Wound Care

Not too long ago I had to counsel a family about a surgical procedure their loved one needed in order to have a chance at survival but which, at the same time, she might not survive. I told the family I needed to place a breathing tube for the surgery but that I was also unlikely to be able to remove it afterward. Our conversation was long and quiet but intense, and in the end I could offer no better news for them. "Thanks for explaining it to us, doc. You do what you gotta do." What I was able to do for that patient was very little. She survived the surgery and was in guarded condition when I left the hospital for the day, but she died later that night.

There's a lot that's hard in medicine. The hours. The demands. The stresses. These are merely exhausting or frustrating, but confronting our own impotence - that has something else to it. Something really humbling, a kind of sadness.

So why do it? Why did I? How did I end up in med school at all?

I was an English major in college, and a good one. I loved to read great books and write good papers. I was into music and dance, medieval and Renaissance history, ancient languages, modern languages, scripture exegesis, art history. I dabbled in theater and even performed the role of Connie in A Chorus Line. Later I would get interested in social psychology and anthropology. In short, I was a humanities student through and through, not an ounce of the science geek in me, nor the aptitude of one. I was fascinated and awed by science - especially molecular biology and astrophysics - but I had no facility with it. If I managed to get through a science class at all, it was with a lot of tears and sweat.

In my last year of college, while I was writing my English thesis, I took an EMT class for fun. Should I have or shouldn't I have? I ask, facetiously, because in the middle of that course a voice in my mind said, "Uh-oh. I think I want to be a doctor. I love taking care of people, and using clinical skills and science to do it." Here was science that had the breath of life in it! Physiology, the logic of the body, was a tantalizing intellectual pleasure. I wanted to learn all I could about it, and use it to be of service to people. The first (and, intially, the only) person I admitted this to at the time was the man I would eventually marry (at a time when we were "in neutral," between fitful bouts of dating). His reaction then is what it still is: whole-hearted, affirming, faithful support. We would wind up marrying and starting a family before I ever set foot in medical school, but set foot I did, for better or worse.

I wasn't always going to be an anesthesiologist, though. I was going to be a pediatric specialist and spent most of my electives in medical school preparing for a life in pediatrics. I took a special course in an inner city hospital in New York on the evaluation of victims of child abuse. I was attracted to the field of medical genetics because of its integration of child development, in which I had a master's degree, and counseling, and I had the chance to spend several stimulating weeks at the National Institutes of Health learning the ropes in its division of medical genetics. They wanted to hire me as a resident and fellow, in fact, but sometimes life takes its own circuitous path. Choosing anesthesia involved a "voice in my head" kind of moment too: after mask-ventilating a child for the first time, I knew I wanted to be the doc that was doing that every day. So here I am.

Sitting here on the eve of the anniversary of 9/11 I realize that though my life was left intact by those dramatic moments in our history, I was not entirely untouched by those events. When the planes hit the towers I was in New York, completing another elective in medical genetics at Mount Sinai Medical Center. The first nail in the coffin of my dream of becoming a medical geneticist was hearing one of the medical geneticists comment, "Should we go and help? Oh, wait, we can't really...unless they need IVs or something..." I was bothered by that. I wanted to be a doctor who COULD help in that situation, and even though I knew the ongoing care given by medical geneticists to their patients was irreplaceable to those patients, I also knew how abstract it could be, and I realized I wanted to be able to see the help I was giving. I'm a lot like Doubting Thomas in many ways.

Academic activity was suspended that day, but all fourth-year medical students were asked to assemble in one place and offer assistance if needed. Someone had the presence of mind to make a note of anyone who was multilingual. It was all for naught, as we now know: there were few if any survivors to help, and rescue workers needing medical attention would go to hospitals downtown, where some of my classmates were on rotation, not uptown.

That day was the most intense example of what for many physicians is one of the worst aspects of medicine: its limitations. When I look back on the times in medical school or residency that left me feeling utterly disconsolate, I remember moments when I or the clinician next to me would have to say some variation of "I'm sorry, but there's nothing I can do."

I recall a beautiful young girl who had been maimed somehow and who came to the orthopedist's office with the hope of restoring some function to her arm, the upper part of which had been shattered and faultily repaired in some foreign country. She couldn't lift her arm to the side, so when I asked her to extend it she had to unfold it in a broken-winged sort of move. The orthopedist was using my imperfect Spanish to communicate with this lovely girl and her mother, and I felt stupid, frustrated, and helpless telling them we couldn't do anything for them.

Another time in the ear/nose/throat clinic I examined an African American woman with downcast eyes whose eardrum was blown wide open.

"How did this happen?" the ENT fellow asked.
Her bottom lip started to quiver. "My boyfriend..."
We remained silent, hoping to give her space to tell the story.
"We got into a fight..." Large tears started to roll down her cheeks.
"He hit you," the fellow said quietly.
"Will I be able to go back to my job?"
"What sort of work do you do?"
"I'm a..." The woman was laboring to suppress a sob, but couldn't. "I'm a telemarketer."
"Oh," said the fellow. His manner was serious but gentle, like his voice. "The injury is quite severe. We could attempt a surgical repair, but I can't guarantee that surgery would help."
"But it don't feel right. Can't you do nothin'?"
"I'm sorry..."

When something of ourselves rips or breaks, there is grief, a futile yearning for things to be as they were, unhurt, unchanged. Healing is an astonishing process, as is our capacity for it; but there is a melancholy aspect to it: we are forced to learn to live with scar tissue, with changed selves, and to accept that things can never be as they were before a blow was dealt, whether with words or ideas or fists or fortune. Perhaps in the end our scars are meant to teach us that while in some respects "there is nothing we can do" but let things be, and find new ways of accepting and transforming imperfection, it's also true that we can do more than we realize, especially when we recognize, get involved with, and learn from the wounded around us, and the wounded within.

Declaring Death, and Life

A few years ago after being up almost all night on-call during my pediatric internship, I had finally managed to lie down and doze for about an hour, probably less, when my infernal beeper went off. Again. What was it this time? Another IV that had fallen out of an infant's gauze-covered hand? An order written by someone else mistakenly attributed to me? Yet another admission for an already-crowded ward?

I fumbled for the beeper and glanced at the neon-red numbers on the digital clock in the call room. 4:57. Nausea rose inside my chest, sickening, like swells of filthy water lapping against a dock.

I dialed the extension, and a nurse at the main desk answered. "You have to pronounce Jones*."

"What?" I heard her words like someone who was just beginning to piece the English language together. "What do I have to do?"

"Jones died. You have to pronounce him."

"Oh..." The impact of sudden clarity was like a splash of cold water on my sleep-deprived face. The little two-year-old in 301. The smoke-inhalation victim, who had been discharged from the ICU to our floor to die, because that was all we could expect, was dead.

That particular hospital allowed me fleeting passage into the outskirts of human experiences that no one would want for themselves. It had a large population of pediatric cancer patients and a fair number of child abuse victims in addition to the other medical conditions that send kids into hospitals. Many of those conditions involved tragic accidents, like this one.

I stepped out of the cramped, smelly call room into the fluorescent lights of the pediatric floor and made my way to the desk. I was tired, filthy, and feeling ill. I didn't want to see this child. I didn't even know what the ritual consisted of, this declaration of death. Feeling like the new kid lost in grammar school, I had to ask.

What an arrogant thing, to think we have the right to name the moment when a person's life is no more, when some of the person's cells are still living, when we don't even fully understand what life is and how it arises...But I knew it was nothing so dramatic as arrogance, really. Practically speaking, the county needed a date and time on a piece of paper. That was all.

I entered the room, and little Jonesy lay on the bed looking like a sleeping child, totally peaceful. Like my son at the time, he was two, a thin boy with skin like light coffee and glints of gold on his thick curls. His favorite stuffed animal, a sheep or small cow of some kind, lay in his arms. His mother was curled up beside him, holding him. She had left him with a babysitter when their home caught fire.

I mumbled something apologetic and outrageously inadequate, then placed my stethoscope on his chest. With children you get used to hearing a very fast and vigorous beat. The hollow nothingness that met my listening ears was a disorienting shock. It was so wrong. And frightening.

I remember only vaguely what else happened. The attending pediatrician on-call came in from home to speak to the mother. The nurse at the desk saw tears in my eyes and commented, "Oh, is this your first one? You'll get used to it." I filled out some paper work.

I have been present at the very beginnings of life as well as at life's end. I have not yet tired of the anticipation and joy of those beginnings, or grown "used" to the mystery and sorrow of the end.

***

Today I placed a thoracic epidural in a 100-pound, 90-year-old man with a mass in his colon. I guided a paramedic student as she placed the breathing tube just before his surgery. Upstairs, a laboring mother waited as her body prepared to bring her firstborn into the world. I gave her an epidural too, just another day on the job...but never meaningless work. My 90-year-old gentleman was wheeled to his room just a few moments ago. Today was not his day to depart.

I am on-call this weekend and feeling a little lonely, as I often do on such weekends. I call my children, who are on their way to Vermont with their father. Their bright voices cheer me. My husband and I are both tired, but we still have enough energy for words of affection and support. I watch again, with a mother's obsessive wonder, the videos on my computer of my daughter singing the song "Maybe" from Annie and "Anything You Can Do" from Annie Get Your Gun. It's time for me to grab a simple bite to eat before the beeper goes off again, with another seemingly mundane task that cracks my life open just a bit, letting it wend and weave its way out to brush against someone else's seemingly ordinary life, for just a moment. And so I go.

_____________________________________________________

*Name changed.

A Few Things You Should Almost Never Say to People

"Are You NUTS?!"

When I told people I was going to embark on medical school with a ten-month-old in tow, I got various versions of, "Are you friggin' NUTS?!" in response. See, I think you should only ask that question of someone who's about to jump off one of these (visited today at the Lake Placid Olympic Ski Area):

"We Think Your Child Might Be Retarded." [sic]

When I was four or five my kindergarten teacher expressed some concern to my mother that I might be developmentally delayed. After premature birth at 32 weeks in the early '70's, this wasn't out of the question, but when my mom asked why she suspected a problem, the teacher reported that I couldn't seem to pay attention and often looked blank.

"What are you teaching them?"
"Oh, the shapes and colors-"

"She already knows those."

"How to count to ten-"

"She can count to a hundred."

"The ABC's..."

"She's been reading the New York Times to us for weeks. Look, is there anything else?"

I don't think the meeting ended too well. Just for documentation my mom brought me to Clark Air Base to get psychometrically evaluated by the Americans. Everything checked out reasonably well. She put me in a different school.

"You'll Never Amount to Anything."

Sometimes I think conventional measures of ability and the tendency to judge people based on personality do little justice to the capabilities and gifts people actually have. I came across a wonderful letter to Stanford pre-meds by Michael McCullough, M.D., that I wish were required reading for ALL high school, college, and med school students and teachers. In it he reminds us: "Albert Einstein, Bill Gates, Winston Churchill, Thomas Edison, and Mother Teresa all had something in common: they didn't do well in school. Take home point: Don't rely on a grade point average to prop up your sense of self." We so often define our worth by our successes; it's high time we redefined success!

My favorite example of the school-"failure"-yet-genius is the story of Australian make-up artist Ann Maree Hurley. She kept telling people when she was growing up that she was going to be a make-up artist, and the best response she ever got was, "That's nice, dear." She failed her last year of high school and struggled through Wodonga Catholic College. But she persevered with her true love and has now worked as a make-up artist on all three Pirates of the Caribbean films. To that I say, you go, girl.

Oboist Caroline Plamondon posted a story on the Oboe BBoard relating how her school band teacher discouraged her from trying the oboe, because she was "too shy," then later tried to persuade her mother not to allow her to audition for the Montreal Conservatoire and two other colleges: "He called my mom and told her it would be a good thing if she discouraged me from entering those schools, because I didn't have any chance of getting in, let alone becoming a professional musician. Well, I got in to the 3 schools, chose the Conservatoire, studied there for 6 years before changing schools to obtain my Master's degree." SO THERE! Way to go, Caroline Plamondon!

***

When I was applying for pediatric residencies (before my anesthesia days) the chairman of pediatrics told me that Children's Hospital in Boston would be a "reach" and I shouldn't bother. In many ways he was quite right and the advice was practical. A couple of years later, after I had fallen in love with anesthesiology and switched my career track, I couldn't help laughing at the whole episode when I found myself practicing medicine at, guess where, the O.R.'s at Children's Hospital. The only way to know if you can reach something is to stretch for it.

This was the same chairman who, during my internship, after listening to me explain the molecular mechanism of hyperkalemic periodic paralysis, asked me in front of a roomful of pediatric interns and residency applicants to draw a diagram of the mechanism on the board. After a split-second silence, I said, "Sure" and walked up to the board and drew it. Then I left that program and started my anesthesia career.

But that's when learning became grueling.

During my first year in anesthesia residency I took an early leave-of-absence to help my husband and children move to the Boston area, and the day I returned, with my "skill set" still nonexistent (how I hate that phrase), or embryonic at best after only two weeks on the job, the attending physician I was working with sniped at me all day with insults before finally saying, "Maybe you shouldn't be doing anesthesia." When I looked at him in disbelief that a teacher could be so un-helpful to a trainee, not to mention in pain at being disparaged all day, he just emphasized, "Yeah. Maybe you shouldn't."

His labeling of me haunted me in various ways throughout my training, and despite some genuine teachers, like my residency program director, who were willing to judge me for the good progress I made and the expertise I attained by the time our training ended, there were still those who didn't have the capacity to look past that prejudicial incident and my early struggles during that challenging first year. Thankfully they weren't able to discourage me from taking good care of my patients - from the Peruvian child at Children's who put his arms around my waist and thanked me the day after I had to intubate him awake with a fiberoptic device, to the elderly Korean gentleman who spoke no English but conveyed his thanks with a squeeze of my hand. It was in these unseen, uncredited moments that I felt I was truly a physician my program could be proud of.

To the teachers who actually TAUGHT, I send out a heartfelt thank you, for bringing me to this successful place: