sick and in a pretty desperate state. This is no more true than in trauma surgery – people get shot or have an accident, and while that is tragic we are forced to do only our best with what we have to work with. But in surgery like we performed on this gentleman, we have more of an active role. And we have more options at our disposal. No, we didn’t kill him directly, but he did die as a direct result of what we did. At least for me, the hurt from losing a patient like this is the worse kind.

The next day I spoke with the attending surgery and we replayed the whole thing, and every decision we made. We second-guessed certain things, but ultimately decided that we did the best we could given a bad situation. I guess the morbidity and mortality conference at the end of the month will judge us in their own way.

Our conversation was cut short by the OR staff telling us that our patient was ready for us in room two. This patient had come into the office about a week ago and needed her gallbladder removed. Just as the gentleman had placed his confidence in us, so too was this women deciding to go under the knife with us in control of her fate. She didn’t know of the events from the night prior, nor would she learn of them. She needed surgery, and she needed a surgeon who could perform that safely.

As I scrubbed for our new patient, the events from the night before slowly faded away. With every pass of the scrub brush, the memories dissipated. When the gown and gloves were placed on me, the feeling of loss had gone. And when I was handed the scalpel, all that mattered in the whole world was her gallbladder.

What was done was done. I could second-guess, I could doubt, I could question all I wanted to – it wouldn’t have mattered. I could feel bad for myself, I could cry, I could complain, but it wouldn’t change what I had to do. Reliving the past not only would do me no good, it would potentially hurt our next patient.

This isn’t to say that I can’t learn from the past – of course I can! We all can, and all should. But when we have moved past a challenge, regardless of the outcome, the most important thing at that moment is to focus on what is up ahead.

Surgery residency teaching many things, and surgery is only one of them. How to move is another. And that gallbladder came out just fine - she is now home, safe, and moving forward with her own life.

Letting Go

Like everyone else, cancer patients die in a variety of ways. But more often than not, those deaths are long, protracted, and agonizing. Sometimes the vicious cycles of chemotherapy and radiation and surgery simply fail to capture the rapidly mutating cells and the body ultimately shuts down system by system. The kidneys fail, the lungs need support, and the bowel stops functioning. Other times, the patients – hopefully with the support of their families – decide to stop pursuing treatments, and opt instead to die on their own terms and in their own homes. And too often the diagnosis is made too late, and someone who wants to fight the good fight isn’t really given that option – the war has been raging secretly inside for who knows how long, and it’s outcome is already decided. To fight is futile.

I’ve witnessed all of these this past month, and I’m not sure which one is worst. But I am sure of this – at some point we have to let go.

All month while serving on the thoracic surgical oncology team, I found myself battling an old demon in a new context, and that was the memory of my grandmother. A British nurse during WWII, she met and married my grandfather, a US Army soldier stationed in England. They would eventually move to the states and raise their five children, and I have countless happy memories of them together and of her in particular. She always said that he was her best friend, and that’s what made their marriage work for such a long time. My best friend, she would sometimes say. When he died she was devastated, and moved in with our family for a number of years. A lifetime smoker, she died of complications from lung cancer a few years later.

Her death was not a pleasant one. While she did not have surgery on her lungs, she did endure all the other torments of a long fight against cancer. She held on and fought for a long time – long enough, in fact, to see all of her children. On her final day, she did not die until she had seen all of her children one last time. All of them. Only then was she ready to go – and so she went. She slipped into that eternal unconsciousness the moment she decided to let go.

It’s never easy to let go. But when the time is right, there is no better thing to do. And so…let go.

Wind and Souls

At the church I am currently attending, the organ is under construction. From the pulpit, the Rector explained that the 100 year-old blower needs a tune-up. The organ, he explained, is truly a wind instrument. The blower forces air through the network of pipes, and the keyboard simply directs that air as needed to produce sound. In this way, he explained, the organ has a sort of soul – a breath that flows through it and gives it life. Take away the breath, and you’re left with an empty shell.

This month I am rotating with a thoracic surgery team. We spend most of our time operating on lungs – the organ that is responsible for blowing our air, and distributing the oxygen throughout our bodies. Maybe this is really the seat of the surgical soul, just as the blower provides the soul of the organ. Take away the lungs and the oxygen they provide, and you’re left with a lifeless body.

When we resect part of a lung to remove cancer, the remaining lung tends to leak air into the chest. We place chest tubes so that this doesn’t compress the remaining lung and crush the heart. We call this an “air leak” – maybe now I’ll think of it as a soul leak.

I feel like my soul has been leaking out of me for some time. Maybe I need a chest tube so that my heart won’t be crushed. Then again, maybe it’s too late, and the soul that was such a part of me is forever changed because some of it has simply leaked away.

The organ repair will take at least all summer, the rector reports. How long do you think my repair will take? Is my soul easier or harder to fix than a 100 year-old organ? Certainly mine takes up less space on this planet. And given the size of the congregation, I’m sure many less people care about mine.

At about 3 AM today one of our patients died. Her cancer had just run too wild, and our surgeries were not enough. Her soul was destroyed. I had to tell her daughter.

Fortunately, the church I attended is grand enough to actually have a second organ in the back of the church. The postlude was the marvelous prelude and fugue in E by Bach. The organ – with its pipes and wind and organist – was spectacular. I knew an organist who once told me that she chose to play Bach whenever her soul was troubled, and that somehow Bach’s music had a way of helping her make sense of all that seemed wrong. Today I felt that same sense, as I sat there and let the music pour over me – a perfect manifestation of soulful music. Somehow the organ made sense. It was inspiring to literally feel the soul of the organ, and to image one day my own soul being just as grand.

I can’t wait.

Sunshine

There is nothing quite like living in a new city. It’s exciting, challenging, but ultimately – for me – quite lonely. It exacerbates all my insecurities, and serves to emphasize my feelings of isolation. It’s a strange thing to feel alone in a city of eight million, but maybe that’s why it’s so unsettling.

It has been gray and cloudy recently. It rained much of my day off last weekend – why not?

I am working this month on a thoracic surgical oncology service. The patients could not be more different than those I encountered while serving on the trauma team. These patients are older, much more educated, and carry with them that loaded label of cancer patient. Theirs is a death that is slow, not unexpected, and usually very painful. It is an agonizing process to watch, as their bodies mutate and grow uncontrollably, killing them from the inside. One woman looked at me yesterday and said “I don’t recognize myself anymore.” It’s horrible.

Yesterday the clouds and rain continued. But the floor secretary had the antidote. She came waltzing in, with a big grin on her face. She pulled from her bag a plastic flowerpot with a single yellow plastic daisy standing in the middle. She plopped it on the counter and hit a button – and the flower sang:

You are my sunshine, my only sunshine.
You make me happy when the skies are grey.
You’ll never know, dear, how much I love you.
Please don’t take my sunshine away.

I used to be a ray of sunshine. But not anymore – not now.

Right on cue, the sun broke through the clouds. I guess I can defer the role of sunshine for the time being.

Self

There are lots of ways that I could have ended up my month on trauma. I suppose this one was as appropriate as any.

She was 67, thin, and otherwise healthy. She was a week away from her 40th weeding anniversary. And late that evening she took the family gun, held it to her temple, and pulled the trigger. The bullet passed clean through her brain and out through her skull on the other side. The cops found it lodged in the wall of her house, amidst a splattering of blood.

Amazingly, she wasn’t dead. Her blood had spread all throughout her head, but the two holes left by that bullet served to decompress her skull and stave off the high intracranial pressures that are usually fatal in this sort of instance.

We worked very hard over the next two days on this lady, while her family gathered at the bedside and slowly came to grips with what had happened and what the likely future would hold.

In medicine we often end up prolonging life under dubious claims. But it struck me that there could not be a clearer instance of someone telling us that she did not want to live. If you believe the statistics, women attempt suicide much more often then men do, but because they often choose less violent methods (e.g., overdosing on pills) they are less successful than their male counterparts. Needless to say, out patient chose as violet a way as possible to try to end her life, and so sent a powerful message as to her wishes. It didn’t dampen our efforts, but I’d be lying if I said it wasn’t on my mind.

We often hear suicide described as a selfish act. And this became obvious as I stood in that room and saw a husband, a brother, and a friend gather at her side, speaking words that fell on bloodied ears – who knew if she could hear? – the only response being the methodic beeping of the monitors and the eerily empty breathing of the ventilator. The police would pull them out one by one to question them – a final insult to the torture of the whole process. Who was suffering the most at that instant?

And what could have been so bad as to bring someone to that point? How do you get there? How is that even possible? How can you be that self-absorbed?

I started to write my explanation, but I erased it. Why even pretend that I really understand? Besides using the clichés of hopelessness and alienation, I would write only from speculation. And anger. I’m not suicidal and I never have been – I don’t have it in me, and for that I am grateful.

We see a lot of horrible things in surgery. But suicide, for me, is the worst. Nothing turns my stomach or puts me more on edge than an attempt at one’s own life. We are hard-wired to survive and preserve our life against all odds. There is nothing so unnatural as self-destruction. Maybe it’s because so much of what we fight is accidental, or by fate, or at least out our hands – suicide is just the opposite. It is intentional. Deliberate and purposeful, it is precise in its perverted meaning. It messes with my emotions more than I care to admit.

Ask anyone who’s worked in a hospital, and they’ll tell you that death has a certain look. She wasn’t dead when I walked out the door, but you see that it was coming. Just as she had wanted.

And that’s how my month ended.

The Surgical Soul

Thoreau once said that talent writes with coffee, but genius writes with wine. Tonight, I write with gin.

What seems like a lifetime ago someone very special gave me a book entitled “Mortal Lessons.” It is written by a surgeon, Richard Selzer, and it’s less about surgery and more about his observations on life while being a surgeon. One of his more memorable essays is called “The exact location of the soul.” It raises probing questions about what makes us who we are.

Flash forward a few years and I’m now an aspiring trauma surgeon. One of the popular texts written by a giant in the field – Kenneth Mattox – has a chapter titled “The wounded surgical soul.” Mattox describes the “seat of the soul” as a “spherical area, not much larger than a silver dollar, centered on the head of the pancreas.” He calls injuries to this spherical areas soul wounds because “they are more lethal than any other type of abdominal trauma.”

The mortality of these wounds stems from the critical anatomy that is in this area. The portal vein, the superior mesenteric vessels, the pancreaticoduodenal arcade, the inferior vena cava, and the origin of the right kidney all converge here. Furthermore, accessing this area for the surgeon can be impossibly difficult under the chaotic circumstances likely present.

Last night a young man came into our trauma center having sustained a single gunshot to his surgical soul. We operated for hours, and nearly depleted the blood bank, but it wasn’t enough to save him. The multi-focal exsanguination was too much and he died with our hands inside him trying to stop the bleeding.

It’s interesting to think of a soul as something less abstract than we normally do, but rather to think of it as a space with defined borders. A space that, when violated, has predictable – and catastrophic – consequences.

Of course, the thing about our souls is that – unlike our bodies – they are eternal. Everything we do is not about building up our lives but more about building up our souls. Every action we do to one another, and everyway in which we react, and everything we preach in the process all serves to impact our souls.

It is nice to think that I can sometimes help individuals whose surgical souls are wounded. But it’s nicer still to believe that my own soul is being mended by someone far greater than I.

My glass is empty - more gin?

Robbed

One of the amazing things about being a physician is getting to know your patients. This, I suppose, is obvious, but nonetheless it is one of the things that medical students look forward to.

Spending so much of my time in the world of trauma and surgical critical care has altered that aspect of medicine for me. For one thing, most of our patients are so sick that they are not able to talk or even capable of forming a relationship. And for another thing…a lot of our patients are, well, quite honestly, not people that I would normally befriend. A lot of our patients are not exactly stand-up members of society. It doesn’t mean they don’t deserve the best in care – hence what I do, and the hours I serve – but it does give one pause. The majority of our patients are drunk drivers, addicts who had an accident, or victims of violent crimes who are almost never as innocent as they proclaim.

The other night a bunch of kids got drunk, held up a store, and pulled a gun on the clerk. Shots were exchanged, and one of the kids ended up taking a bullet in the eye. We spent all night – and the next several days – taking care of him. He’s minus one eye, but should do fine.

Driving home yesterday (always an interesting task after a 30 hour shift) a homeless man approached my car at a stoplight. He held a sign that simply read, “I don’t rob, I don’t steal, I’m just homeless and need money.” Hell, if he’d only start robbing he may risk an eye but he would at least end up off the streets for a few days. Would it be worth it? I didn’t have any cash on me. All I could think of was that if I were homeless, I bet I would steal. God forgive me, but I probably would.

I recently remembered the French root for the word “bereavement” is “to have been robbed.”

Speaking of forgiveness, today is supposed to be the end of the world. Do you ever wish it would be so? Do you ever find yourself wanting to have things so completely taken out of your hands? So much of trauma surgery is about eliminating the mayhem that surrounds critically ill patients. It’s exhausting. The rapture of God’s creation is one scenario that I wouldn’t be expected to try to control. It’s a refreshing thought.

Well, I fully expect to wake up tomorrow morning and go to work. I’m sure my one-eyed patient will be waiting for me.

Wrong

I recently heard an interesting presentation by the journalist and author Kathryn Schulz. In short, the talk was about being wrong. The part of the talk that most stood out to me was an analogy using Roadrunner and Wile E. Coyote. It seemed that in every episode there was that scene when the roadrunner ran off a cliff and the poor coyote followed. The roadrunner simply started flying, but the coyote kept running. And it took a few moments for him to realize he had just run off a cliff. In other words, there was a brief second when he was thought he was still running and in fact he was about to fall.

The lesson, Schulz tells us, is that being wrong doesn’t necessarily feel like that anything. Or more specifically, it feels exactly like being right.

And that got me thinking. There are so many parts of my life that could potentially turn into Wile E. Coyote moments of disaster that it’s simply terrifying. The trauma bay, the operating room, personal relationships, my faith…Am I about to fall off a cliff without even realizing it? Who is going to get hurt most in that process?

We’ve all heard that beautiful sentiment of the wings of faith: that when we come to the edge of all that we know, we must believe that we will either be given hard rock to stand on or wings to fly. Lovely – but it never seemed to happen to the coyote. How does that fit in?

Schulz argues that being wrong is fundamental to being human – it’s what makes us who we, as a species, are. She mentions that Saint Augustine – nearly a thousand years before Descartes wrote “I think therefore I am” – proclaimed “I err, therefore I am.”

I guess it’s comforting to realize that we live in a world full of mistakes, many of them our own. I don’t think it means that we have to accept them, but it does mean that, one way or another, we will encounter them. Lots of them.

I just went for a walk. It’s a lovely evening, so I figured I might as well enjoy it. I walked up long flight of steps leading to art museum and turned to gaze at the city skyline. I stared at those buildings and those lights, and as I did a warm breeze touched my face. How many mistakes, I wondered, had I made up until now and never realized it? What can I do to start realizing it before it’s too late?

Souls at All

Sometimes I just have to wonder.

Consider my two most recent patients. The first is a young woman, barely twenty. The father of her child found out that she had moved on to another boy, and so he quietly followed her one night. When he saw them coming out of his house, he ran over her with his car. He crushed her spleen, caused massive internal bleeding, and broke her neck. More specifically, he caused an atlantoaxial dissociation, which is a fracture at the very top of the spinal column. It’s what we call “functional decapitation” because, while the head is still attached, it has been severed from the rest of the body. These patients don’t do well.

Another young woman – this one just over twenty – got into a fight with her boyfriend. He simply pulled a gun and shot her in the neck. The bullet managed to blow apart her esophagus and trachea on its way to implanting in her back muscles. The five-hour surgery is an indication of how long her path to recovery will be.

And when I hear stories of my friend’s ensuing custody battle, I hurt – and get sick – on a totally different level. Anger, betrayal, deceit, manipulation…words whose meanings are so painful that even typing them unnerves me.

These days, I find myself spending much less time wondering about the eternal destination of our souls, and more time asking if we have souls at all.

The world changes when you start actually entering the idea that we are soul-less, purposeful-less, utterly useless creatures here for our own devices and desires. This world sucks. I hate it. I hate living in a place full of soulless creatures.

One of my favorite places in Philadelphia is the garden outside the Rodin museum. At the entrance to the museum stands his impressive masterpiece “The Gates of Hell.” Standing over twenty feet high, it depicts humankind’s ultimate condemnation. It’s inspired, in part, by Dante’s description of the gates of hell in his Divine Comedy, with the famous inscription “Abandon hope, all ye who enter here.”

But I know I have a soul. If not, then what am I feeling, and why is it so powerful? I’ve seen in so many others, and I know (think?) I’ve felt it in my own self. I don’t think it’s just my wishful thinking. As Annie Dillard writes in her essay An Expedition to the Pole, “What are the chances that God finds our failed impersonation of human dignity adorable? Or is he fooled? What odds do you give me?”

And maybe that’s just it. Maybe we do have souls, we’re just really, really bad at knowing how to use them. And as depressing as it may be to realize we’re not quite as good as life as we may think, at least – at least – we have hope.

And that is good enough for me for now.

Let it Rain

It’s raining today. A dark, heavy, steady rain – the kind that almost makes a wall. I was standing at a window in the hospital just now, and looking up it was like I was standing at the base of a great wall, one that extended from the hospital tower to the heavens. Only it was a wall of water, or rather, a wall of tears. Looking out, it was like I was staring at a wall of tears.

On Palm Sunday we sang one of my favorite hymns, “A Stable Lamp is Lighted.” It’s one of my favorites for so many reasons…I first heard it at the Christmas Eve service in my parish church when I was in third grade. I had a small solo that year, and I was incredibly excited. And I sang it well, to be honest. But later in the service – and unbeknownst to me – a slightly older girl sang “A Stable Lamp is Lighted.” She knocked it out of the park; it my have been the first time I experienced the raw power of music.

All these years later, in a different parish church, we sing this hymn on Christmas Eve and then again during the Easter season. Again I re-experience the raw power of it all, as I am forced to connect Christmas and Easter in a way that we are seldom asked to do. And even as I fight back my own tears, I sing:

And every stone shall cry
For thorny hearts of men
God’s blood upon the spearhead
God’s love refused again

And every stone shall cry! I see another wall of tears – a transparent wall between me and Christ crucified. A wall of water, but not one that is falling but rather one that is rising up, out from the crying stones on the ground.

On Palm Sunday we heard a sermon from an old friend of mine who loves to start things off with a story. This time around he recounted a Civil War tale. On a bloody battlefield in Georgia, a young Confederate soldier refused to kill. Amidst a torrent of bullets and knives and all manner of chaos, he stood there firing his gun skyward, unloading every last round into the heavens, refusing to shoot another man. He was exposed, defenseless, totally vulnerable…willing to take whatever came his way while refusing to do the one thing – killing – that might actually preserve his own life. And even now I see yet another wall – a rainy wall of bullets falling around that brave soldier. I picture him almost dancing as he empties his rounds – dancing to that haunting tune “A Stable Lamp is Lighted.” And every stone shall cry! The rain of bullets nearly forms a halo around him.

Sometimes I feel like that soldier – or maybe I just want to. With chaos and death and injury and hurt and sadness all around me, what choice do I have but to feel like I am simply firing my gun skyward and accepting whatever blows come my way? Or rather, what choice do I have but to fire my gun skyward?

There is something empowering, however, to think of myself as firing a gun into the air, and to say to the world that I can take the consequences. I’ll only go so far – I won’t kill – and I’ll take whatever comes from that. It’s very close to feeling totally defeated, but it is very different.

The rain has stopped, and the sun now shines. The buds of spring are all around – newness is thrust upon us.

Alleluia! He is Risen!

Working on major holidays always makes for an interesting night. I’ve only actually ever worked on one Christmas Eve – and I’ll never forget it – but yesterday evening/this morning was the first Easter I had ever worked. I kept my fingers crossed.

Of course, on this day of new life and rebirth, the horrible tragedies just kept rolling in. A horrific set of injuries in a car accident; a husband whose wife had stabbed him in the neck and whom we have to take the OR; a young man shot through his car windshield into his arms, face, and back; a young women found floating in a creek near her wrecked car.

My God, my God – why have you forsaken us?

I forced myself to get a bite to eat before leaving this morning. The cafeteria was basically empty, and the options were slim. But I settled for a yogurt, juice, and a corn muffin.

It’s hard not to think of family on Easter Sunday, and as I ate that silly muffin my thoughts drifted to my grandfather. He attested that the Revolutionary War was won, in no small part, because of corn. Fresh, New Jersey corn on the cob, to be exact. According to him, the bloody Lobster Backs were so entranced by the fresh corn that they couldn’t help but to just keep eating it – and all the while with the Yankees shooting away, winning the war, one ear at a time!

And while telling that story always makes me smile, it somehow saddened me to tell it only to myself, with no one else around to hear. Still fresh in the wake of the destruction that was the night before, I felt lonely, even further from the message of Easter.

My prayer this Easter – for me and for you – is to feel the warmth of the love of the risen Christ. He is with us in the car accidents; he is with us during the shootings and the stabbings, no matter which side of things we find ourselves on. And he is with us during somber moments of reflection. May we never feel alone – because we are not.

Happy Easter!

Thirst

There are many uncomfortable things about being a surgical patient. We put big IVs, and tubes, and drains into nearly orifice of your body as we try to get you better – the term “violation” comes to mind. But really what we’re doing is attempting to put your body in a position to best heal itself while we just provide the support.

One of the things that patients complain most about, interestingly enough, is when we don’t allow them to eat or drink. Nil per os – or NPO – is the designation for nearly every surgical patient who has an active issue. Part of this is to allow the GI track to rest, which sometimes is enough for recovery. Other times this is needed in anticipation of surgery. When a patient undergoes induction of anesthesia, the risk of aspiration – or regurgitation followed by choking – is greatly reduced if the stomach is completely empty.

It’s always been interesting to me that patients complain about being NPO at least as much, if not more, than anything else. We literally have patients who are recovering from gun-shot wounds to their bowels, or who are fighting life-threatening pancreatitis, or who are going to the OR imminently for repair of their pelvis which was fractured during that horrible car accident just a couple hours ago, and all they want is a simple drink of water. That’s it. They are experience excruciating pain and discomfort, not to mention emotional turmoil – and all they want is some water. And the answer is no; the risk of complications with anesthesia is just too great, and too unnecessary to take.

One of our attending surgeons recently made an interesting observation. On the trauma service here, we are forced to deal with a fair amount of death, and therefore a lot of end-of-life issues with patients and families. He observed that in conscious patients who are nearing death – and for whom we are providing comfort measures to – one of the last things they will do is ask for something to drink.

Yesterday was Good Friday, the celebration of the remembrance of Christ’s crucifixion. Because of certain circumstances, I was scrambling to find a church to go to, and my best option was a Catholic parish just a couple of blocks away. I’d been told before – by someone who, like me, loves the Episcopal tradition but who, unlike me, had Catholic roots – that while the Episcopal faith was beautiful, the Catholics just always seemed to get Good Friday right. I half smiled as I wondered where she would be going to church that afternoon.

The Mass was indeed lovely. And as it happened they read the Passion from the Gospel of John. Some scholars will remark that the big breakthrough in Biblical studies came with the understanding that the four Gospels were not necessarily four different historical accounts, but rather four different works of historical literature, written with different biases and for different purposes.

The Gospel of John is unique in that it explicitly has Jesus, while hanging on the cross and just before he dies, looking out and saying “I thirst.” He is given a quick drink, and then exclaims “It is finished.”

And now we wait.

Dreams, Part II (or Heartburn)

I haven’t been sleeping well lately. Again. Maybe it’s because work has been especially demanding these past few days. And it’s in the throws of those sleepless nights that my dreams become so vivid.

The other night I dreamed I was a trauma victim. I saw myself there, on the gurney, with tubes and lines and monitors all hooked up to me. I wasn’t in any pain, but I was fully aware of my predicament. In the dream, a couple of members from the trauma walked up to me to check things over, like we do on every trauma patient, several times a day. But they were unusually hesitant. I looked up at them and uttered “it’s different when you know the person, isn’t it?” They were silent, and tried to go about their business. Just then the situation changed. Alarms sounded. My pulse shot up, and my blood pressure dropped – I was struggling to breath now. Somehow I knew – like can only happen in a dream – that I was having a tension pneumothorax. This is when air escape the lung but stays inside the chest. The air expands, and pushes your lung and heart to the other side of your chest. It can be rapidly fatal, as it collapses your arteries and veins and allows for no forward blood flow. The only solution is to decompress the chest with a needle, and to release that air. My friends stood motionless as I thrashed on my bed and somehow found a large, 14 gauge needle. I unsheathed it, and held the tip of it right between my second and third rib spaces on my left – just above my heart. I took one frantic look at my friends who nodded their approval. With only a tad of reluctance, I stabbed myself.

And then the pager went off. I was awake. I clutched my breast to make sure there wasn’t anything sticking out of it.

The page was alerting me to a new trauma. A guy ran a red-light and then attempted to avoid being pulled over from a police car and had managed to flip his vehicle in the chase. He had suffered some obvious orthopedic injuries to his lower extremities. Likewise his passenger suffered injuries to her legs. What became apparent, though, through some questioning, was that this gentleman ran from the cops because he didn’t want his wife to find out that his passenger was actually his new girlfriend. The plan didn’t work out too well, though, because while he was lying there in the trauma bay his wife was notified and she immediately came in. And so she saw the both there – her husband and his girlfriend – lying side-by-side in the trauma bay. With their matching lower extremity injuries and all.

Running away – it just always has a way of making things worse.

I finished my work and pulled myself back to the call room and hoped to get another hour or two of sleep. But just as I shut off the light and put my head down I felt something very unusual for me – heartburn. Massive, burning, nearly incapacitating pain like I have never felt before. I was literally writhing in pain. I imagine the pain was located somewhere between where I was going to stab myself and where our new patient’s wife was feeling her own hurt.

I searched high and low, but there were no antacids to be found. I settled for some crackers and milk. What could have been a nice two-hour sleep turned into a thirty minute nap.

I hope I don’t dream again tonight.

Dreams

The Stanley Cup Playoffs have finally begun, and while the Flyers have been a tad disappointing lately, I always rest my hope in their fate and blindly cheer them on. I like to tell myself that the pit I feel in my stomach these days is not at all something deeply personal but rather my nearly visceral concern over their goaltending situation.

I’ve had a recurring dream lately, which is odd because I seldom used to remember my dreams. I’m playing hockey in this one. I’m effortlessly carrying the puck through the neutral zone, nearly dancing as I glide over the ice. My head is up, I’m stick-handling well…I’m doing nearly everything right. Just then a new player appears, behind and to my left, and so out of my view. His stick is raised, and it comes down and chops at my feet. I never saw it coming. My skates are forced into each other, and I am thrown through the air. I crash onto the hard ice and slam into the boards, where I curl up and remain motionless. Suddenly it is all darkness. And then I feel a hand on my shoulder. A soft, gentle, sweet hand, whose every contour I know and love. It…feels…so…wonderful.

And then I wake up. I guess it’s more of a nightmare, really, or at the best a cruel joke.

Today is Palm Sunday. The Mass, no doubt, will be beautiful and moving. The triumphant start to Holy Week. We all know what’s coming.

On the Brink

Las Vegas is quite the place. A bit overwhelming, to say the least – it’s the place where you see quiet couples clutching each other’s hands to make sure neither gets lost in the crowds and chaos.

It’s definitely a town of consumption. Food, drink, sex, gambling…you know the list as well as I. And it’s all there for the taking. Of course, with some of us, the concept of taking doesn’t set very well. You shouldn’t take what’s not yours – we teach that lesson in preschool because it’s that’s important.

For the last couple of hours of my time there, I found a quiet ledge overlooking the fountains at the Bellagio resort. These are big, spectacular ones from all the movies – I loved them. In the dead center of Sin City, I found myself alone, and in quietness. I wore sunglasses so nobody could see my eyes. One year ago I spent time overlooking a very different body of water, under very different circumstances. I was not alone then.

A few days earlier I had actually been doing pretty well. I was laughing, making sarcastic comments, energetically going about my work – maybe it was the right combination of sleep, breakfast, and company. Who knows. But I actually caught myself – you’re not supposed to be this happy, I said. Stop it. Remember? And looking at the fountains I found myself angrily saying – you’re not supposed to be this sad. You’re in Vegas! Remember? I get to the brink of happiness and I bring myself down. I get to the brink of throwing myself into that water and I somehow pull myself up. Up and down I go until I’m exhausted.

Right on cue the fountains came alive and started dancing. “Time to Say Goodbye” echoed over Vegas, and the fountains put on a show that nearly put tears to my eyes – yet another good reason for the sunglasses. Of course, the song isn’t a gentle, inspiring bit of empowerment that we might think it to be. It’s more a testimony that the world forever changes once you find love. Indeed. And once that love is lost – or taken – the world changes again. Thanks for the reminder.

I am glad to be out of Vegas. There's only so many ups and downs I can handle.

Ora Labora

One year ago. It was the happiest weekend of my life. There were families, friends, flowers, music, rings, and promises. There was joy and excitement. There was a dress, suites and ties. There was nervousness, and yet there was peace. There were memories of the past fueling hopes for the future. It all felt so real.

And of course, there was love.

Now what? What’s left? From the list above, not much.

How could things have changed so profoundly in a year’s time?

Come, labor on. Who dares stand idle? Not I! Not I!

So for now I'll stop crying and start standing up straight again - and try to become whatever it is I'm supposed to be.

Goalies are Crazy

I’ve spent a significant amount of time standing between goal posts attempting to keep small, hard, rubber objects from getting past me. Whether on the cool ice of a hockey rink or the worn grass of a lacrosse field, I just – for whatever reason – always felt comfortable in the goal.

Everyone knows that goalies are crazy. I mean, who in his right mind would willingly choose to block pucks and balls with his body? Most kids dreamed of scoring that winning goal; I dreamed of preventing it.

In my earliest days of playing hockey it was all I could do to stand on my skates without falling over. I have a video of my first game. Everyone is in position for the opening faceoff, but they all had to wait as I slowly made my way from the bench to the goal, falling several times along the way. In those early years when I was scored upon – which happened quite regularly – coaches and parents and teammates would all come up and express words of encouragement. And this mostly consisted of them saying “it’s not your fault.” When I was six, that was helpful to hear.

As I grew older I allowed far fewer goals. And it became increasingly clear to me that, as a matter of fact, it was entirely my fault when a goal was scored. Whose fault could it be? Goaltending is very difficult, but it’s also insanely simple: keep the puck out of the net. That’s it.

And that’s a pretty hard line to take on your own performance. But I did it, every day, and still came back for more. Goals would score, I’d blame myself, and inevitably more goals would come. I’d have good days and some bad ones too, all the while trying to give off the impression of an even-keeled goaltender. I loved it. Maybe that’s why goalies are crazy.

But the real crux of the matter isn’t the degree to which I blamed myself. The real test came after the goal was scored and the teams were lining up for the next faceoff. What then? How would I react? The goal had already scored, the right light had flashed, and the crowd was still excited…but what will you do now? Because another shot is coming. At least I know that much.

Scarred

Last week a young man came into the surgery clinic complaining of severe abdominal pain. His pain was crushingly bad. He had been nauseous and was vomiting, and his belly pain would come and go with the sharpness of a knife. It actually reminded him of the time he got stabbed last summer.

At that time he came into us as a trauma victim. The knife had passed through his abdominal wall and torn a hole in his small intestine. He was taken immediately to the OR, where that segment of bowel was resected and the remaining portions reconnected. He would walk out of the hospital with a rather long scan down his belly, but other than that he was good as new.

Except that, as I tried to explain to him, his body hadn’t forgotten that little incident. The scar he still sees on his abdomen – although it’s somewhat faded – was the result of us cutting his skin. But the same scarring process was going on inside him. The area where his attackers knife passed and where our scalpels would follow was an inflamed, wounded mess, and his body was trying to scar it out. Unfortunately this is not without consequence. The scars form long bands – called adhesions – ad they can wrap around your intestines, causing life-threatening intestinal obstruction. Can you imagine? A healing process gone horribly wrong.

The next time you see me, look closely at my face, and see if you can see the scar from the scalpel. It will have faded by then – hopefully – but realize that it’s really nothing more than a representation for the scarring that is ongoing within me. And even as the outward version is improving, it’s impossible to tell what’s really going on inside. Perhaps it’s nothing. Then again, perhaps one day I’ll be so buckled over in pain that I’ll need surgery. Here’s hoping.

Cavitation

The other night a man was brought into the trauma bay. He had been shot in the back, just inside his left wing-bone, and the bullet had traveled through his chest and exited just to the left of his sternum. “Through and through,” as we say. It never ceases to amaze me how small the wounds look on the skin. They so small, in fact, that they often fool us into thinking that they are not serious. A large chest tube was placed into his thorax, and two liters of blood rushed out. It was off to the OR.

With the help of a cardiac surgeon, we sawed through his sternum and exposed his heart. It actually looked pretty good – essentially injury free. We looked next at his left hilum, which is the beginning of his left lung and the confluence of arteries and veins there. It was a pulverized mass of destruction, hardly recognizable, with blood pouring out of a gigantic hole. He was dead, even as we identified the fatal blow.

When a bullet travels through someone it makes a track – a simple line of damage along the path of the missile. But it does something else as well. The kinetic energy of the bullet causes a cone-shaped area of destruction which is wider than the simple path. This is called cavitation.

The analogy that is often used is that of the wake of a boat. When a boat travels through the water – let’s just imagine for a moment that it’s off the coast of Maine in happier times – it obviously disturbs the water along its path. But the wake reminds us that the disruption extends much further than we might have imagined.

Personal relationships are the same way. I don’t know if it’s possible to have a serious relationship without cavitation – without that energy reaching far wider and wounding much deeper than imagined. The wounds on the surface may look deceptively small, but inside – right next to the heart – they cause massive, and potentially fatal, hemorrhage.

Ischemia

When a patient presents with signs and symptoms of an ischemic limb – that is, an arm or leg which is slowly dying from lack of adequate blood flow – there are a number of simple observations we can make to grade the severity of the disease process. The patient will develop pain and a loss of muscle function; the limb will become pale and cold, and eventually pulseless and avascular. Death. The very first thing to go, however, is sensation. The webbed areas between the fingers and toes will grow numb, and the palms or hands will lose what’s called “two-point discrimination.” That is, if I undo a paperclip and bend it in a “U,” the patient will not be able to tell whether one or both points of the “U” are touching their skin at a given time.

Sensation, we must conclude, is pretty important, because when our bodies are facing anoxia and are threatened, it’s the first thing to go. And failing to process what’s going on can mean serious consequences – like the loss of a limb.

But as important as it is for the doctor to evaluate the sensory capabilities of the patient, the simple act of doing so can be nearly just as important. The osteopathic medical profession places a lot of importance on physical contact – that is, assuring that the patient positively senses us. One of the most common complaints raised against physicians is “he never even touched me.”

I’ve never been a particularly touchy-feely sort of guy. I’ll give anyone I meet a handshake, but when it comes to hugs and long embraces or even a gentle rub of the back – it just doesn’t come that natural to me. I go out of my way to do so, however, because I realize it is important to most people. What I never realized was truly how important it is to me.

Yesterday I was having a terrible day. I just was. I was working with a colleague and apologized to her for how useless I had been over the past few days. She smiled, said not to worry, and very innocently and honestly gave me a gentle rub behind my shoulder. It was the strangest thing in the world – it was totally asexual, yet her hand on my back felt like white lightning. I realized that her touch was the first from a women – other than my mother or sister – that I’d experienced in a long time. I had no idea that that sort of physical contact was important to me.

It seemed I had lost sensation, and after months of gut-wrenching pain had become simply numb. Like an arm whose blood supply was cut off, I was going through the stages of ischemia, starting with the loss of sensation which would have ended ultimately in death. And this gentle touch on my back was the lightning bolt of revelation to the process at hand. It snapped me back to reality, like a rush of oxygen to my brain.

When we re-vascularize a limb – when we do surgery to make sure more blood gets to the arm or leg – it nearly instantly gets more pink and warm. But the sensation is slow to return in full. In fact, where the patient once felt numbness or maybe even nothing at all, he will now actually feel pain. That pain will eventually go away, and morph into normal sensation.

My personal ischemia left me completely numb. Now I am back to feeling pain. I only hope it is on the way towards normal sensation.

Completion

He looked like any other ICU patient. He was young, sure, but other than that he was pretty typical. The endotracheal tube down his throat was attached to the ventilator, which controlled his every respiration. The Foley catheter drained his urine into a bag at the side of the bed. While he lay still, the leads from the monitors indicated that his heart was beating rather fast, and that his blood carried a healthy amount of oxygen.

The only thing is that there was really very little at all that was healthy about this boy. Because this boy was dead. Brain dead. We were merely keeping his organs alive so that they could be harvested and donated to people currently fighting for their lives. This boy had already lost that fight.

His parents said their goodbyes, and kissed him one last time. We took him to the OR where we made an incision from the base of his neck to just above his pelvic bone, exposing his entire viscera. After some brief blood tests, the process commenced.

First a preserving fluid was infused throughout his body. Then he was exsanguinated. His heart was stopped and then quickly removed in a matter of minutes. The cardiac surgeon cradled it like a baby as he hurried to get it safely packaged for travel. At that point all the monitors were turned off and the anesthesia team left. The typical bleeping of the monitors went silent – it was as if our patient had somehow become more dead.

Attention was then turned to his abdomen. His liver was next to go. The student standing next to me remarked how big it looked – the surgeon had to scoop it with both hands as he turned and placed it on a table behind him. It was big, I thought to myself – until very recently it had been rather busy keeping a young, active boy alive.

His pancreas was dug out from behind his stomach, which had become eerily white now that all the blood had been let out. Finally the kidneys were plucked from the now relatively empty body cavity.

In “Never Let Me Go” Kazuo Ishiguro writes of individuals who are forced to donate their organs to society. It typically takes two or three trips to the OR before the individual finally succumbs, a process he calls completion. We completed this boy in just a couple hours.

It was an odd thing to stand there during this procurement process. In my mind were the horrible scenes from “Never Let Me Go” that turn organ donation into horrible thievery thinly cloaked as generous science. Yet what I was witnessing was truly an incredible gift that would help save the lives of numerous individuals. He was their prayers answered. And for his parents, it was a way to never let go of his precious memory and sense of vibrant life.

Never, ever, let me go. Please. Even when I am gone.

Death Actually

It is all around us. This is what happened.

Last night a boy got into a horrible argument with his mother. She had sensed something wasn’t quite right, that they had become distant somehow, and she was devastated. She somehow found a stash of pot in his room. They fought. They cursed. And he left.

About six AM he got into a horrible car crash. At seven AM he arrived in our trauma bay. We spoke to his mother and father at about ten. We told them that he had suffered a massive brain injury and that his chances of survival were essentially zero. The pain and the guilt in their faces were devastating to witness.

The only things left to do were the brain death exams. As a trauma team we tried to elicit pain by pinching his nails; we dripped water into his eyes to see if he would blink; we brushed gauze against his corneas to see if he had any sense at all in his eyes; we blasted cold water into his ears to see if his brain was active enough to sense the temperature change; we turned off the ventilator to see if he would breath. Another physician came and did the same exam with the same results – our patient was dead.

Another women came in a few hours earlier. She was young, too young to have already survived high-grade breast cancer, and the chemo-radiation and surgery and subsequent reconstructive surgery needed to do so. She had regained her life, and was working with mentally challenged adults, helping them get to and from whatever activities and appointments they needed to life a somewhat normal life. The other day a man fell on her, and hurt her arm. Over the next day her arm became swollen and tense. Her heart raced, and her blood pressure dropped. She came into the ER with a very palpable radial pulse – that’s the one you can feel on your wrist just above your thumb. It’s the one people try to sever when they commit suicide. This morning she lost the sensation of that pulse, which meant the internal pressures in her arm were so high that it they were occluding the blood from flowing into her arm. And so we took her to the OR to explore her arm.

Her arm was dead. All of it. Her muscles, her fascia, her nerves, even her veins….all dead. We went into the operating room thinking that we might make a couple incisions and relieve some excess pressure – we ended up disarticulating her shoulder joint and amputating her entire right arm, putting on a temporary dressing, and transferring her to another hospital where they could treat her with hyperbaric oxygen – a last ditch effort to save her life.

Sometimes I feel my own pulse, just to make sure it’s there. I place my left first two fingers on my right wrist and feel the pulsations transferring from one wrist to the other hand. I think that it’s so odd, that here is the place where I (well, where others) would take their life, and it is here where I (yes, I) feel to confirm life.

It’s nice to know I have a pulse, even as death actually is all around us.

Left for Dead

A trauma victim came into the emergency room in the early hours of the morning the other day. He was clearly drunk, mentally challenged, and he had just gotten out of prison. He had been badly beaten – his eyes were swollen shut, he was missing teeth, he had broken glass in wounds all over his arms and legs, and a huge gash in his scalp which was bleeding badly. We stopped the major bleeding, made sure none of his other injuries were immediately life-threatening, and then began the arduous task of cleaning and mending his every laceration.

The most disturbing thing of it all was that, as far as we could piece things together from the police, this assault had happened several hours ago. The police found him unconscious in a pool of his own blood, hours after the nearest bar – which he had been seen at – had closed. It seemed his assailants beat the heck out of him, and simply walked away as he lay on the asphalt, with a slow, dark red pool forming underneath him. He wasn’t exactly dead, they must have known, but maybe, with enough time, he would get there. Fortunately for him he was discovered and brought to us.

I’m not quite sure which is worse, really – the physical abuse of someone, or the walking away. Because walking away necessitates being fully aware of the suffering and therefore fully aware of the solution, and yet choosing to do nothing about it.

When you are left for dead – and I pray it will never happen to you – you end up with a lot of time to reflect. “Time on my hands, could be time spent with you” quoth Sir Elton John. It turns out he knows what he’s talking about.

And what have I done with that time? Gone for walks. Starred out the window. Drank way too much. Had bad thoughts. Drank again. And again. And through it all I keep asking myself – how are you not watching? How is it that I’ve been left for dead? Like that man on the street I lay still, drunk, unable to move, with the blood slowly filling in the spaces between me and the cold pavement. It’s nice to know my blood is so warm.

And all I can do is wait patiently for the police to come, and bring me to some over-worked trauma resident to mend my wounds and stop the bleeding. I hope it happens soon.

Going Back

Not too long ago we had a terrible trauma. A teenage driver lost control and wrecked his car, and in the process killed his best friend who was riding in the passenger seat. I wish this sort of thing didn’t happen very often, but sadly it does. The boy’s recovery was a long one. He had to have multiple surgeries to repair his many fractures, and he needed intense therapy to re-learn how to walk.

He also had difficulty with his brain. Diffuse axonal injury – or DAI – is a condition that happens in many trauma patients. In short, it is tiny foci of injury that happens to lots of areas of the brain all at the same time. It occurs most commonly in car accidents, when the rapid deceleration causes the brain to strike the inside of the skull and rattle around like a tennis ball inside a shoebox. It causes people to be incredibly slow to wake up, and to profoundly affect their behavior when they do wake. In our patient, it altered his memory. It altered it in such a way that he would forget the accident and his role in it and his dead friend – he would “remember” it, as if for the first time, every morning for months. It was like some perverted, new brand of torture.

Or was it? Maybe it was just his way of going back to that moment as often as it was necessary for him to come to peace with it. CS Lewis writes of sin in this way by making the analogy to a lengthy math problem, with several steps, each building upon the last. If you happen to make a simple error in step number two, obviously the final answer – even if you performed the next twenty steps correctly – will be wrong. Pushing onward, despite doing so perfectly, will never get you to the right answer. In fact, the only way to ever find the correct solution is to go back, all the way back to step two, and make the correction, and then complete the rest of the problem.

The boy is doing well now, I’m told. He’s been able to move on. And in a certain sense I think it’s because he had to go back to that moment of the accident and figure out a way to confront it head on. He didn’t just push forward with this tragedy in his past – he went back, found peace, and then moved on. It doesn’t mean he forget the accident or in anyway feels less pain – it just means he found a way to live with it, and not blindly go forward.

It is Lent now – a time of self-examination. I am daily trying to go back, find my errors, correct them, and find peace so that I too may move forward.

Forgive and Remember

Last night two trauma victims came into the trauma bay in rapid succession. The EMS gave a quick report on the first one: a woman, sixty, pedestrian, hit by a car and thrown roughly fifty feet. Her right leg was snapped right below the knee, and her tibia was sticking through the skin. Her left leg felt like jelly. Her pelvis bone – which normally is solid as a rock – was a loose, broken mess. Her right shoulder had bad bruises on it, and there was a large amount of blood coming from the back of her head. We started to work on her. Her eyes were open, and she as moving, but that was it. We got IV access, and intubated her for her own airway protection. I drew some blood from a vain in her groin and handed it off to the lab tech to get us STAT labs. But…we couldn’t get a blood pressure.

At that point the second trauma came in. A male, twenty-five, with an obvious deformity of his right lower leg. The bone wasn’t sticking out, but it looked pretty bad. Other than that he seemed to be OK. He looked up and asked “how is my mom?”

We got him out of the trauma bay right then – he didn’t need to see or even hear what was coming next.

His mom didn’t have a pulse. CPR was started. In trauma patients, sometimes this is caused by something called a tension pneumothorax, which is a collapsed lung that is pushing against the heart, rendering it useless. We placed large needles in her chest followed by large chest tubes to decompress the chest cavity. Still no pulse. We put a huge IV in her neck vein and transfused her massive amounts of blood. We ultrasouded her abdomen – all negative. I took a scalpel and made a 3 cm incision below her umbilicus, and gently placed a catheter into her abdominal cavity, looking for blood or any other signs of where the trouble might be. Nothing. Her pupils became fixed and hugely dilated – her brain was literally herniating down into her spinal column. She was dead.

The placed looked like a war scene, with blood and gowns and gloves and needles everywhere. And when it all stopped – when the code was “called” – the room was silent, and everyone slinked away, defeated. And she just remained on the table, lifeless, and cold. But yet, after that last hour of hell, she finally looked at peace.

I’d almost forgotten what it was like to lose someone that quickly. What a horrible thing to say! I’d almost forgotten what it’s like to stop, take off my gloves, and stand there quietly, listening to my racing heart and panting breath as I stood over death. There is a prayer I always say in this situation:

Dear LORD, have mercy on us all who tried to help. And have mercy on your servant who passed away. Hasten your angels to this bedside, and usher her into your presence, that, if it may please you, she may this day be with you in paradise. Amen.

In this season of Lent, we hear so much about forgiveness. What I’ve learned recently is that forgiveness should not be confused with forgetting. Forgive and remember, I say. Remember the pain, the suffering, the neglect – but forgive. For it is only in that forgiveness that we might find peace.

I pray now for both forgiveness and that peace.

Cutting

It’s one thing to feel sad, and to be upset, and to cry. It’s another thing altogether to confront those feelings. In the absence of being able to properly confront them, sometimes just taking a good long look in the mirror gets the job done.

The other day I did just that. Blood-shot eyes, tear-streaked cheeks, and unshaven chin, I thought long and hard about the person staring back at me. I tried to look into my eyes but it was too painful, and felt unnaturally awkward. So my eyes strayed to my cheeks. I stared at them because there was nothing else to stare at. And I noticed something peculiar – a large, ingrown hair, slinking under my skin. It was nearly completely unnoticeable, but in the absence of anything else to do – that is, except more crying – I felt the urge to rip it out. So I picked, and clawed, and scratched…all to no avail. This just won’t do, I said to myself. I’m a surgeon – I have better ways.

The next day I found an unused disposable scalpel at the hospital. Perfect, I thought. I slipped it in my pocket and hurried home after the day had ended.

I brought my face close to the mirror and strained my eyes to focus on that spot as best I could. I caught a glimpse of those same eyes in the mirror – there were no more tears or blood-red capillaries. Only rage, and obsession. Perhaps this is progress.

I unsheathed the blade and held it up close to my skin, and marveled at the cool steel as it reflected the bathroom light. My eyes were angled such that I was straining to focus the blade and my skin in the mirror – I saw two of everything. I tried to steady my hands against each other and against my face, but they were shaking rather significantly. Not good for a surgeon. I had to focus. I brought the scalpel closer, focused my eyes, and steadied my hands. I let out a long breath.

And I cut.

And then I cut again. And then a few more times. Every stroke took off a little more skin, and shed just a few more blood cells, and came that much closer to exposing that damned ingrown hair. And it burned with every pass. It stung. It was real pain – but it was pain I was controlling. And for a moment – a precious moment – it was all the pain in the world, and all of my pain too. No other pain mattered. And I alone controlled it.

It was finished. The hair was exposed. Out it came, and into the trash went the scalpel. I caught my breath and looked back into the mirror. My eyes were hollow. My face was scared. And I am still alone, though more hideous than ever.

Drowning

Today it’s raining rather hard. The sky is unusually light for the amount of rain that’s falling. Walking in, I stood and stared skyward, stretched out my arms, and tried to open my eyes. There was water all around me – soaking my cloths, falling up my nose, getting into my eyes. The light grey clouds above almost seemed like a place I could escape to.

I read an article the other day about an elite surfer. He described what happens when you wipe out on a really big, serious wave. You go under violently, of course, but then the wave keeps pummeling you while you’re underwater. You open your eyes and look up, and the blazing sun dances its way through the ocean, reminding you of the peace and safety above. But you can’t get there – you have to endure and take your beating until the wave has passed and you can surface. The trick of it all is that you have to be strong enough to not drown until your pummeling is over with.

Recently I’ve been taking a beating like I’ve never felt before. I don’t know exactly when I fell off the really big wave, though I know now that I am surely underwater. I’m taking my licks as best I can. But I’m beginning to feel as though I’m drowning.

I stood outside today so I could look upward, and pretend I could see a light, and know that there was something up above that offered peace and safety. The trick of it all is that I need to be strong enough to not drown in the meantime.

I guess time will tell. But for right now, between me and you, I’m getting close to closing my eyes, opening my mouth, and taking in a big, final, breath of water.

Fortunately for me a car drives by and startles me. I walk into the ICU where sick patients need me. The rain beats against the windows – a reminder of the wave that is still crushing my heart.

End of the Line?

You can’t make this stuff up.

This morning – after an early trip to the OR for a stab wound – as I was running around trying to get some of the paperwork together, a familiar tune came on over the hospital loudspeaker. It was Brahms’s Lullaby. And, as in this case in most hospitals, that means that a baby had just been born. It’s obviously a very calming song, and it usually has a very calming effect on me. And that effect is often magnified during a morning such as this one, where I had just participated in the care of someone who had suffered a violent injury. To be fighting death and yet be reminded of new life is a wonderful thing. But this morning, I confess, I was jealous.

I was jealous of the mother as she realized a new life had been created inside her. I was jealous of the father as he watched his wife deliver a child. I was jealous of the hopes, fears, dreams, and challenges that a baby brings. I was most jealous – can you believe this? – of the look my wife would give me right before things got really serious. It’s the look that says “can I do this? Is this real?” and the look I give back that says “of course you can do this – this is our child.”

I thought lunch might help my hurt. But after sitting down two unusual things happened. First, my colleague pulled out his phone and started showing pictures of his one-year-old baby boy. And then, right on cue, a whole train of pregnant women and their husbands came into the cafeteria. It seems they were getting a tour of the hospital, so that they and their families would be well-acquainted with the facilities during that emotional time. They were happy, nervous, and anxiously looking around, taking it all in.

That day – the day when I get to walk around the hospital, or look into my wife’s eyes, or hear the music – that day feels further away from me right now than it ever has before. It’s a day, I’m beginning to realize, that may never come at all.

And that is a horrible thing to feel.

Abandonment

A “friend’s” brother has a dog – a funny looking dog – who was apparently left as a puppy. When you leave the dog alone, even for a bit, he goes crazy – barking, jumping up into the window to see you leave. It’s said. The poor dog has a fear of abandonment. He was left as a puppy, and now he’s afraid anyone who takes care of him or loves him or whom he loves will leave him for good.

Another friend of mine – an old teacher/priest – once said that, after observing plenty of people face death, that the only thing that seems to matter is how well you have loved and how well others love you.

Relationships are complex, for sure. And mistakes happen. But strong relationships are supposed to endure. They endure because they matter. Because the people involved care. Because when you commit to something, you stay committed. That’s supposed to matter.

When those commitments fall short, people get hurt. When they are terminated, people get destroyed. And that destruction takes its form in the feeling of abandonment. The feeling of being completely left alone by the one you love, and the one who used to love you. It’s terrifying how thoroughly you can be hurt by someone.

I’m the dog barking crazily. I’m a dog! I’m looking at the window at anybody I’m close to as they walk away, even if I know it’s just for a little while. I’ve now been abandoned.

Mistaken Identity

We’ve all heard stories about mistaken identity in the medical world. A patient gets the wrong procedure, or the wrong medication, or the wrong study…I can’t say I’ve ever been involved in anything even remotely serious – at least, not that I’m aware of – but I’ve had a few stumbles. I’ve had to ask patients which side we’re operating on, or make sure we’re doing the right surgery – it’s all part of the checks built into the system.

Just this morning I was trying to find a patient before the OR. The nurse handed me the chart and pointed to an elderly woman in a stretcher. There’s your pre-op, she said kindly. I opened the chart and started reading as I walked. Suddenly the chart was taken out of my hands and a new one put in its placed. Sorry, the nurse said, this is the correct chart. She gave a sheepish smile. No worries.

Yesterday afternoon I got an email that made me stop dead in my tracks and break out in a cold sweat. The title of the email was simply my last time, and the body of the email was a forward with several correspondences. I didn’t recognize the return address, but it seemed like he wanted me to review a conversation. He was a lawyer, a “family defense” lawyer. It seemed that his client – who shared my last name – was being sued for divorce by his wife. The emails were a series of conversations between lawyers who were trying to clarify the ugly details. Somehow it got forwarded to me by mistake.

I read it again. And again. And again. And every time my heart raced faster and my face got more flushed. This isn’t supposed to be me, right? Are lawyers trying to find me? Is my wife suing me? My heart was drowning myself out. No, it was clearly an accident – right? – check the names again. It’s just a mistake, but one that stung more than most accidents are capable of. It hurts to even think of it. It wasn’t me. Relax! It wasn’t me! But so close. Too close.

It’s a funny thing, to have your identify mistaken. And it’s odd to realize the different levels that it can be hurtful. There’s the simple insult of being confused with someone else. But there is also hurt in confronting the confused situation. Is it better or worse than my life? Is it too close to home? Is it possibly knife-piercing foreshadowing?

I hate being confused. I hate confusing others. Know me for who I am. And let me know you for who you are. Then, finally, there will be peace.

Community

An old teacher of mine – a friend, really – once reminisced on a job interview he had at a new school. And he remembers feeling this: that what made this particular school special was that he had an overwhelming sense that this would be a wonderful place to experience a tragedy.

It’s an odd notion to have during a first impression, maybe, but it’s an important feeling to have. Oftentimes it might be a school, or a church, or a workplace. But let me say this: it is also a wonderful thing to experience that feeling in a person.

I see a lot of tragedy at work. And I see a lot of different family dynamics take on that tragedy. I see people dying in the most dignified way, with their families and loved ones all around. And I see people dying who desperately want to keep fighting, and keep living. And I see people dye alone, without anyone there to love them except some doctors and nurses.

I often think – what will my death look like? Who will be there? I’m sure plenty of folks will stop by or be sad for a bit – but who will really be there with me? Holding my hand, and tying to make me happy, even at the last? And who wants me to be there at her death? Who really wants me there, offering my love, and my support? Anyone?

For a combination of reasons, I slept well last night. And I slept on my left, of all things, and even woke up that way. And today, for the first time in a long time, I felt just a little bit like myself.

Back Pain

Driving in the car this morning I realized how badly my back hurt. Back pain is something new to me – it wasn’t pleasant. But realizing why it was there in the first place was even less pleasant.

I love to fall asleep – I just love the whole process of coming to peace at the end of the day and realizing that tomorrow will come anew. The words of The Book of Common Prayer – so often uttered at Evensong in my childhood – wisp me away:

O LORD, support us all the day long, until the shadows lengthen and the evening comes, and the busy world is hushed, and the fever of life is over, and our work is done. Then in thy mercy grant us a safe lodging, and a holy rest, and peace at the last. Amen. (BCP)

So falling asleep is a peaceful thing. I hear these words and roll on my left side. I sleep on the right side of the bed – that’s my side – so I turn to my left so I can see.

The problem is I can’t turn on my left side at the moment because I don’t want to see. Because there is nothing to see – there is only emptiness. So I slide as far to the right as I possibly can and turn on my right. And it’s uncomfortable. And rather than hearing soft words of prayer and drifting slowly away, I grit my teeth and tense my back.

It’s no surprise then that driving this morning – a trip that is always shorter than I think it is – my back started aching. I tried driving faster, but I couldn’t help but notice that the ETA on the GPS never changed. How could that be? I even got stuck behind a truck near construction, and again the ETA never changed. I was trapped in that car for as long as it was going to take me. For a moment I felt I had lost any control on my life – on my sleeping, my psyche, my body, even where I physically was.

The only thing to do was keep driving. Eventually I would arrive at my destination. Eventually.

Burned

I’ve just wrapped up another month at the burn center. My rotations at that little specialty ICU over the years have managed to coincide with some emotional times in my life, and as a result they’ve proved the starting place for some important revelations.

Burn victims have the potential to be some of the sickest patients in the whole hospital. But aside from just that, one of the most difficult things for the families and friends is the total disfiguration of their loved one. Your skin is your largest organ, and when it’s violently removed it can have a devastating effect. Just last night I was asked by a women where I might find her dearest friend in the world whom she had traveled to visit. I didn’t know what to say – she was standing right in front of him. But his face was missing, and the tracheostomy tube at the base of his neck was a gruesome reminder that we were performing for him the most basic of human needs – breathing.

How could this be? Her pain was so clear. Just last week he was fine, working long and happy hours at his store, spending time with his family. She’d seen his recent picture on Facebook – on her computer she could still see his precious face and look into his eyes and feel that trapped happiness that was more temporary than he could have ever imagined. How can change come this dramatically, and this quickly? How is that even possible?

I have no idea. But consider this. As I started to walk away another family member, from two rooms down, popped his head out and tried to get my attention. He’d spent many evenings here, and I’d spent plenty of time speaking with him and his sisters over the long month explaining all aspects of our care. “Hey Doc,” he said as his eyes locked on mine, “thanks for giving us our mom back. She looks terrific.”

In every possible sense, the burn center is a transformative place. I guess I just never imagined myself being transformed there. Then again, if this line of work didn’t change me somehow, I’d wonder if maybe I wasn’t missing something. Lord knows, I’ve missed plenty of things before.