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.