Herniation

In the simplest sense, a hernia is when something goes where it shouldn’t. This requires a breakdown of the usual barriers in the body. Sometimes these barriers are simple, and sometimes they are quite elaborate. The consequences of a hernia, as you therefore might imagine, range from mildly irritating to rapidly fatal. As general surgeons we deal a lot with inguinal hernias, or hernias that arise in the groin area. This a place of natural weakness in the body – especially in males – and therefore has a predilection for herniation to occur. The bowel pushes through the floor in this region and can cause pain, or even a true obstruction of the gut. If there is enough pressure on the bowel it can become ischemic and die – off hand, I can think of one person who died under these circumstances. As trauma surgeons, we deal a lot with traumatically injured brains. When the brain is injured – from assault, or a car accident – blood forms inside the skull. When the condition worsens, there is too much pressure that then expels the brain downward through the base of the skull – the foramen magnum – on its way to the spinal column in a vain attempt to relieve the pressure. This kind of herniation is rapidly fatal. The other day I saw a hernia unlike any I have ever seen. This woman had her uterus removed several years ago. The remaining cuff – that is, the portion where the uterus opens into the back of the vagina – is either sutured or stapled. This particular woman had recently undergone chemotherapy, and as a result that cuff opened. As luck would have it, her intestines worked there way through that opening – she eviscerated her intestines through her vagina. By the time we got her to the operating room, that portion of her small bowel was dead and needed to be removed. It’s a miracle she didn’t die. It’s safe to say that none of us – neither me, nor the colo-rectal surgeon on call – had ever seen anything like this before. But we were all in agreement: nothing we had ever seen just looked so wrong and obviously in need of repair. The body has countless built-in defensive barriers, and when they fail the consequences are too-often catastrophic. Something things are just supposed to stay put. As we look towards the new year, let us assure the barriers in our own lives are solid, and that we don’t herniate where we’re not supposed to. Let us stay where we belong, wherever that is.

Between Two Worlds

The other night on call I was presented with a very sick patient. A woman in her early 70s had been admitted with abdominal pain. After a couple days of testing and retesting a CT scan of her abdomen ultimately revealed an ominous finding: pneumotosis colitis, or air in the walls of her colon. It likely meant that she had infracted part of her intestine and would need urgent and massive surgery. If she didn’t, we feared, she would die very quickly. Unfortunately what was required was a resection of whatever portions of her intestines were dead. Sometimes just a little, but often quite a lot – either way, it’s the type of operation that can kill you because it’s such a stress on your body. And so she had to make a choice. Spend a few quality hours with her family and likely be dead by morning, or take a chance at a massive operation which she might not survive. I hated pressuring her, but every moment we waited we risked more of her intestines dying. She looked at me with wide eyes – “I’m not ready to dye tonight.” A part of me wanted to tell her that that decision had likely already been made for us, but I resisted – she needed to find hope in the surgery I was offering. She signed the consent form. And so she was there, stuck between two worlds – so delicately in this world, and so close to entering the next – I could see her closing her eyes and wishing all this were a dream. But it was not. We put her to sleep and cut her open. With my scalpel I took long swipes over her abdomen revealing her damaged bowels. It wasn’t as bad as we thought – I’m haunted by the notion that she might have made it ‘till morning after all. I’ll never know. And so it is often in this work – we make decisions and live with them. But we get to live. Others, not always. The choices are ours; the consequences, theirs. All we can do is our best. And at this Christmas time I am reminded that long ago in Israel someone stood between two worlds, this one and the next. And then too decisions were made, decisions that ended in death. It is all so fragile. The family thanked us for our efforts. I pray we did right.

A View of the Forest

As I walked into the majestic church the bell was tolling. Steady, soft, ominous, it rang its monotone melody with a notable sense of purpose. As I scampered inside I was struck by how full the nave was. Sneaking into the very last pew on the left – for some reason the side I always sit on – I gazed upward. The gothic arches form a weave which, while architecturally similar to the underbelly of a great ship, is visually similar to the way the branches of tall trees interlace and form a canopy above a dense forest. The trickling beams of light from the stained glass often forms lasers of dense light, the way sunbeams pierce through leaves. On this day a few hundred of us faithful souls gathered in the nave of a gorgeous church to honor the life of a dear friend. As the incense rose upwards and the noonday sun intensified, little lasers of light dotted the congregation. I wonder, sometimes, what God thinks of us there, gathered in His church, honoring one of His servants. Sifting through the canopy of the church and the incense, His omnipresent vision piercing through, dancing among us like a firefly – momentarily intensifying and then shifting – He looks at all of us. Does He pity us for mourning something as petty as a human life? What does such a think amount to when compared to the eternal divine? Of what is my friend’s life when weighed against the resurrection? But no. Our God’s own son has gone before us into death, so He knows exactly what it is to lose a loved one. To feel the emptiness in our gut; to wonder incessantly about the prospect of eternal death. I utter softly: Dear God, have mercy on your servant Richard. Hasten your guardians to his side, and usher him into your courts; have mercy on his soul, and, if it be your will, I pray that he may spend this very day and all days forward with you in paradise. It becomes clear to me as the service continues, as the choir chants and the organ thunders…the business of building God’s kingdom on earth was entrusted not to angels or archangels, but rather to humans. To us. And so we must go onward, in the confidence of His love, to do His work while we still can. So go. Go to work. Let us make our time count.

On Call

There’s nothing quite like being on call. As I write this I am all alone in my little call room. As call rooms go it’s fairly comfortable – I have a bed, a bathroom, a TV, a desk with a computer…everything I need, really. Some calls are insanely busy – a hectic continuation of the day, with hardly time to swallow a drink of water before the morning arrives. Other calls are slow – a strange calm blankets the place. It’s not exactly the calm before the storm, but rather more like the eye of the storm – there is destruction swirling all around, which inevitably will blow my way. There are two aspects to call that I’ve never gotten completely used to. The first is the waiting. The pager will eventually go off, or the phone will surely ring. The door will knock. Someone will need something. When? Soon. At least, probably. Knock and the door shall be opened? Sort of, only I’m the one opening it (which may be very anticlimactic for some!). People ask questions of me – all sorts of questions, all day and night long – because they need to. Otherwise I wouldn’t need to be here. I remind myself that it’s an honor. The second is the loneliness. As a surgical resident, like it or not – and it turns out – I’m alone quite a lot. I don’t necessarily mind it, I guess. I can think, write, catch up on things…all alone. I’m getting pretty good at it, though something tells me I’m being prepared for something. I’m haunted by an old man who worked at a little restaurant near where I went to grad school. I went in late one night for a dinner, and while I normally went in with my classmates this evening I was by myself. He noticed this and made a comment about how I was alone – “but you’re supposed to be alone, I think,” he added. It struck me as an odd thing to say – perhaps he knew something. And so what will this call bring?

Goodbye

So I’m finally back to writing. And oddly enough, I’ve come to say goodbye. It’s important to keep a record of things. As some writers have expressed, it’s impossible to know where our emotions are taking us if we’re not perfectly clear on where we’ve been. When I was writing here over a year ago, one of my friends expressed how remarkable it will be to someday look back and review this record of my sadness, and, God willing, be grateful for my progress. I didn’t really understand how right she was until last week, when I reviewed some of what I had written. That was some journey. So goodbye to all that. Goodbye to the sadness, and to everything that that sadness affected. And it’s only now, now that I can hold my head up and say these things, that I am ready to fully welcome my new life. A new city, new state, new job, and new love. Hello to all that!