It couldn’t have been more than twenty seconds before the warmth of our initial interaction returned: “Here in America, it doesn’t matter that you’re not a Muslim. Africans in America are one.” She asked, “Are you married?” A ten-minute explanation of the importance of marriage for me, a young, bright African woman with a promising career ahead of me, followed. She talked like my mother, or aunt, or grandmother would: “Look for someone as smart as you … Go to every African wedding … Join the African cultural group at school … Attend get-togethers at the business school and law school, too … Don’t forget your life and family just because you’re in school.” I smiled as she spoke—all of it was familiar advice.
I left the exam room smiling—and thinking. As one interested in practicing medicine internationally, particularly throughout the greater African ark, I wonder whether religious differences will affect my ability to earn the trust of, and subsequently deliver quality care to, my patients. I wonder whether there is a place for religious belief in medicine. When is it necessary to be cognizant of religious persuasion in interacting with patients, and when is it harmful? Religion, like ethnicity, is such a salient part of all of us that it should have—must have—a place in the world of medicine. How I will incorporate my religious beliefs into my career as an African—and American—woman remains to be determined. I am sure that society incorporates both religion and division into its fabric. I am equally sure that division and medicine are utterly incompatible. Inshallah, the reconciliation of these two truths will one day become clear to me.
Inshallah is an Arabic word meaning “God willing.”
The Twelve-Hour Child
Wai-Kit Lo
SHE WAS LYING on the hospital bed in a small, curtained room in the pre-op area of the OR; she looked tired and wan. It was seven o’clock at night, and she had been at the hospital all day. Her eyes were wet; she was quiet. Her two hands rested on the curve of her lower abdomen, as if to shield it from the outside world.
Karen had come in to the hospital that morning. She had already tried for many years to get pregnant, and now, at the age of thirty-eight, after one miscarriage and three cycles of hormone therapy and intrauterine insemination, she was fifteen weeks pregnant with her first child. So when she noticed some bleeding from below, she took it upon herself to go to the hospital, to make sure everything was still OK.
That morning, her physical exam was, for the most part, normal. Perhaps her abdomen was ever so slightly larger than would be expected in a fifteen-week pregnancy, but not alarmingly so. She had no pain, the bleeding had stopped, and she felt fine, if a bit nervous. The ultrasound revealed a healthy fetus in her uterus—the right size, the right shape, the right position.
However, there was something else that the ultrasound showed. On the left side of her abdomen, somewhere outside the uterus but very close to it, the imaging revealed a round shape with a different echoic pattern than the surrounding area. It was fixed and painless. Given the patient’s pregnancy status, we ordered an MRI.
There was the pregnant uterus, with the fetal soft-tissue structures inside, curled up in a tight little ball. There was also a large mass in the patient’s left lower quadrant, definitely outside the uterus and not really part of the bowels either. Funny, it looked just like the mass inside the uterus.
Then it dawned on me: I wasn’t looking at a peritoneal or adnexal tumor, but at another fetus that was growing in the woman’s abdomen. A follow-up ultrasound confirmed it. Karen had a viable heterotopic pregnancy: she had twins, one growing in her uterus, the other in her abdomen, both alive and well at fifteen weeks’ gestation.
Heterotopic pregnancies are rare, but intra-abdominal ones are one of the rarer subtypes. And with the pregnancy at fifteen weeks, and viable, there wasn’t much literature that could help us decide what to do next. I found isolated case reports from Africa and Asia, featuring termination before week eleven and healthy delivery after week thirty-four, but there was nothing comparable to our situation. Nevertheless the ob-gyn team knew that the abdominal pregnancy could proceed only at great risk to the mother and the intrauterine fetus, primarily because of the increased risk of internal bleeding.
I wasn’t there when the senior resident went to tell Karen the news. But I imagine it must have been difficult for her, finding out that she had not one but two babies, and then realizing that she had little choice but to terminate one of them. How does a mother come to terms with that? I could only hope that she took some solace in knowing that the intra-abdominal fetus was a real threat to her health and that if she were to continue to carry it, she risked losing not only both babies but her own life. Still, the decision was up to her, and thankfully, she chose surgery.
The surgery went smoothly. The intra-abdominal fetus, so fragile in its little sac at fifteen weeks’ gestation, was removed along with the attached placenta, with moderate but controlled blood loss. You could see all the little features—the hands and fingers, the arms and legs, and the big head—the way that you could only if you looked inside a uterus during a pregnancy. I kept glancing over at the specimen tray at the end of the procedure, half expecting the sac to move, ever aware of the weight of our actions.
After the procedure, I waited for the effects of the anesthesia to wear off a bit, then went to see Karen in the recovery unit. I wanted to ask her how she felt, what she was thinking, whether she wanted some company. In the end, I didn’t have to say anything. “It’s just a miscarriage,” she said. “I’ll be fine.” As she smiled, her hands drifted to her abdomen, right hand cradling the healthy child still growing in her uterus, left hand resting on the spot where a child had been, a child that for her had existed for only twelve hours.
On Saying Sorry
Alejandra Casillas
IT JUST FELT REALLY WRONG.
That is really the only way I can describe how I felt after we had taken care of Ms. D. one call night during my inpatient rotation in internal medicine.
Ms. D. arrived on Friday night from her nursing home. The ninety-something-year-old black woman appeared delirious and confused. Her thin, frail body lay on an emergency-room stretcher in the hallway as we arrived. She moaned and wailed unknowingly. Thick sputum crusted at her mouth. Her eyes were closed. She could not understand what we tried to tell her. She reached for any hand nearest to her and squeezed tightly, despite her apparent weakness. Her daughter stood by the paramedics, perplexed and shocked. Ms. D.’s mental status had been perfectly fine two days ago. She had been, until now, a completely articulate and spunky old woman, known for her sparkling southern charm.
Finally, after an hour, we were able to admit Ms. D. to our service, and it became clear to me why we had not acted more aggressively when she first arrived. The intern I was working with, Dave, leaned over and explained that Ms. D. had specific wishes outlined. She would be in for treatment, but without invasive measures. No central lines, no need for an emergency ABG (arterial blood gas). We would try to make her better, try to treat her apparent infection (most probably an aspiration pneumonia), but comfort came first. Comfort first.
Ms. D.’s daughter made that increasingly clear to us before she left. She half-joked that her mother would run the other way if we were to chase her with a central-line needle. She knew all too well that her mother’s time would come soon. After talking with us for a while, she moved over to her delirious and semiconscious mother and said loudly, “I love you, Mom. I’ll see you soon. Have a good night.”
What? At this point in the evening, I started feeling a weird knot at the bottom of my stomach. You know that your mom might pass away sometime soon, and you are not going to spend the night with her? If it were my mom, I would have been at her bed every single minute, not letting a moment go. I tried to check myself; I did not know this daughter’s story. She probably had good reasons for leaving, had been through this before.
The daughter left, and Dave and I started to go over the plan. The associate nurse came over. Ms. D. was
an intravenous nurse’s nightmare—weak pulses and an impossible arm venous stick. And no central-line option. How would we get blood cultures? How would we know how to treat this infection?
Dave proposed a third option: a femoral stick. The pulse would be better, and getting the blood would be quick. “Alej, you’ll help me do it,” Dave said. “OK,” I replied.
“How many femoral sticks have you done?” the nurse asked.
“One,” he said.
The nurse raised an eyebrow that only I caught. And afterward I knew why.
A femoral stick is not easy. And it is very painful. Dave and I proceeded into Ms. D.’s room. My job would be to hold her legs down and grab her hand as Dave stuck the inside of Ms. D.’s thigh with a thick needle. I will never forget the first stick.
“Please, no, no, please,” Ms. D. wailed, wakening from her septic, sleepy coma as the first piercing went through. I bore down stronger on her skinny legs and arms as she flailed around. No blood. He moved the stick around. More screams. No blood. Needle out.
Another needle, another stick. He moved this needle around for another fifteen minutes.
Second needle out. At this point, I was almost on top of Ms. D., restraining her as if she were a madwoman, knowing she was anything but that. She looked like a meek, blind, ninety-year-old angel.
We were sweating like crazy. Dave looked disconcerted, frustrated, and angry with himself. He took the second needle out. OK, we were giving up, thank God. I could not do this anymore.
“Just one more, Alej. And if it doesn’t go through, then we’ll just give up and figure out something else.”
What? I thought. We were torturing her, and to what purpose? We would have to start treating her with antibiotics anyway, and she would most certainly die soon! Another stick—I could not believe it.
Another needle went in. “You’re almost done, Ms. D.,” I choked back tears as she yelped again. She squeezed my hand. I felt like such a liar. I had been saying this throughout the last two sticks. Dave continued to fiddle with the needle. Another ten minutes passed, and finally he gave up. Three sticks later. Bloodless. An elapsed forty-five minutes of pain.
Later, Dave thought that it would be a good idea if I placed my first Foley urinary catheter into Ms. D. Oh, boy, I thought once more. Again, Ms. D. endured a second set of clumsy hands as they attempted to pull on her rigid legs, inserting that tube into her small-framed pelvis. Although the nurse could have done it in two seconds, here I was, practicing on Ms. D.
On my second attempt at the Foley, her pain finally ended for the night. That night, I did not admit a patient. I spent most of my time with Ms. D., holding her hand. She would squeeze once in a while. She kept saying she was cold. She felt like ice. She would moan, “I love you, sweetie,” in her half-asleep state. I would squeeze her hand back. In her delirium, I think she thought I was her daughter. It was the least I could do to repay her.
Two days later, Ms. D. died quietly in her sleep. Gary, the team senior, gave the daughter the news when she came in to see her mother, and I asked if I could come with him, since I had spent so much time with Ms. D. As Gary talked to Ms. D.’s daughter, I looked over to Ms. D.’s resting body. So calm now. Ms. D.’s daughter’s tears came pouring out. “I didn’t expect she would go so soon. She was a good mom. I loved her, and I’m glad that we chose not to impose any extra suffering on her.”
“Yes, you made the right decision,” Gary said.
I wonder what she would have thought, had she been able to talk to her mom again, or had she been there that first night after her mom was admitted. I looked at her, and as I left, I held her hand and stifled the tears before they could come out. At least I knew now that Ms. D. had a daughter who really cared. But I felt so guilty. Guilty for having let Dave continue with the sticks, for not speaking out at least. But Dave, being a genuinely good guy, felt it too.
As doctors, we make decisions on the fly, sometimes with little time to think. We make these choices, and we can only hope that they are for the best. But if I have learned anything from this experience, it is the fallibility of a physician’s desire to “better.” That wish is what makes a physician’s spirit so special; that determined nature to help is our weakness as well. By the time we wake up from our miracle-mission coma, three needle sticks later, a helpless old woman is at her deathbed, wailing for mercy.
I’m sorry, Ms. D. I needed to say sorry to you.
Coney Island
Yana Pikman
FOR THE FIRST TIME during that week, I was told about the patient’s story before entering the room and reading her chart. “This is a young woman with metastatic cervical cancer, which is impinging on her ureter. We will place a stent to keep it open,” the attending told me. My heart sank. I had been living in a world where cervical cancer is detected early by Pap smears and was shocked to see this woman squeezed into the operating-room schedule between a TURP (trans-urethral resection of the prostate) and cystoscopy cases. Did the medical system fail this person?
When we walked into the room, the patient was already on the operating table. I expected her to be distraught but found a smiling, calm, and very warm woman. She had a rosary and a religious pendant pressed tight against her chest. We chatted about her kids, three and five years old, living in Florida after having grown up in New York, and her most recent procedure to remove several abdominal masses. We talked about Brooklyn and discovered that we were both from Coney Island. She had moved to Florida to be with her husband; I was considering the possibility of moving across country for my love. I could see myself in her: immigrant, growing up in the same place, similar goals of living the American dream. But the idea of her cancer could not leave my mind. As she was dreaming, eating, laughing, her cancer was feeding itself, decreasing her chances of seeing her kids grow up with the same dreams. I wanted to ask her how she could be so strong and composed, smiling and making jokes.
We started the procedure. We intubated her, and the urologist went in with his scope and injected dye into the urinary system. She had a bifurcated, or branching, ureter on the side of the compression. People really had that! I was amazed by the stent placement, the images of the ureters, the serial fluoroscopy views for visualizing the constriction, stent placement, and filling of the ureter afterward. I was amazed by the technique, the visual stimuli.
But afterward I felt guilty for not thinking about her throughout. It was a strange juxtaposition, the surgery and the personal story. The most interesting cases are often the most devastating for the patient. My scientific interest and patient experience had originally attracted me to the field of medicine, but now, after talking to her, I felt guilty looking inside her with a scope. I felt as if I had invaded her, and after having connected to her, I felt almost invaded myself.
Later in the evening, I went with another student to do a post-op check on her. Again we chatted about her sister, who had come up from New York to be with her in the hospital, and about her husband’s struggle with keeping up the household in her absence. The other student interrupted us to ask about pain, gas, and bowel movements. He wrote down her answers carefully, making sure to cover all the necessary surgical points. I did not want to know about her bowel movements. I was really enjoying chatting with her and wanted to try to make her feel comfortable in the cold hospital, so far away from her family.
But I was not doing my job. I had an assignment to do a post-op check, and yet my colleague seemed the only one focused on that goal. I wondered what would have happened if I were alone. Would I have been able to do my job in a case where I related so closely to the patient? Was it too dangerous to be emotionally connected to the patient? But at the same time I had little control over the situation. When the other student was done filling out the form, he sent me that eye signal that means “We have somewhere else to be,” and after doing a quick physical exam, we left the room.
“Cervical cancer is a sexually transmitted disease,” the student told me after we walked out. T
rue. But I felt as if I had been slapped in the face. I was offended. He was saying that it was her fault, and I wanted to defend her. But did he mean it that way? I could not handle the objective, scientific fact. I had taken to her, and the facts were too painful. If it was up to me to do a procedure on her at that point, I don’t think I would have been able to do it. How was it possible to try to connect with a patient, to try to understand what she was going through, but at the same time to remain able to perform the necessary job?
I felt powerless against any sort of disease process and found myself wondering how the medical profession even works. Combining the mechanism of disease with the personal experience of disease and the fight against it, on the part of both the patient, their loved ones, and the physician, seemed to be an issue greater than life itself. We were on the side of treatment, fighting against the invading tumor. Her kids were at home, waiting for their mother to return. Where was the disease? I guess this is why the patient needs to be treated as a whole, but in her case I could not consolidate all of those parts. She was a person whom I connected with closely, someone I would have talked extensively with if we had met at a bar. I had looked inside her with a scope. I could not effectively do a post-op check, and when I heard a poorly expressed statement about her disease, it sent a pain to my core.
Given another chance, I would still have talked to her as I did and probably would have connected just as much. I do not want to become a doctor who does not know her patients. But how do you provide good care when you cannot remain productive and objective? Perhaps that is where the medical team comes in, with different parts of the team serving different parts of the person. I tried to think of how I would want my doctor to act and which questions I would want to hear two hours after my surgery. I wanted to be asked about my pain, though perhaps not about my bowel movements; I would also want someone to care enough to ask about my visitor or the pictures on my nightstand. But I wonder if all of these types of caring can be combined in a single person. Perhaps that consolidation is something I can learn on the wards.
The Soul of a Doctor Page 5
