“Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.”
― Paul Kalanithi, When Breath Becomes Air
Thursday, July 11, 2019
Intern Year: Stories, Part Two
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?
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.
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.