Intern Year: Stories, Part Two

9.

I once counted bullet holes in a patient.

1…2…3…where do these all go….4…5…is this the entrance or exit wound…6…7...wait wait wait, nearly missed that one…8…shit, did one go in his abdomen…9…10… hold up, what the hell is that– oh it’s just a bullet beneath his skin, keep looking for holes…11…I don’t understand how this just happens to a teenager…12…13.

He was 16, and he had nearly as many bullet holes as the amount of birthdays he had celebrated.

Since no bullets miraculously pierced his abdominal cavity, we didn’t have to take him emergently to the OR. However, the injury to his spinal column left him paralyzed from the waist down.

Stay in your lane, the NRA once said to us. 

But they haven’t walked through the blood on the floor or had it on their scrubs. They haven’t watched a family lose their parent or their child. They haven’t heard patients screaming in agony as we urgently examine and treat them, blocking out their curses with practiced detachment since we know that the temporary pain that they are feeling is a much better tradeoff than the morbidity and mortality that could await them if we gave into their cries.

Look for holes, look for holes…keep looking for holes. 

Later, once we had rolled the patient up to the ICU, my senior handed me a blank sheet of paper. I was confused at what it was for and she instructed me to draw a human sketch and mark where the bullet holes were, explaining that it was so the teams taking care of him moving forward would know exactly where the injuries were and so that none would be forgotten as time went on.

I started drawing – two crude, two-dimensional human outline figure drawings side by side, one to represent the front of the patient and one to represent the back. Now for the bullet holes. Head to toe, front to back. Hmmmm…do dots or X’s better represent bullet holes?13 marks littered across the sketches. It felt nearly surreal – as people moved around me in quick, chaotic fashion, I stood and awkwardly marked dots on my roughly drawn sketch, moving quietly amongst the multitude of people in the cramped room to recount where the holes were.

How many people, both children and adults, are going to be needlessly and brutally injured or murdered before something changes?

This is our lane,I want to say to them. How about you stay in yours?

10.

I once had a patient who lost his leg. 

He had developed an infection from hardware in his ankle that had been placed to fix an ankle fracture. After weeks of nonhealing wounds, antibiotic courses, and washouts to no avail, the next option was inevitable – amputation. 

It was a two-step process – an ankle guillotine amputation to remove the source of infection followed by a formal below-knee amputation a few days later after the infection had fully resolved to ensure that the stump would adequately heal. 

There’s something about amputations that’s hard to put into words. I try to imagine the mental and emotional process that patients must go through when we tell them that the best thing for them is to remove a limb, but it’s certainly not something I’ve come close to being able to fathom….the idea of going to sleep and then waking up with such a visible and important part of you missing.

Upon waking from anesthesia – is that the first thing they look for? Or do they try to ignore it for as long as possible?

It’s no wonder that it can sometimes take weeks for patients to consent for an amputation to be done.

I also have a hard time describing what it’s like to do an amputation, not from a technical standpoint, but from a mental one. Covering a patient in surgical drapes does a good job of helping with sterility in the OR, but they also sometimes serve as a helpful dissociation tool to some extent, allowing us to more objectively do our jobs. 

A metaphorical drape as much as a physical one.

Amputations are largely no different in that regard. I can cut and cauterize through skin and muscle, tie off vessels, and cut through bone with a whirring electronic saw with no issues. 

However, there is always a temporary, brief moment – right when the limb is fully amputated and I’m handing over someone’s detached foot or leg to the scrub tech – when the dissociation abruptly ends and the sudden awareness of what we’re doing is acutely discomforting. In my short career as a surgeon, no other procedure has given me that sense of momentary uneasiness.

I did both of my patient’s amputations. 

After my patient’s first operation – the ankle guillotine amputation – I went to his room one morning to change the dressing. The first operation, I feel, is particularly difficult for the patient since we don’t close the skin over the leg stump, leaving bone, muscle, and tissue exposed for a few days until we do the second operation and then close the skin.

He was an extremely pleasant and patient person, a perfect example of what healthcare professionals mean when we say that the worst things often happen to the kindest of people.

As I started unwrapping his dressing, I noticed him staring down at it. One layer down, on to the next one. He was still watching as I worked, and I noticed he was starting to cry. Oh no.I could feel my own eyes grow misty as I listened to his sniffles and saw him wipe his eyes out of the corner of my gaze. 

Go go go, as quickly as you can. 

I got to the last one and peeled it back quickly to examine the end of the limb and make sure everything looked as it should be, and then started to swiftly re-wrap it. When I was done, I took a deep breath. Okay, done. I stayed and talked with him for a few moments after, and I wasn’t able to stop myself from tearing up in front of him as we conversed, my voice intermittently cracking. 

Being able to quickly dissociate during a variety of situations has been an interesting experience this year – it’s certainly been a learned skill over time. My own mental drape, so to speak. It goes up when I need to get a job done. And then comes down when that job is done, or when I’m emotionally ready to process. There are instances where it feels as simple as turning on and off a new light bulb. 

But sometimes I just simply can’t detach completely. And that’s okay. On the other hand, sometimes it takes longer to reinstate the humanity back into my thoughts and actions; like an old light bulb that struggles and flickers for a prolonged moment before turning completely on with a steady, reliable hum. It’s the latter that worries me, and I try to keep that part which inevitably occurs with my job in constant check. 

However, the meaningful moments, whether good or bad, consciously or subconsciously, always catch up and bleed into our lives in some way.  

After I got done with work that day, I got in my car, thought of my patient quietly crying with his soft voice and kind demeanor, and I cried without restraint on my drive home.

11. 

I once had a patient who wasn’t able to find her husband. 

She was laying in her hospital bed during morning pre-rounds explaining this to us. It was said almost in passing, though certainly without a lack of bewilderment, before we moved on to discuss how she would need a drain placed for her ruptured appendicitis.

Later in the day, she found out where her husband was - he was one floor up and down the hall from her in the ICU. 

I can’t remember whether he had a stroke, a fall that led to a head injury, or a combination of both, but he came into the hospital as an unnamed Doe.  He was eventually identified and his wife went upstairs to see him. The prognosis was without hope and he was quickly placed on comfort cares to allow him to pass. 

Later that evening, I walked into her room once I had a lull to express condolences and see how we could help her. The room was dark and she was laying in the bed in complete silence, alone. I wonder if she had any other family in the area, or if her husband would have been her only visitor.

Her only request was to discharge her immediately in the morning so that she could take of arrangements for her husband. She cried, but also seemed, understandably so, shocked and overwhelmed. 

I can’t fathom the torment of not only being hospitalized and knowing a loved one is literally upstairs dying, but then to also have it happen unexpectedly in such a bizarre sequence of events. If he had fallen, could it have been something she could have prevented had she been with him and not at the hospital? It wouldn’t have been her fault regardless, but I hope that wasn’t the case…that she wasn’t grappling with guilt amongst everything else. 

She was discharged the next day, and although there has been no shortage of terrible situations since I started working clinically there was something about this story that still strikes a different chord for me. 

Perhaps it’s because even though it involved two people in a hospital for medical reasons, it felt - and still feels - like it really had nothing to do with medicine at all. I still have a hard time identifying why I feel that way when I’ve witnessed and heard other stories of death and suffering.

I suppose it’s because the potent combination of love, loss, and timing serve as reminders to not take life – and the people in it - for granted.

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October 8, 2017 -  Shades (1-5)

June 18, 2019 - Intern Year: Stories, Part One (6-8)

Intern Year: Stories, Part One

6.

I once told a patient that everything would be okay. 

He died, suddenly and unexpectedly, less than an hour later in the pre-op area waiting to have his gallbladder removed.

It had been an easy and straightforward Emergency Department consult. He was a young male in his 30s coming in with cholecystitis, an inflamed gallbladder. My resident team and I had tackled it together in a coordinated, well-practiced dance – gathering history, consenting him, marking him, and explaining that the best treatment was to remove his gallbladder.

The patient had answered our questions in simple, short bursts, an underlying tone of hesitation and trepidation lining his words. I had started to pick up on it during the beginning of our interaction but as I started to explain what the surgery would entail in order to consent him, the fear in his eyes was hard to ignore. I remember that it stuck out to me in the moment that he was more fearful than most patients usually are.

After he signed the consent, I squeezed his shoulder. “Don’t worry,” I said. “It’s an odd day when we don’t remove someone’s gallbladder; it’s pretty common and we see it a lot. It’ll be okay.”

He was rolled to the pre-op area within twenty minutes of us seeing him. Not soon after, he seized, coded, and died. 

The autopsy report was puzzling, the findings not consistent with what one would typically find in a young male. Other than that, it had been a freak occurrence that was out of our control.  A haunting reminder of the reality that routineis a word that one should hesitate to – or never - use in the context of medicine.

I felt stunned when I heard the news, the look in his eyes and the words I had spoken to him replaying in my mind. It’ll be okay, it’ll be okay, it’ll be – oh no.

“We’re going to take good care of you,” is what I try to say now to patients. I think of this patient nearly every time the words tumble from my mouth.

Medicine can bring cruel, swift reminders that there are no guarantees in life.

7. 

I once had a patient who was watching Harry Potter.

She was also crying, softly rasping how she shouldn’t be alive.

The patient was a young female that developed necrotizing pancreatitis. The disease had wreaked havoc with most of her abdominal organs and wall, leaving a literal hole in her abdomen, exposing her organs to the outside world. She was a perfect example of the dilemma that can come from modern medicine – kept alive and functional due to extraordinary medical and surgical feats, but yet a gateway into the overall ethical discussion of quality of life and whether medicine in this day and age can do just as much harm as it can good. 

I was on call one night when I received a page that her wound VAC – a device that essentially covered the hole in her abdominal wall – was malfunctioning, close to the midnight hour. I did my best to evaluate and troubleshoot it on my own, but I was still a fresh intern and the patient was in the tenuous portion of her hospital course. I texted my senior resident, uncertain of how to proceed. She came to look at it and after a few moments, she told me to stay in the room as she went to get a fresh set of supplies. 

Like any good intern would do, I sat down in the chair next to the patient’s bed and waited.

Harry Potter and the Prisoner of Azkaban was playing on the TV, illuminating the dark room. Ron and Hermione were confronting Draco Malfoy at the outskirts of a snow-covered forest, unaware that Harry was nearby underneath his Cloak of Invisibility.

“I shouldn’t be alive,” my patient uttered with a quiet cry.

Harry Potter was throwing snowballs at Draco in retaliation for the insults that had been aimed at Hermione. 

I had no idea what to say. 

I had never been her primary caregiver – I didn’t know her like the primary day team did or the nurses that took care of her. I felt like an intruder, the MD behind my name without meaning in a situation that required a natural rapport built over time between two human beings rather than a fill-in provider and a patient. 

Many don’t know that I almost chose Psychiatry as my career path; I have always felt a natural comfort with having difficult conversations in emotionally challenging situations, and I have never been one to shy away from digging deeper into the darker aspects of humanity in relation to medicine and mental wellbeing. But this was certainly pushing the boundaries of that comfort zone.

“It hurts so much, I’m in so much pain.”

Harry, still invisible, is messing with Draco and his two cronies, pulling the pants down on one and swinging the scarf around on the other, before tripping and dragging Draco a few feet. 

The stark contrast of the moment – between Draco getting up and running away in comedic fashion punctured with intermittent cries from my patient about how she essentially wished she were dead – created an indescribable feeling of surreal disbelief and the sobering reminder that life can just simply be cruel, piercing through distractions and attempts at minimization without preamble, without cushion, and without decorum. 

I attempted to offer some words of comfort in the moment, though I quickly realized the patient was in such a distraught state (understandably so) that it almost seemed like I wasn’t in the room. After a bit, I stopped speaking, figuring that sitting in silence was simply the best – and only - thing I could really do. 

Harry Potter continued to play on and I could only hope it was succeeding in distracting the patient, though a part of me knew it was most likely just a background noise filler in what must be an overwhelming, terrifying reality in the grand scheme of the patient’s life. The scene moved on and at that point, I wasn’t really paying attention either. 

In what felt like an interminable amount of time later, my senior returned and managed to fix the wound VAC. I lost track of what scene the movie was on when I left the room, moving on to tackle the rest of the chaos the call shift had to offer. 

I haven’t forgotten the discomfort and the feeling of woeful inadequacy from that moment, but I also haven’t forgotten the realization that those moments are normal, and okay, to have.

We’re human, too, after all.

8.

I once had a patient who cried about his breasts.

He was an older, transgender male with gallbladder cancer and a terrible prognosis. He had come to have a port placed so that he could begin chemotherapy. The patient and his girlfriend were kind in the pre-op area, offering smiles and warm introductions as I shook their hands. 

When we brought him back to the OR and moved him over to the operating table, we worked to get him ready and secured as anesthesia worked from the head of the table. Towards the end of the preparation, we rolled down his gown as we normally would to examine the site – his chest – and get it ready to be sterilely prepped.

He started crying as soon as his gown was moved down. “I shouldn’t have these,” he sobbed, clearly overwhelmed, nodding down at his still-female breasts.

At that time, anesthesia started to sedate him. “Try and think of a happy place,” she said from the head of the table, the oxygen mask starting to come down around his face. 

“I have no happy place!” the patient cried out.

I wonder now if the patient felt like he was devoid of hope. Perhaps having gallbladder cancer wasn’t the worst thing the patient had ever experienced. 

I stood next to him as everyone worked silently after his admission (confession?). A few moments later, the patient was under (if he were to dream – what would it be about?)and we were able to start the procedure.

I have no understanding of what it feels like to be transgender in this world – to be born with a body that doesn’t match your gender identity….and then to experience all of the misplaced, horrid, inexcusable hatred that society has to offer. 

“We’re about to roll he-she-it back to the OR,” I had heard out in the pre-op area. I’m still ashamed that I didn’t say anything then, a combination of letting my timidity as a beginning intern win out along with being shocked at the blatant rudeness and disregard for another human being.

The patient unfortunately passed away a months after the procedure. If the person that said those things were to find out about his death, would they wish they had said or thought anything differently? 

Why is it necessary to say such things? Even if one has their personal viewpoints, why be hateful or spiteful, especially about someone they don’t know? 

Why not still be kind and respectful, even when the person isn’t around or isn’t listening? Nobody’s perfect, we all make mistakes and sometimes fail at that concept - but that, in my mind, can be a true marker of integrity. 

Maybe if people would spend more of their time and energy trying to genuinely connect with and understand another human being, then maybe my patient might have had a different response – maybe he would have had a happy place. 

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October 8, 2017: Shades (1-5) https://mylifeasafuturesurgeon.blogspot.com/2017/10/shades.html