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

The Best Lasts

At anytime of transition, there are those special “lasts” that come along.  There is the last time you go to your favorite restaurant; the last time you go to your beloved church; the last time you see a dear friend. 

Some of those are met with an appropriate recognition.  At graduation there is honor and a family dinner; at church, there are hugs and prayers. 

But what about those lasts that you don’t recognize as being a last?  Often, it’s because you don’t realize they are lasts.  They just…are, as a way of your normal life.  And they slip away into oblivion peacefully, much, I suppose, in the way they entered in the first place. 

I’ll always remember my last time at the hospital, or the last time at church.  But I don’t think I remember the last time I saw the Philadelphia skyline, or the last time I saw the art museum, or the last time I saw any one of a number of special friends.  I never made it to a “last” Phillies game, or a last stroll through Rittenhouse Square. 

Maybe these are the best kinds of lasts, because it somehow leaves the door open for return.  It’s nice to celebrate things for sure, but it’s also nice to quietly slip away.  Even now if I close my eyes I can see the vast skyline of the city I called home for so long, as if it were just up the road from me now. 

Part of the wonder of being a trauma surgeon is this slipping in and out of peoples’ lives with barely their knowledge.  In a way I feel like that with Philadelphia – I’ve come and gone. 

And now…a new start.  

Homeward

It’s funny, being away from home.  As part of my job I stay in the hospital at last one or two nights per week.  Those nights are a mix of lots of things…so much happens at night.  With less people around there is more chance for real disaster, and it’s often here that our skills are really tested.  And of course there are the occasional slow nights – nights when we can relax a little, and reflect. 

The simple math is that I spend more time away from home than in it; the majority of my time is spent within the hospital walls.  More time is spent in the trauma bay, the wards, the OR…more energy is spent talking to colleagues, staff, and nurses…than home with my own family. 

A part of me is totally ok with that.  A large part of me is a workaholic, type A go-getter that wants to – even needs to – spend all night in the trauma bay and the OR with strangers doing what I do best.  But another part is crushed when I have to leave in the morning and know how long it will be until I return. 

I’m reminded of a story of an old surgeon sitting in the lounge between cases.  A younger doctor was also there, complaining about work.  He turned to the older doc and said, “with the way reimbursements are going, soon, we’ll have to pay to operate instead of getting paid!”  The older doctor thought about this, looked at him, and simply asked “how much?”

We love of our work.  We have to.  If we don’t treat this work with real passion, mistakes happen.  And in this line of work, mistakes translate into deaths.  And while the work gets me out of bed in the morning, keeps me up reading late at night, and gives real meaning to my life…I don’t think it will ever be everything to me.  I think home – family – will always be…more. 

It’s hard to explain, but being home brings a certain peace that nothing else can provide.  Even though it’s often chaotic, it has a certain calm.  There is such obvious purpose, such hope for the future, such…peace.  I miss it.  And I love it.  And being away from it makes me desire it even more.  As much as being at the hospital or preparing for work is a part of my life, and as much as being in the hospital feels totally comfortable and natural to me, it’s just not really home. 

Today is my last full day here at conference in Chicago.  Tomorrow I get to go back home.  

Review

My program director use to always preach this simple axiom: read as if somebody’s life depends on it, because someday it will.  It may sound a bit dramatic, but in a very real sense it’s true.  And it was that severity of our work – that true sense that it mattered – that made the endless hour of studying, the endless hours in the library, the blood-shot eyes…it’s what made it all so manageable. 

Of course, there is nothing so helpful as experience.  Just last week we were working-up a post-op complication.  I was explaining things to a concerned family when one of the daughters interrupted and said “But doctor, have you seen THIS before?  This scenario?”  I was glad I could look her in the eyes and answer that I had, and that I knew what to do, and what she might expect.

But that is not always the case.  Some circumstances are rare.  Or some are variations.  We have to be prepared to handle situations that we are less experienced in; that’s why we study so hard. 

So now I find myself in a board review course.  It’s somewhat surreal, really.  Some days I can close my eyes and surgery is still a distant dream; other days I still can’t believe how far I’ve come.  To be here, this close to the end – 2 months! – just seems unbelievable. 

But there is no romance in a review.  The most common question running around these hallways is “what is the board answer?”  Here we are not reading in the hopes that it will save someone’s life.  No, here we read with the anticipated bias of an examiner, hoping to out-guess the question regardless of how we feel about it. 

I guess it helps to stay focused on the bigger picture – I do, after all, have to pass this stupid test if I want to actually be a surgeon.  It’s just one more ridiculous hoop to jump through.

And I can take it for this too – surgeon is an immense undertaking.  It is easy to lose track of some details that shouldn’t be lost.  It’s easy to get swept away in the minutia of life, or of one particular institution’s habits…it is nice to see what others think is truly important, regardless of their motive. 

With that, I better run or I’ll be late!  Here’s hoping for a productive day.  

Less than Super

People often ask me what is the most realistic medical TV show. My answer comes without hesitation – Scrubs. I get confused looks right away, but somehow that quirky show with the lengthy inner monologues captures the spirit of what actually goes on inside hospitals.




The opening credits to Scrubs run to the Lazlo Bane song “Superman.” And the credits are timed to end with the lyrics “I can’t do this all by myself. No, I’m no Superman.”



This is, of course, not what a budding trauma surgeon wants to hear. My whole goal is to be a surgical superhero. Someone has a horrible thing happen to them, and I rush in and – nearly anonymously – fix the problem, only to fly away to the next patient, never to be seen again. A secret angel of the night.



Periodically this fantasy gets just enough reaffirmation to persist. Not long ago I was making early morning rounds with one of my co-residents when we went into the room of a lady who had underwent several large abdominal procedures. We were there to do an extensive dressing change and update her on the plan, just like we did every day before the sun came up. She slowly opened one eye, then the other, and then allowed herself a half grin – there are my supermen, she whispered, good morning! I allowed myself a little smile in return – it’s nice to be appreciated.



The only problem is that, in medicine, something is bound to come around that knocks you right back to earth. And, in medicine, that trip normally takes casualties.



It was Easter Sunday and I was on call in the hospital. I got a routine consult for abdominal pain, which quite honestly didn’t sound that exciting. The story was vague – intermittent colicky abdominal pain over several days, worsening this morning. Her labs were normal, an x-ray had some minimal changes in her intestines, but nothing crazy. Cardiology had some concerns, so she was put in the ICU and I put in a central line.



Within 24 hrs she was dead. She got really sick the next morning, and a CT showed pneumatosis intestinalis – air in the walls of the intestines, which we only see with necrotic bowel. It’s a surgical emergency, and one that doesn’t normally end well. In her case there was nothing to do. She was rushed to the OR, and her stomach, small bowel, gallbladder, and part of her liver were all dead. Her family withdrew care shortly thereafter.



Did I miss some obvious red flag? Everyone tells me no. Should I have been more suspicious and ordered the CT when I saw her? Everyone says there was no reason at that time. Are people just being nice to me? I’m not sure.



I know this much – that poor lady was dying when I saw her, and I didn’t realize it. I was her last chance at survival, and I failed at that task, the only task I had. Not so super at all.



There’s no good end to this story. A family lost their mother. I could go on and say that I’m more inspired to learn and work harder and all that, but that would just be rhetoric. I always try hard. That makes this even harder.



Perhaps the truths of Scrubs strikes again. I am not perfect; I’m no superman. I got that one loud and clear.

Moving

Moving is miserable. In part because it just is. And because I’m a legitimate pack-rat with a vivid memory, moving becomes a long and emotional process. I have SO much that many would consider trash – receipts, ticket stubs, cards, knickknacks…and they all bring back a flood of memories that very nearly pushes me over the edge. It’s a long process.

The other day I was sitting on my couch looking at a bare corner of my apartment. And oddly enough I was transported back to the spring of 2000. I was a sophomore in college, and had just finished a difficult semester that focused around the conclusion of organic chemistry. “Orgo,” as we called it, is the ultimate weed-out class. Some huge number of first-year college students start off as pre-med, but orgo somehow manages to make a lot of students change their mind.

Chemistry didn’t come easily to me; I really had to work at it. I did alright the first semester, but the second was too much. I got a C, and I was crushed. And as I was packing up my things for summer break I remember seeing my orgo book on the floor. And I looked at that weighty book and had such an overwhelming feeling of disappointment. I felt like I hadn’t reached my potential, and that more of me was left to give. I felt genuine failure.

I had a similar feeling in high school after a disappointing loss to one of our rivals in a big lacrosse game. We could have won – should have – but somehow it got away from us. I remember driving by that field several hours later, thinking to myself that this place was full of such hope, such excitement, and such joy just a few hours ago. And yet now…emptiness. It was incomplete.

I am moving for all the right reasons. Happiness, excitement, and joy are all at the other end. And in no way do I have any regrets about that. But still, when I look specifically at my apartment I get a sense of failure. The marriage, the relationships, the hope for a family – none of the things that I wanted before I moved there happened. And while the joy I have now wouldn’t be possible save for that failure, when I stand in my living room and see the empty walls and scattered furniture, the negativity is all I feel.

It’s time to move.

Relationships

The “doctor-patient relationship” is an often-discussed paradigm. It’s one of those things that prospective applicants talk about during interviews, and that older physicians love to pontificate upon. For me, it was something I looked forward to, but have only rarely experienced in all the glory I thought it was going to be.


The other day a lady saw me in the elevator, and excitedly addressed me by my name...


Who was she again?


She went on to say how great it was to see me…



Do I know you?


And she told me how great she was doing…



Do you have me confused with someone else?


And she thanked me profusely…

And then I remembered. Of course! She came in with abdominal pain, and we saw on her CT scan something concerning for a mass. We took her to the operating room and performed a major colonic resection. She ended up having a T3 lesion, and the oncologist was considering chemo. Her post-op course was longer than expected, but otherwise fine. She should do well.


And how could I have forgotten? How could I? I spent every day for about two weeks seeing this lady, and I spent about 3 hours with my hands literally inside her abdomen operating. And I had totally forgotten.


Maybe it’s because we all, on some level, try to disconnect with patients. How could we not? I thrive on emotions, and am at my best when I am emotionally engaged, but even I distance myself at times. We build connections, establish trust with patients and their families, but then it’s helpful to turn it off when it’s time to cut.


Or maybe it’s because the relationships we form aren’t really that secure. How could they be? We see patients for a couple of minutes a day. Even if we do this for a week or two, that’s really not that much time.


Or maybe it’s because this relationship – while life-altering for my patient, was just another day at work for me. It was incredibly intense for her, and business as usual for me.


My cousin recently lost her child during a C-section. She carried him for 9+ months, and was used to feeling him move every day. And so, a day or two past her due date, when she no longer felt him, she rushed to the hospital. Some monitors were placed and quick tests were run, and soon she was in the OR where the doctors were trying to get that child out of her as quickly as possible. But it was too late. He was dead. She held him for 3 hours – the funeral is this weekend.


My cousin, along with her family, is appropriately crushed. Her life will never be the same again. And it’s all because of a most unique relationship – one that developed daily over 9 months, but one that didn’t even involve speaking or touching, only a magical sort of feeling. In one very plebian sense she had no time with him at all; and yet in another, every second of her being has been spent making him, and preparing for life with him.


I guess it’s really not time at all that defines a relationship, but rather intensity. Our challenge as physicians is to make every patient feel that we are giving to them the same sort of intensity that they are feeling within themselves.

Ashes

I always used to laugh at doctors who wore their scrubs out of the hospital. How hard could it be to change? And isn’t that the whole idea, anyway, to keep the dirty scrubs at the hospital?

It wasn’t very long into surgical residency that I realized that, on occasion, there was indeed a time for wearing scrubs out and about. Not often, mind you, but sometimes it was just the reality of my exhausted existence.

But I hate to wear scrubs to church. I love church, and I take it seriously, and so I like to dress in a way that not only outwardly reflects that seriousness but also causes within me a certain focused nature.

And so I wasn’t too thrilled when yesterday – Ash Wednesday – I didn’t have time to change before the noon service. I arrived just in time wearing my hospital blues and sat in the back. But oddly enough I smiled, because immediately two scenes jumped into my mind, both from intern year. The first was at a small Catholic hospital where I was working. I had a difficult week – so difficult that I began to seriously question if I was on the right path – and so I sought out the chapel. I remember falling to my knees in a little pew and praying vigorously. I had my scrubs and white coat on, and somehow during those prayers I felt…comfortable. At peace. And I knew I was going to be OK. And the second…at a small inner city hospital (where I am currently working), receiving my ashes on Ash Wednesday. A local priest was in the main lobby, bestowing ashes on anyone who asked. And so I went to him, scrubs and white coat, and closing my eyes and tilting my head backwards received the ashes. And again I felt comfortable – at peace. This is who I had become; this is who I would be.

The sermon offered at church yesterday – preached by our brilliant associate rector – was all about God interjecting himself into our lives. Life doesn’t stop and let God in – God enters when He chooses. And to have the ashes once again placed on my forehead while I was in my scrubs somehow made me realize how our love for God needs to becomes manifest in our daily works, not just our weekly worship.

Oh man, remember that thou are but dust, and to dust thou shall return.

Secret Messages

The other day a woman presented to the hospital with vague abdominal pain. It had been nagging at her for about a month, and she just felt that something was wrong and wanted to get checked out. The emergency room scanned her over, and decided that there was something to her pain, and so she was admitted. The admitting medical team concurred, and consulted the gastroenterology group. Everyone was in agreement – her story, her looks…it all pointed to her gallbladder.

The only thing was that ultrasound – which is usually the best test for the gallbladder – was completely normal. But her blood-work indicated some sort of pathology- perhaps the gallstones had already been expelled from the gallbladder and were now stuck downstream? An MRI was ordered to confirm, but it, too, was normal. Her labs continued to worsen, and her pain persisted, so a nuclear medicine test was ordered. These are very good at picking up an occult cholecystitis, or attack of the gallbladder – sadly, it was negative.

I say sadly because patients like to know what’s wrong with them. Even when we hunt for a diagnosis and it comes back something scary, there is a certain relief in at least knowing what the problem is. There is a degree of comfort to at least giving your enemy a face, even if it is an ugly one. Most patients who have abdominal pain get a CT scan at some point during their hospital stay – in all honesty, it is often the first thing ordered. But in this woman’s case, the testing was more discretionary, and rightfully so. But now, with all roads turning up empty, worsening labs, and continued pain, a CT was justified.

When a CT scan is performed, it collects hundreds of images in just a few seconds to compile the pictures we see. Oral contrast is ingested to illuminate the bowel, and intravenous contrast is injected to illuminate the blood vessels and the highly vascular organs. When we ordered this particular CT, we asked the radiology tech to time the imaging to optimize our views of the liver and pancreas – the supposed region of interest – in the hopes that it might pick up any pathology. And it’s a good thing we did. The venous phase of the study showed the portal system was largely occluded. The liver actually has two systems of blood supply. It has an arterial supply (via the hepatic artery) which is analogous to every other organ in the body. But it also has what is known as the portal system. This is the network of veins which drain the bowels and bring their contents to the liver for processing. This is actually the major source of the liver’s blood. The clot within the portal system was so extensive that it had managed to kill the central portion of the right half of her liver. She wasn’t sick from a simple gallstone – she was sick because a major blood clot was killing off her liver.

She needs to have her blood thinned right away. And she’ll need that for about six months or until the clots dissolves. And we need to find out why this happened. There are really only two possibilities – either she has a disorder of her blood that causes her to make clots, or she has an occult malignancy, like lymphoma, that is causing her blood to behave this way. Either way, her life has been severely altered. It’s humbling to arrive at conclusions that are so far from where we start. Life’s messages are often hidden – we just need to keep searching to find them.

Pathways

A couple of weeks ago in church we heard the familiar tale of one of the most famous journeys ever undertaken. A long time ago, in a land far away from here, three wise men traveled a great distance to worship a child. The details of their trip are not recorded, but I can imagine that it was long, exhausting, and…indirect. I somehow doubt that their trip went too smoothly, and I am quite certain that it took them to a place – literally and figuratively – that they did not expect. For how could it not? It brought them to such a foreign land, with a radically different culture, where they experienced divine incarnation. Now how’s that for a road trip?

It’s interesting to think of our lives in this way - as a wondering journey, with some vague and abstract guide, leading us on to some foreign place. And what will we find? And how will it change us? Will we be so lucky as to encounter the divine along the way?

The great comfort of any journey is knowing that others have gone on before. Things are somehow less scary when we think we’re not alone, or at the least that the emotions and fears we’re experiencing are not totally unique. It’s comforting – don’t you think? – to pause and realize that others have done this before. A class in school, or a move, or a surgical residency…others have taken this path before. And made it. And the journey at the end of life – the pathway into death – I guess that’s the journey none of us really want to take. But as my friend’s father said at his wife’s funeral: how great the comfort is, knowing that our Lord has traveled there before.

I think about death often. I guess it’s because of the work I do, and that death is so prevalent around me. I think of my patients journeys into death, and what a wondering and twisted road it must have been – all the more twisted because somehow I became a part of it. I ended up being a part of their story, albeit at the end.

Today I told someone she was going to die. She is seventy-two, has five children, and yet I doubt that even one month ago she imagined she’d be sitting in that tiny hospital room she was sharing with someone else, with the curtain half-drawn and the TV next door still on, listening to some young guy like me tell her how mortal her condition is. Some journey. But then, in my mind…the knowledge and comfort that so many others – including our Lord! – have traveled this road before keeps me from breaking down. I pray that it brings us all peace, and that the journey – with all it’s indirection – leads us to encounter the divine.

Gut Check

The other day we were consulted to see a patient in whom they had discovered a pancreatic mass. This type of consult carries with it a mix of emotions. It usually means pancreatic cancer – a deadly diagnosis that often claims the life of its victim quite rapidly. Conversely, pancreatic surgery is some of the most challenging and rewarding operating there is. In a perfect world, we cure these individuals in fantastic manner. This patient was not the healthiest I’d ever seen. Pancreatic cancer normally strikes elderly, sickly folks, and this gentleman was no exception. He had smoked enough for two lifetimes, and it took its toll on his lungs and arteries. To even consider operating on a guy like this meant a meticulous pre-operative work-up. A work-up so involved, in fact, that we wanted to transfer him to a larger hospital because they had a greater ability to run more thorough tests. He was hesitant. He liked the hospital he was in – he felt comfortable, and it was close to his home so his wife could visit easily. She’d never be able to see me down town, he said in complete earnestness, even though it was hardly a fifteen-minute ride by car, bus, or train. It might as well have been half way across the country, to hear them talk. We argued gently. This was cancer, after all, and the bad kind – the kind that kills, and painfully, too. We weren’t even at the point to offer surgery. We just want to run some tests, and talk to some specialists….we just want to see if we can even do the surgery. Can’t we do it here? No; not well. We need you in a larger facility. He looked me in the eyes. I just have a bad feeling, he said quietly, his oxygen tubing snugly in his nose. Doctor…have you even had a feeling that something just wasn’t going to work out? Of course. Of course I do. Al the time. It’s my job to worry about the worst-case scenario, and to put my patients in the best possible position to survive should something catastrophic happen. Ok, he conceded, you’re right, I’ll go. But I just don’t think I’m going to make it. He went quietly. He thanked us and smiled. Two days later he was dead. I don’t know what happened, and nobody does. A heart attack, or a pulmonary embolus? He was in the hospital getting his myriad of tests and he just coded and died. Just like that. I guess he was right, this wasn’t going to work out for him. He knew something none of us did. He should have ignored us and just gone home. He should have – we all should have – listened to his gut.