Baby!

Not long ago my wife and I were blessed with a baby.  A beautiful, healthy, little girl.  Our lives are joyously forever changed. 

It’s amazing how delicate the whole thing is.  Two tiny cells come together, and start dividing, and dividing, and specializing, and then they become organs, and those organs start functioning, and then…she came out with all her countless complexities working just fine.  How does that happen?  And then, after she is born, she’s totally dependent on us for everything.  For nutrition, and warmth, and care, and protection…everything.  She’s so delicate.  I feel as if the whole thing could go wrong at any point, and that it hasn’t so far is an absolute miracle. 

I recently heard a sports commentator say that having a child is something that unites all people, in all lands, across all times.  It’s just something you don’t understand until you experience it first-hand.  And when you do, you see how hard it is – how crazy it is! – and then you realize that it’s something that every single parent in human history has experienced.  There’s not a lot out there that unites everyone. 

I keep thinking about those ancient humans, wondering through fields or mountains or deserts, without the comforts of 21^st century America – how did they do it?  How did they struggle so hard for simple survival and take care of little ones?  How did we, as a race, survive? 

Maybe my daughter isn’t so delicate?  Maybe humanity is stronger than I think?  No…she’s pretty tiny, and pretty helpless.  Beautiful, but totally helpless. 

I also think about the baby Jesus, being just as dependent on his parents as my daughter is on my wife and me.  That God humbled Himself to become a human is something I’ve tried to understand; that He became an infant is something I never even thought about until just now.  I got that there was supposed to be a connection between God and me though Christ, but right now, I think, I feel a certain connection to Mary and Joseph, a connection that has caught me off-guard, and one that has brought me even closer to the divine. 

For the birth of my child, and for all children – Thanks be to God!

Take 5

I’ve noticed that I only tend to write when things aren’t going well or when I’m terribly stressed.  I don’t know why – I wish that weren’t the case – but the truth is, I think, that I use writing as an outlet to distract me and my emotions.  I don’t necessarily write about stress or about hardships in my life…I write about nature or religion or medicine or surgery or whatever happens to strike my fancy that day.   I should say more clearly that I don’t overtly write about my life, but if you happen to know me and happen to know what’s going on, then I suppose it’s not too difficult to connect the dots between anything I’ve ever written and my life.  Hell, there are only so many possibilities. 

Writing, for me, is kind of like running – I feel much better afterwards than I do during it.  And so when life is going well, I tend to not put the effort into writing.  I guess I get lazy. 

So here I am, out of shape, wanting to get back into the game.  Not because I was ever particularly good at it, but rather because, in a very real sense, I know that I need it.  And I need it as much as when I’m happy as when I’m sad. 

And so let’s be clear – I am very happy, and very stressed.  I’m tired of people telling me how terribly stressed I look, how much more gray my hair is, how sunken my eyes are.  I drink more coffee than I ever have, and I get more heartburn than ever before…I’m never far from my stash of Tums. 

And why?  Why now?  It’s not because of anything particular, and not because of anything anyone has done to me…it’s just my life.  I just need to complain.  I realize my issues may pale in comparison to yours, or somebody else’s – I get that in the spectrum of humanity I really have no business to complain at all.  I get it.  But I also just need 5 minutes, then I’ll shut up and write about happy things.  Promise. 

You see there is this pesky thing called oral boards that is the culmination of the last seven years of my professional life, and it’s beginning to weigh on me.  It’s less than two weeks away, and it’s pretty intimidating.  It’s kind of freaking me out.  I’m supposed to know everything and talk my way through it.  And then there is the job hunt that should be much further along than it is – it’s really not going well.  And the prospect of having to find a real job, and move, and get a house, and start new schools for the kids, and a new job for my wife, and hope it all works out…it’s just kind of bad timing right now.  And trying to be a good husband and father to a child and a brand new baby through this all is not very easy either.  I often feel like a terrible husband and father, not because I do anything bad but because I have so little time and energy to do all the good things I’m supposed to do.  And it makes me feel terrible, and inadequate.  And then when I’m at work I’m taking care of the sickest people in the whole damn hospital, and somehow I’m supposed to be doing that with compassion and a smile and not mess up even though I’m terribly distracted.  And sometimes it all seems like a too damn much. 

That felt good.  So that’s all, I complained…and I’m done.  Thanks for listening. 

I can do this – I can do all of this, I know I can.  Heck, I know I will.  I just need the occasional pat on the back, the occasional reassurance, the subtle compliment.  In the absence of that, I just need vent and let it go.

Grace under pressure…that’s what a good goalie is, that’s what a good trauma surgeon is.  I’m ready! 

Ignore

It happens all the time in the world of trauma – we take care of people that most would rather ignore. 

Somewhere in the depths of this city a cycle of gang-related violence led to the death of several innocent women and children.  The suspected murderer was the target of a police raid, and when that raid got violent his motionless body came into our trauma center.  His airway was controlled, his brain was scanned, his pressures were normalized…within a week he was finally talking, and within two weeks was read to leave. 

This patient was under police custody, and so there were guards outside his room.  Armed guards.  And it was always odd walking past them to see our patient.  It felt a little like we were crossing a picket-line.  The police exist to protect us, or so we’re told, and here we were trying to take care of someone they were trying to put away.  We literally had to ask them to step aside so we could see our patient.  They would always look at us as we entered his room, and if to ask us why we were taking the time.  One day the guard was looking down at the patient’s mug shot – the guard was smiling and shaking his head, saying how he’d “been looking for this one for years.”  I remember being struck by the word “years.”  The patient was only a teenager – how long could the police have been searching for him?  More recently when we exited his room and the door closed, the guard uttered “I don’t know how you all do it; this is a really bad guy – really bad.” 

If I told you what this patient had done, and why the police cared so much about it, I’m willing to bet that you would agree that he did something absolutely terrible.  The worst, repulsive thing imaginable.  But we had no choice.  He was our patient, and we’re under oath to take care of people, just as the police are under oath to protect and serve.  There’s just no other option.  Patients are patients, people in need are people in need.  It’s rather simple, really.    

And so there we found ourselves each day, police and doctors, looking at each other with vastly different motives.  I’m not certain if there was mutual respect or not. 

Our patient improved, and was discharged – to jail.  What his fate will be is uncertain – I suppose it’ll be in the news one day soon.  Or maybe it’ll just go ignored

Bloodless

At this point in my life and career, there’s really no reason for much of anything to surprise me.  Not that I’ve seen it all or anything – far from it – but I’ve seen enough to know that most anything is possible. 

But I guess I’m always somewhat disappointed to find that those of us in the medical world are genuinely surprised by matters of faith.  Men and women have been dying for their beliefs since, well, forever.  The whole point is that one’s faith is stronger than what is logical to those who don’t share that same faith.  That’s why wars are fought, and it’s why people – even the very young – dye happily when they don’t necessarily have to. 

And the other day that happened right here.  A young women – she was twenty – was mauled by her neighbors dogs.  Six of them, in fact – six dog she knew – somehow went crazy and attacked her.  As you can imagine they did a lot of damage.  Her scalp was nearly completely ripped off; her left breast was torn in two; there were slashes and puncture wounds that were too many to count scattered throughout her body.  Under normal circumstances these would be terrible injuries, but nothing that we likely couldn’t get you though.  However, this women posed a unique problem, because she was a Jehovah’s Witness. 

Jehovah’s Witnesses are a branch of Christianity – nearly 8 million strong – who, amongst other beliefs, refuse blood transfusions.  According to their official website (jw.org):

This is a religious issue rather than a medical one. Both the Old and New Testaments clearly command us to abstain from blood. (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29) Also, God views blood as representing life. (Leviticus 17:14) So we avoid taking blood not only in obedience to God but also out of respect for him as the Giver of life.

While all denominations hold certain beliefs, I can say that, in my experience, this particular belief amongst Jehovah’s Witnesses is unwavering. 

And so our young patient was in a bad place.  Her blood count was already dangerously low when she arrived, and by the time she was done with her necessary surgery to repair her scalp and clean her wounds her counts had dropped even further.  Truthfully, they were nearly incompatible with life. 

While I can’t predict the future I can say this: in my best estimate with blood transfusions this young lady would have walked out of this hospital in four or five days with some really bad scars but no lasting disability.  Without a transfusion, she would likely die.  The patient was awake enough to understand these words and she insisted on not receiving a blood transfusion.  Her mother was at her bedside and was adamant about honoring her daughter’s wishes. 

Within two days her brain was showing signs of not receiving enough oxygen.  By the fourth day she was brain-dead.  I guess it was a peaceful death. 

And all she needed was some blood.  A few bags hanging amongst her other IVs.  Maybe nobody would have even noticed.  We routinely transfuse our trauma patients.  It’s so easy. 

But this women didn’t want it, and while that’s nearly impossible for us to understand I guess that’s not really our job.  We’re here to serve, and sometimes that means putting the patients’ beliefs over our own understanding of life.  We did what this women and her family wanted, and I suppose for that we honored her.  But by the same token we sat back and watched her die, when the treatment was literally within out grasp.  If she had walked in off the street and asked us to help us die we would have refused.  Somehow this was just enough different. 

At least, I pray it is. 

Out of This World

I admit it – I’ve spent hours watching the reports of Malaysian Flight 370.  It’s bizarre and fascinating to me that, in this day, a Boeing 777 could just vanish.  How does that happen?  How can something as big and strong – as vibrant, event – as big jet airplane just go away?

In the world of trauma, we’re pretty good at keeping people around.  You may not be as good as when you first came to us, but…still, we tend to keep most of our patients alive.  People generally just don’t go away.   

But the other night that wasn’t the case.  An elderly man had a heart condition that necessitated a very powerful blood thinner.  His old, loyal cat got stuck on their roof, and for some reason this man decided to go after it.  He slipped and fell off, breaking his back in this process.  He had been a heavy smoker, and when people when bad hearts and bad lungs break their backs they get really sick.  One by one his organs began to rapidly fail him, until we were keeping him alive with a ventilator, massive amounts of blood transfusions, and vasopressors. 

The problem is that when someone gets such a massive amount of fluids, their intestines and abdomen get incredibly swollen.  This man’s swelling got so severe that it was affecting his breathing.  It’s called abdominal compartment syndrome, and the only cure is surgery to decompress the abdomen.  Unfortunately this man was too sick to even transport to the OR, and so we had to bring the operating room to him. 

And that’s just what we did.  In a flash of nurses and techs, a small, mobile OR was brought to the man’s bedside.  His skin was rapidly cleaned, I got scrubbed, and before anyone even knew what was happening I was opening his belly.  I made a huge incision – from his pubic symphasis all the way to his xyphoid – as quickly as I could.  I cut down past his muscles, through his fascia, and into his abdomen. His intestines burst out with a rush of fluid as the pressure was released. 

And quite rapidly he got better.  His oxygenation improved, and his blood pressure and heart rate normalized.  He was so close to death – so close to vanishing – and now here he was, showing us he was alive.  We got some supplies that we could use to temporarily cover his abdomen and went back to work, thinking that we had at least staved off death for now. 

But then he started bleeding.  Just as I was finishing we noticed blood welling up from beneath his liver.  His blood pressure started to drop, and I had to open up my closure.  The blood thinner was still in his system (some cannot be reversed, and this was one of them), and he was bleeding out.  When patients have a discrete injury it can targeted and ligated, but this patient was just bleeding from everywhere.  We tried to compress the bleeding but it didn’t work.  Dissecting just seemed to make it worse.  We packed and packed his abdomen to try and stop it, but all that did was stop the blood flow back to his heart.  Within a few short minutes his heart stopped. 

And that was it; he was gone.  He had been a vibrant man – a husband, a father – just a few short hours before.  And in a flash he had disappeared from his family forever. 

The family was gratefully for our efforts, but clearly devastated.  And so was I. 

I don’t really think we did anything wrong – I think he was just a really sick man who had a bad accident, and it was just too much for him.  And sometimes that happens.  Sometimes people vanish off this planet without a more satisfying explanation. 

Charlie

It’s interesting how certain things hit you certain ways. 

I deal with death almost every day.  Terrible, violent, and sudden death that rips families apart.  Sometimes it is really gruesome, and sometimes it is subtle and underwhelming – and in the world of trauma, it is always unexpected. 

I like to think that I handle these situations pretty well.  While I can plainly (even robotically?) explain the situation to families, I also have enough emotion in me to show genuine empathy.  In fact, I think I have much more emotion than the average trauma surgeon – I’m just good at hiding it when I need to. 

The other day I got word that an old friend of mine had died.  I hadn’t spoken to Charlie in a number of years, honestly.  We had one of those friendships that was on hold – we grew up together, but after going our separate ways to college and adulthood, we just drifted apart.  We’d see each other on occasion, and when we did it was as if we had never left – we just picked up right where we left off.  And so to hear of his passing thrust me back to my boyhood. 

Charlie was a gifted musician.  We met in the magnificent Washington National Cathedral, where we sang as boys in the cathedral choir.  We spent A LOT of time singing together…we had multiple rehearsals a day, sang five services a week, and performed on countless other special occasions.  I could only keep up that pace for three years.  Charlie did it for four, and then sang an additional two years in the men’s choir.  Every time there was a big solo it was his – he had the best voice, by far, and we were all very glad to give him the spotlight.  And even after our Cathedral singing days were over, we sang together in the high school chorale – we just couldn’t let go. 

The best singing we ever did, though, by far, was at Christmastime.  Christmas is a very busy time at the Cathedral.  In addition to the regular services, there are numerous other services, and all of them filled with music.  We had very little free time, but starting in the 6^th grade (so…1991!) we joined in a tradition of caroling at local hospitals.  (And the two of us – and others – would continue that well into our 20s.)  So on Christmas Eve, before the big midnight mass, we’d grab our hymnals and make our way to the hospitals.  It was just a small group of us – 7 or 8 or so – and we just sang.  We sang hymns, and anthems.  We sang in harmony, and took turns doing solos.  I guess we were better than most of the carolers that come to hospitals at Christmas, because doctors and nurses and patients alike would stop what they were doing and just listen.  Of all my years singing, it was on these occasions when we could so clearly see the joy and peace that our music brought to those in need. 

Charlie’s parents often invited us all to their house before and after caroling.  One year – we were in college, I think – they had us over the week before Christmas for a little celebration.  We ate some cookies and then made our way to a local inpatient hospice center.  Here, it was clear, we would be singing for patients’ final Christmas.  We tried to be upbeat, but found ourselves singing Silent Night over and over again.  From there we drove to a local hospital.  We sang our usual pieces, and at the end of the night ended up singing in the nursery.  A local couple had just delivered – we gathered around the babe and sang Silent Night once more.  On the same evening, we sang for someone’s first and last Christmas. 

Charlie’s favorite Christmas hymn was “Lo, How a Rose E’rr Blooming.”  We would sing it over and over and over again…he loved it.  The hymn speaks of the promise of Christmas, and the joy of heaven on earth.  It ends “Bring us at length we pray, to the bright courts of heaven,/ and to the endless day!”  I pray that Charlie is now in those bright courts, singing his heart out, and bringing joy and peace to all who hear. 

And I am lucky to have heard. 

The Quest for the Surgeon's Soul

I always thought I wanted to be a trauma surgeon for the same reason that a lot of young doctors do.  I wanted to save the world – one dramatic, glorious exploratory laparotomy at a time. 

About two weeks ago I got just that chance.  The young man was nineteen, and he was the victim of a single gunshot wound.  Upon surgical exploration we found injuries to his transverse colon, jejunum, gallbladder, his pancreatic head, his duodenum…our eyes collectively widened as we realized that what we had in front of us was the perfect patient for the notorious trauma Whipple. 

As we worked our way through the dissection, I kept thinking of Kenneth Mattox’s chapter titled “The Wounded Surgical Soul” in Top Knife.  If any patient ever had a soul injury, then surely this one did.  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 area soul wounds because “they are more lethal than any other type of abdominal trauma.”[1]

It is interesting to think of one’s soul as something discrete, and even more fascinating to think of it as something curable by surgery.  There it is!  There’s his soul!  Look at it, see it pulsating, feel it in the palm of your hand. 

Why does a surgeon quest for soul wounds?  Why are we so excited to attack this particular injury?  It may be the most challenging area to operate on under ideal circumstances; in the context of trauma, it becomes harrowing.

I think we look for soul wounds because trauma provides the best mirror there is for the otherwise invisible.  We are obsessed with anatomy and yet we never get the chance to see our own.  How many times have we treated victims and imagined ourselves – or our loved ones – in their position?  I look for soul wounds because I want to see what my own soul looks like.  When I operate on a young trauma victim, on some very real level I am operating on myself. 

And what does my soul look like?  What does it feel like in the palm of my own hand? 

It’s terrifyingly fragile; impossibly compact, and beautifully functional.  I marvel at the general similarities between all of our surgical souls, and also at the subtle differences that make them unique.  And as I’ve gone through my training, I’ve learned that what is unique about my surgical soul is that it needs trauma surgery to stay alive.  I need that mirror.  I need to be reminded that I am so similar to you, and yet also so unique.  And I know enough about my own soul to realize that healing another is curative for me.  Why am I becoming a trauma surgeon, you ask?  Because I have to, for my soul’s sake. 

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[1] Hirshberg, Asher, and Kenneth L. Mattox. Top Knife: The Art & Craft of Trauma Surgery. Castle Hill Barns, Shrewsbury, UK: Tfm Pub., 2008. Print.  Page 115