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

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.

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.