Saturday, March 31, 2012

Trauma Surgery

I wake up in the pitch black to a sound, some sort of beeping that won’t go away.  Waking up is arduous; my limbs feel like tree branches, even my blood feels sluggish.  I don’t just not know where I am, I don’t know who I am, or what “awake,” is.  That is how deeply I was asleep. 

And then it dawns on me, that I am a medical student and I am in the on-call room, and that god-awful noise is my beeper.  I reach for my glasses and end up knocking the lamp and my pager off the bedside table.  I flail around in the sheets, trying to reach down and right the lamp.  Finally, I close my fingers around the pager and silence the alarm.  I think seriously about going back to sleep, but I don’t.  I read the tiny display on the beeper, “trauma alert: 39 yo male.”  I struggle to stand.  The beeper goes off again while I am still holding it.  More details: “trauma alert: 39 yo male. sledding accident.”  This should be good.

I stumble into my clogs, pull a surgical cap over my bed-head, and put on my white coat.  I shove a granola bar into my mouth as I trot off down the hall to the maze of tunnels that will take me to the trauma bays.

Trauma Male #1 is just being rolled off the ambulance as I arrive.  He is sitting up on the gurney, neck braced, moaning and holding his stomach, a line of blood dripping from his right nostril onto his shirt.  I pull on a gown, gloves, and a mask, and dig the shears out of my white coat pocket.  As the medical student on the trauma team, my main job seems to be Carrier of the Shears, which are useful for removing pesky things like clothes and bandages.

And this is no exception.  As the nurses swarm the patient and start shouting out vital signs, my chief motions me over, “Cut off the shirt and the pants,” he says, and then whirls off to make sure we are next in line for the CT scan.

I sidle up to the gurney, trying to introduce myself to the patient before I cut off his clothes and avoid getting in the way of the nurses, who seem to be doing actually important things, like placing IV lines and taking a history.

I stand to the left side of his head as he tells the nurse, “I was in the toboggan and couldn’t steer and we turned sideways and slammed into a tree.”  He points to the upper left side of his abdomen. “It hurts right here,” he draws a perfect circle over his spleen.  Hmm. I remember that spleen lacerations are graded, but I can’t remember what the criteria are.  Hopefully I will have time to sneak off and look this up before my resident pimps me on it.

“Hi sir, I just need to cut off your clothes so we can see your injuries without moving you too much,” I tell him. 

“You don’t need to cut them, it’s just right there, I can just pull my shirt up.”

Well shit.  Cutting off the clothes is my one job, and my resident will not be happy with me if I fail to do it.  Also, while I see his point that the area is already pretty accessible, it could be that this pain is distracting him from other injures. 

“I’m sorry sir, but we need to make sure you don’t have any other injuries.  I will cover you up with this sheet--”

He cuts me off, “please don’t cut my clothes.”

My resident appears behind me, holding his own pair of shears. (Way to make me feel useless.)  “Sorry sir, it is protocol here in the ED.” And then starts cutting.  “You get that side,” he says to me.

So I do, despite the fact that I am pretty sure this is assault.  Gritting my teeth, I start at the ankle and cut his jeans all the way up the leg to the waist band.  My resident does the same, and soon we are able to peel off his pants.

Which is when we notice that in addition to whatever sled-related splenic injury he has sustained, Trauma Male #1 has been shot in the penis.

My eyes dart up to the patient’s face – he looks horrified and humiliated and also a bit pale.

I have a sinking feeling in the pit of my stomach.  Partially, I am sure it is a visceral reaction to this type of injury, which I must admit squeaks me out the same way the all-wrong angle of broken bones still makes me queasy.  But the other part of this feeling is just knowing that we are in a rural hospital in Virginia.  I don’t believe the social and psychological awareness of the medical staff here is going to be sophisticated enough to deal gracefully with any of the scenarios that could lead to a man being shot in the penis.  We deal well with tractor accidents.  But mental illness? gender dysphoria? domestic violence?  These are not our strong suits.  And above and beyond the relatively temporary violation of having his pants cut off against his will, I have the sense that this man is about to have a whole prolonged interaction with healthcare that will be marked by violation.  And of course, I will participate in it. 

The resident raises one eyebrow and then sort of shrugs.  There is some dried blood around the patient’s crotch, but no active bleeding.  No one else on the trauma team seems to have noticed our discovery – it’s a small caliber hole and I guess most people make an effort not to stare at the patients’ junk.  My resident grabs the sheet from my hands and covers the patient up before directing the team to roll him onto one side and inspect his back.  We roll him up, and the intern runs her fingers down his spine. “No visible injuries,” she reports, and we lie him back down.

The resident listens to his heart and abdomen, pokes his belly a bit to elicit some groaning. Apparently nothing is concerning.  “Ok,” he says, “take him to CT.”  Lead-covered technicians appear and whisk him down the hall to the radiology suite.  I stay behind and look at my resident.  “I’m paging urology, go see if he has any spleen lacs.  If not, he’ll be on their service.”

Obediently, I trot off to the radiology control room.  If his penile injury is visible on CT, it certainly isn’t visible to me, and no one else comments on it.  We stare at his spleen, which looks normal.  The radiologist confirms – no laceration to the spleen.  We also “clear” his cervical spine – meaning we don’t see any fractures, so he is allowed to remove the horribly uncomfortable collar.  Normally we would probably discharge him now, but the resident appears to tell to technicians who are maneuvering him off of the CT scanner and back onto the gurney, “take him to room twelve.”

Room twelve is one of the more private ER rooms, with a real door that closes and is not made of glass.  Usually this room is occupied by women with gynecological complaints, so that a pelvic exam can be performed in relative privacy.  We wheel Trauma Male #1 in there.  A nurse gives the resident a questioning look and he says, “we’re waiting on a consult from uro – just keep him comfortable until they get here.”

And then the pagers are going off again – mine, the resident’s, the nurse’s.  “Trauma alert: 62 yo male. MVA.”

“Motor vehicle accident,” my resident explains, “bay two.”

I ready my trauma shears, hoping my task is less complicated this time. 

After the whirlwind of Trauma Male #2, I try to go back and check on #1, but he is nowhere to be found.  It is hours later, he could have been admitted to urology’s service or discharged home or he could have left AMA (against medical advice).  I don’t actually know his name or medical record number, so I can’t check the computer.  On our next shift together, I ask the resident, and he says he has no idea either.  Then he says, “I hope that guy did ok.”

I’m impressed with the way the resident handled the situation – maybe not with a nuanced theoretical understanding of the various issues that could lead to someone shooting himself (or being shot by someone else) in the penis – but at least with decency and discretion.  Decency and discretion delivered immediately after he cut the man’s clothes off against his will (which I still think is wrong and feel wrong for participating in).  

But it’s good to be reminded that people aren’t all one thing.  We aren’t either all good or all bad, we have good moments and bad moments.  I hope that Trauma Male #1 did ok, too.  And I hope that I will do better next time.

Monday, March 26, 2012


I matched!  To my first choice program in Baltimore, where I already live.  No moving!  Now all I need to do is figure out the best way to tell them I will need maternity leave immediately following orientation. 

Thursday night, Benjamin and I went out to dinner with an old friend of ours from the youth group where we met.  We went out to the Indian restaurant that catered our wedding, and I got the same dish we had at the wedding.  I had been feeling pretty queasy all day, which was unusual since this has been a fairly nausea-free pregnancy. 

Next thing I know, I am excusing myself from the table and hanging out in the restaurant bathroom, splashing water on my face.  I threw up a few times, rinsed my mouth out, and went back to dinner.  I still felt queasy but not terribly sick.  For the ride home, Benjamin fashioned me a bucket by sawing the top off of a plastic one gallon gas can with his leatherman. 

We woke up early the next morning to drive down to Charlottesville for the Match Day festivities (makeshift vomit bucket in place).  And my financial aid exit interview.  Let’s just say that over the past five years, I have borrowed an absurd amount of money.  It’s not that I couldn’t have figured this stuff out on my own, but I feel very lucky that Benjamin happens to love financial planning and filling out forms. 

Benjamin thought it was fun to keep saying things like “only eleven hours until Match,” “only four hours until Match,” etc.  I found this very helpful and calming.  I only hope he is this supportive during labor. <eye roll>

Finally, it was time to go.  It isn’t traditionally a formal event, and I opted to wear a maternity top that is form fitting enough to make it clear I am either pregnant or shoplifting a frozen turkey.

We gathered in the Old Medical School Auditorium.  Since we are now on the 3rd medical school, I guess I should say that this is the oldest existing medical school auditorium.  The atmosphere started off festive and escalated to insane.  Benjamin and I found seats in the back but quickly realized that we were in the middle of the loudest, drunkest group of medical students. 

The Student Affairs folks stood at the podium and began reading names.  When a name was read, that person would go down the aisle, deposit a dollar in the box for good luck, get their envelope, hug the dean, and pick up a champagne flute.  Then they had to sit down, holding their envelope but not opening it while the rest of the class was called.

When my name was called (mispronounced though it was), I waddled proudly down to the front and got my envelope and my sparkling cider.  I had forgotten to count how many names had been called before mine (and they are not called in alphabetical order) so I had no idea how long I was going to have to wait to open my envelope.  The ceremony went past noon, and my phone was already buzzing with text messages from friends, asking about the result.

Then, finally, the last person was called, and we all toasted and tore open our envelopes.  University of Maryland Family Medicine, my first choice.  I was very happy, of course, but it was also a bittersweet moment, because it meant closing the door on all those other possibilities.  Having all those open doors had been frustratingly vague, but the not knowing was also sort of magical.  I was especially sad about giving up my second choice program in Greensboro, NC.  I think I would have been very happy there, but ultimately UMD is a better place for me.

I am usually excited about setting off on an adventure, but in this case, I am really excited to be staying home for an adventure.  Baltimore is my home.  My family is here, however dysfunctional my relationship with them is at the moment.  Benjamin’s sister and her husband are here – and they are expecting a baby, too, so the cousins will get to grow up together.  Benjamin’s parents will be returning here after their year in New Zealand. 

But even aside from the family, Baltimore is the physical infrastructure of my childhood.  The culture here is the one that shaped me, for better or for worse.  I went to these city schools and learned about the Chesapeake Bay and Lord Calvert and the Dominos Sugar sign on the harbor.  I know how to say ‘hon’ and pick crabs and cheer for the Orioles even though you know you will be disappointed every year.

I get to be an adult and a parent in the city where I was born; and that is really cool.  I get to bring back all the things I learned in Virginia and use them to serve my home community, and I am really honored to have that opportunity.

And now, all the things I can’t do until after Match – I can do them now.  Yikes.  

Thursday, March 15, 2012

The Waiting Game

In my life right now, there is a spectacular amount of interesting stuff that is about to happen.  And what that really means is that none of it is happening right now.  Right now, I am just waiting.  Waiting to find out where I matched for residency (and all that entails), waiting to find out how much maternity leave my residency program will give me, waiting to graduate, waiting for my family drama to get better, waiting to meet this little person I’m growing in my abdomen.

I’m not a good waiter.  I’m on the cusp of all this life-changing, interesting stuff, but right now I am mostly just bored and frustrated.

Picking up where I left off yesterday: after interviews are over, the Match starts.  You (the applicant) rank the programs in order of preference and enter them into the National Residency Match Program (NRMP) website.  They give you several weeks to agonize over this list and make changes before locking it down in February.  I changed mine three or four times.  It was just tortuous. 

The programs, meanwhile, are making a ranked list of applicants, in a process that I can only imagine is more tortuous, as it involves group decision-making.  They enter these into the NRMP website as well.  And then the computer runs an algorithm and spits out a letter that tells you where to move.  Theoretically, the algorithm is applicant-centered and attempts to give all the applicants the highest ranked program possible. 

If you want to see how it works, a fairly good explanation is here

I like how they stress over and over that you should rank programs according to your true preference.  As if “true preference” is totally obvious to everyone.  But really, how do you weigh “close to my family,” when that family is only 17% speaking to you?  How do you weigh, “I feel comfortable around these residents,” when you can’t ask them how they would feel about you having a baby as an intern?

Whatever, there is nothing else I can do about it now.  I just have to breathe deep (increasingly difficult) and wait for Friday.

Wednesday, March 14, 2012

A Quick Recap of the Career Path So Far

I find out where I am going for residency the day after tomorrow. 

But before I get into that, I thought I would back up and give a quick recap of US medical training.  I know the whole process is confusing, as various relatives and Quaker meeting members ask me how it works every time I see them.

Ok, so, say you want to be a doctor.  We’ll start at college – you will need a four year undergraduate degree.  What can you major in?  Turns out, anything you want.  I double majored in Biology and Drama.  (People are always asking me how I am going to use my Drama degree.  I use it to act like I know what the hell I am doing.) 

There are some prerequisite courses, like Organic Chemistry that tend to be of the “weed people out” variety.  It almost worked.  I had this amazingly terrible Organic Chemistry professor – he didn’t seem to know any organic chemistry (drew some amazing molecules where carbon had five bonds) and sometimes forgot to wear pants to class.  (Literally, he showed up in boxers and dress socks and a button-down shirt.) The school hadn’t given him a relocation allowance and so he slept in his car in the parking lot of the gym, though I am not sure if it was out of protest or economic necessity. 

It was all just sort of wacky and annoying until The Incident.  He left a mercury thermometer inside a very hot melting point apparatus all afternoon, eventually breaking the glass thermometer.  My classmate went to pull the thermometer out and saw that it was broken.  The professor insisted that it was an alcohol thermometer and that the student had broken it by pulling it out of the melting point apparatus at an angle.  The professor made him clean up the (clearly beading and metallic) liquid with paper towels.  It turns out that much of the mercury was actually vaporized at this point and so the student was inhaling mercury vapor the entire time.  He ended up being hospitalized for several days and losing all his hair and having some neurological effects.  I am not sure why or how there was not a massive lawsuit about this.

Anyway, if you survive Organic Chemistry (literally and academically), you get to take the Medical College Admissions Test, or MCAT.  Oh god that thing was fun.  And by fun, I mean a torturous pain in the ass.  Nothing on that test is remotely useful in medicine.  There’s physics and I don’t even remember what else.  Some sort of essay question.  The scores go from 15 (worst) to 45 (best but statistically unattainable).  I think they usually say 30+ is pretty safe for med school admission. 

Then, you apply to med school.  Lots of personal statements and official transcripts.  Your personal statement will probably explain how you want to “help people.”  Of course you do.  <pats your head>

When you decide to apply to med school and where to apply, you won’t know anything useful about medical school, because of course you have not been there yet (unless you are a time traveler).  Now that I have been to medical school, I can tell you they are all probably pretty much the same.  I picked mine based on the fact that Charlottesville was a prettier place to live than Philadelphia or Baltimore.  I probably should have weighed being close to my family and paying less tuition a bit more heavily than I did, but there you go.

Another thing I knew nothing about was that there are two types of medical schools in the US.  Allopathic schools award the M.D. and are historically more “science-y” while osteopathic schools award the D. O. and are historically more “touchy-feely.”  The jobs each can have upon graduation are indistinguishable.  My undergraduate advisor just told me to apply to allopathic schools because they are theoretically more prestigious.  Clearly, I should have researched this a bit more.  I think it would have been slightly easier for me to find philosophically aligned peers and mentors at an osteopathic school.  Oh well.

Anyway, once you pick a medical school and get accepted, you complete four years of medical school.  Traditionally, the first two years are your classroom or “pre-clinical” years.  They will be absurdly difficult.  I assume these years are some sort of hazing, as much of the information you are required to memorize is quite useless for actually treating patients.  Try not to focus on this, just accept the experience for the hoop-jumping that it is and trust that you will learn real patient care ….eventually.  I spent a lot of time reinventing my note-taking and studying style, bemoaning how difficult it was, and questioning if this was the right path for me.  I recommend not wasting quite so much time on these things, as all they did for me was produce some very dark, Sylvia Plath-esque writing pieces. 

After the second year, you will take Step 1 of the United States Medical Licensing Examination (USMLE).  It’s an eight hour multiple choice test.  Somehow, after first and second year I sort of enjoyed this test.  The test review materials were well-prepared compared to our course materials, and the test is standardized, not written by a bitter research PhD who has been saddled with lecturing needy medical students about the nerve conduction system in the giant electric eel. Still, the fact that I enjoyed it is concerning to me.  Perhaps I am becoming a robot.

During the first two years there is usually some sort of workshop during which they teach you, “how to talk to patients,” and “what to do with your stethoscope.”  Invariably, throughout training, half the attendings you talk to will think that a really good physical exam can locate a brain tumor and diagnose appendicitis and tell what you had for breakfast.  The other half of the attendings you work with will just order a CAT scan of every patient.

Finally, after Step 1, the clinical years start.  During third year, you rotate through all the various specialties such as internal medicine, obstetrics & gynecology, pediatrics, surgery, etc.  These rotations or clerkships are 4-8 weeks in length and each is followed by an exam called a “shelf.”  Third year is really the only year of medical school actually worth the tuition, as you get to act like a real live doctor and learn a ton of stuff that is actually useful in caring for patients.  Also, if you went into medicine to “help people,” you will enjoy actually getting to talk to people again. 

On the other hand, this year has high potential for burn out – mostly because you realize the asinine hierarchical brown-nosing culture of the pre-clinical years does not disappear during the clinical years.  But now, the casualties of this culture of ass-kissing entitlement and priviledge are real people, your patients.  I don’t know what to tell you – the whole thing made me have a mental breakdown.  Um, stand up for your patients where you can and otherwise just try to keep your chin up.  Don’t forget to feed yourself and sleep – the culture of medicine does not value these things but they are still important for all humans.

Moving on, fourth year is full of “elective rotations,” meaning it could be like an extension of your third year, or it could be full of “fluff.”  Some of the more obnoxious nose-to-the-grindstone type people will insist that you should work as hard as possible during 4th year. To some degree, I see their point – getting your money’s worth and learning useful things are always good.  On the other hand, 4th year is a great time to recharge your batteries before residency, travel, apply for residency, interview for residency, and generally stress out about residency for a full year before it starts.

So, after medical school comes residency – a stage of medical training in which you are officially a doctor but you are not an independent doctor, you are still in training.  To apply to residency, first you have to pick a specialty, which is a whole post in itself.  I picked Family Medicine, which is a 3 year residency.

Then you apply.  Dig out that personal statement you wrote about wanting to help people. Add paragraph about something you learned in medical school.  Stop agonizing over it.

The application process is all online through a program called ERAS.  You pay about ten bucks a pop for ERAS to send your application to the various programs.  How do you know what programs to apply to?  You don’t.  Because you don’t know anything about residency yet, since you haven’t been there (unless you are a time traveler).  I don’t have any further advice for you, since I haven’t been there either.  I will get back to you on that.  Oh, but you aren’t crazy, all their webpages DO look the same.

After the applications are submitted, you sit back and wait for interview offers.  Proceed to lose your mind and spend all your money traveling all over the US interviewing at various programs.  My only advice for this stage: buy a suit that you like and always pack snacks.  I was extremely lucky, my husband happens to be unemployed and enjoy driving, so he was able to drive me to most of my interviews, help out with logistics, etc.  All I had to worry about was dazzling them with my brilliant personality.  Ugh.

Anyway.  That is the process that gets you to the glorious day that happens the day after tomorrow: the match. 

Tuesday, March 6, 2012

The Healer's Art

On the first day of Medical School, I shaved a dead man’s scrotum.  No one else in my anatomy group would do it.  It’s not something normal people do. They were trying to tell us that we were no longer normal people.  I didn’t believe them.  I kept sneaking looks at my cadaver’s face, wondering if he liked chocolate or had grandkids or had ever studied philosophy.

In the second half of the first year, some of us took an extra class; The Healer’s Art.  We sat in a circle on the rug or lounged sideways in armchairs.  We wore jeans and chewed gum. I still brought my laundry home on holidays.  I was going to join Doctors Without Borders as soon as I got through residency.

In the middle of the circle, a physician in a bolo tie read us a poem.  An anatomy professor guided us in meditation, sounding a small chime.  Meditation and poetry were my bread and butter, but this seemed so hokey.  We giggled and squirmed on the carpet. 

They asked us what we liked about life before medical school, about who we were before medical school.  I thought they were crazy.  I was twenty-two years old; surely I was a fully formed person; surely they could not make me something less.

Two years later, I participated in the torture of an old woman. 

Mrs. Beedle had been in the hospital for 287 days.  Initially admitted for pancreatitis.  Fifty-three procedures later, she had a colostomy bag and an open abdominal wound stretching from her belly button to her sternum.  It was covered with synthetic mesh and black foam and a vacuum apparatus designed to remove pus and digestive juices.  We were waiting for tissue to grow over the mesh, like shrubbery over the wire armature for a topiary. 

Mrs. Beedle had grown delirious, and her wrists had to be tied down because she kept pulling out her IVs.  That morning, I came with the team of surgical residents to change her wound vac.  We swooped in, pulling on yellow isolation gowns over our white coats.   

Her eyes found my face.  “Help me.  Let me die,” she mouthed around the suction tube in her throat.  She was NPO again.  Nil Per Os.  Starving.

Her hair was short and wispy around her face.  She looked like a bird.  Her skin was so dry and thin it seemed made of millions of microscopic feathers.  Her daughter had signed a consent form, we were to continue treating her.

I wanted to unhook her from all these tubes, rub lotion into her dry hands, stroke her wispy hair.  I wanted to wrap her in a quilt and read to her.  But I could not. 

Mrs. Beedle was going to die, and badly.  I could not go with her.  I had to stay here and learn to change wound vacs and check electrolytes.  I had to finish this procedure and then scrub in for an appendectomy and then try to sneak downstairs to the cafeteria to eat a banana.  I had to get a good grade on this rotation.  Most of all I had to stop feeling her hole ripping through my own stomach.

I was there in that hospital room that smelled of latex and bile, and that was the last place I was. I felt my eyes glaze over and a dullness come into my limbs.

I looked away from Mrs. Beedle’s face.  I cut the new piece of black foam to the right size. I set out the saline solution.  The resident peeled back the old bandage from her belly, and when Mrs. Beedle screamed and thrashed, I helped hold her down. 

I thought about the meditation chime.  How was that pallid sound supposed to help this?

When I was a child, a man once came to our door, asking to mow the lawn.  He needed money, he said, to buy formula for his new baby.  Mom said no, that Dad would mow our lawn.  I ran after him with all forty-three dollars of my saved allowance.  When I gave it to him, he picked me up and hugged me.

Now I think people like that will probably just buy booze. 

I’m not the same person I was before, because now I’ve got this hard, cynical exoskeleton.  It keeps those holes from wheedling into me, the cancer from seeping into my bones.  My patients look different to me, they aren’t like me.  Women with chronic low back pain who just want drugs.  Men with diabetes raging out of control who won’t take insulin.  Children born with AIDS because their mothers were too irresponsible to take their medicine.  I reinforce my exoskeleton with ways it is their own fault, of reasons bad things can’t happen to me: I obey dress codes, speed limits, open container laws, I make good food choices and keep my BMI in the healthy range.

Then there is rage.  I feel it in the back of my throat and in my fingertips and behind my eyes.  I am angry at them for suffering.  How dare they bring me their grief, their pain, their sadness?  What answer do they think I have for them?  I’m just some kid who has attended two and a half years of grad school.  Yet they cling to me, their needs suffocating and insistent. 

It’s an effort to come back to the surface, to quiet the rage, to strip down the chitin from my hard shell.  I study patience.  I practice making eye contact with strangers and thinking un-cynical thoughts.  I adopt an aggressive form of mindfulness, digging my fingernails into my skin when I feel the first prickles of dissociation. I meditate on vulnerability, on filing down my exoskeleton, on really listening. 

It will never come as naturally as it did before.  I am not the same person.  But here I am, in my white coat, and patients keep coming, thrusting their cares into my hands and expecting me to help, not roll my eyes.  And so I keep trying.