“Still in lots of pain,” she whispered back, no longer begging. After four hours of writhing with pain and vomiting on the stretcher, she had learned to give up begging to be seen by a real doctor and had resigned herself to accepting a third-year medical student as her only caregiver. Her female companion had fallen asleep on a chair at the foot of the stretcher, oblivious of all vomiting, lacerations, gunshot wounds, and two-story jumps occupying the emergency department at three o’clock in the morning.
I ran out of things to say and patted her pale, IV-pierced arm. She looked even younger than her age. I could imagine myself reporting at morning rounds: “Twenty-year-old female, status postabortion three months ago, presented with a three-day history of diarrhea and bright red blood per rectum …” I wondered if the residents at rounds would ever put a face to my patient. Perhaps they would never place a ring on that young nose.
“I’m thirsty. Could I have something to drink?” she asked again, for the fourth or fifth time.
“We’re trying not to give you anything by mouth, in case you need to go to the operating room.” I paused. “But I guess you could take some ice cubes.” I made a decision that suddenly seemed momentous after weeks of following orders. A strange sense of pride took over, but her pained face brought me back to reality.
“Thank you” she said.
Three o’clock. Then four. Then five. More abdominal-pain cases passed through, with a few lower-back injuries, one intoxication, and the usual few who were verbally abusive. Pains were mixed together; women and men, the young and the old, the psycho and the drunk and the addicts, the poor and the wealthy, the longtime Bostonians and the been-here-three-weeks Haitians, blended together into an amorphous mosaic of human suffering, rage, anger, anxiety. Five o’clock in the morning. Was it really five already? I sat down on a bloodstained green plastic chair next to the triage area and took a break.
Three weeks in the wards and almost three weeks in the ED have penetrated the core of my soul. I do not know how. I just know that something inside me has been affected, and I am changing invisibly but, paradoxically, so clearly. How am I supposed to feel when seeing an abdomen being cut by a #15 blade, its fascia separated by the Bovie set at forty watts, powerful enough to fill the room with the nauseating smell of burning flesh? How am I supposed to feel when blood and stool from a perforated small bowel overwhelm the suction, flooding the floor of the operating room? How am I supposed to feel when the team stops CPR and pronounces the patient—a husband, a father, perhaps even a grandfather—dead? How am I supposed to feel when my patient cries with pain from broken bones, crushed tissue, and lost hope while I quietly stand by her bedside, equally hopeless?
Reflection seems impossible when the bombardment of diverse emotions never stops. I let everything in, perhaps foolishly, perhaps stubbornly. Everything I have seen remains in me, hiding in my cells, penetrating my heart. I had thought that I would cry, but to my surprise I have not. After twenty-four hours at the ED, I go home and sleep most of the day. Sleep provides the unique luxury of nonexistence and nonfeeling. Then I wake up and return to the hospital, deceiving myself that I am fresh for another day, all the while knowing that I feel the burden of the previous day—no, that is not completely true. I feel the experience of the previous day and the many days preceding it. I love my time in the hospital, but I wonder whether emotions will ever overwhelm intellectual growth, whether tears, when they come, will cloud learning.
I stood up, left that little room. My nose-ring patient had finally fallen asleep, her stretcher still lying in the hallway. I walked down the empty corridor to the radiology department to have her CT images read. Five minutes later, I returned to the triage area. The stretcher was still there, against my faint hope. She was awake again, retching but not throwing anything up. She raised her head as I approached.
“Sorry,” she apologized, probably for appearing so sick in front of me. More retching. I waited, savoring this temporary silence. She finally stopped trying to vomit and lay back down on the stretcher.
“Your CT scan shows that it’s very unlikely that you have appendicitis.”
She let out a loud sigh, even managed to flash a smile of relief. “So I don’t have to be operated on?”
“No,” I said quietly.
She closed her eyes for a moment. “I’m so happy to hear that.”
I stood there, feeling my heels pressing down hard on the Dansko clogs. The CT images were still fresh in my mind. The multiple masses were worrisome to the radiologists and even to my untrained eyes. Of course, I was not going to tell her of anything else. More tests were to be done. No cancer yet, despite the multiple masses throughout her abdomen. No cancer yet.
I walked away from her stretcher. Suddenly I wanted to cry.
Zebras
Hao Zhu
THE SAUDI GOVERNMENT SENT the twelve-year-old boy to Children’s Hospital in Boston to get the best medical care in the world. Before I even started my pediatrics rotation, I had heard his story. He was the Toll receptor mutation on the eighth floor, one of the handful of people in the world with this genetic defect. In fly and mouse models, the Toll receptor and the molecular pathway in which it functions was found to be necessary for embryonic development and basic immune function. In other words, animals with this mutation could not defend against simple bacterial infections. I imagined how remarkable it would be to see the manifestations of such a mutation in a living human being. This was one of the major reasons why I had wanted to do a pediatrics rotation at the renowned Children’s Hospital: to see zebras. Good doctors think of horses when they hear hoofbeats, but they never forget that hoofbeats are occasionally made by zebras. This boy’s case was a zebra’s zebra. Some in the scientific-medical community think of patients like him as natural experiments, individuals with inborn genetic defects exposed to the light of science. A scientist can spend years studying a mouse that carries a mutation like his. To the medical world, exquisite knowledge and suffering were embodied in that small child.
When I arrived on the eighth floor, I was immediately fascinated by the cases that the team was handling. On my first day, the immunology fellow, who displayed intense scientific leanings, presented the boy’s case. The fellow seemed to be completely enthralled, especially when he was discussing how this patient was going to be studied. Apparently there was still a lot of scientific legwork remaining, because the mutation didn’t fit neatly into any classic categories. We seemed to be fetishizing a rare bird rather than treating a sick child. To be fair, the intellectual substance was undeniably thrilling. At that moment, I wanted to be in the fellow’s shoes.
Several days later, I was on call and had the opportunity to see the boy. One of the female doctors knocked on the door to give the mother time to put on her veil. As we put on our own gowns and masks, the intern thought for a second about what he would say to the mother if she asked what was going to happen. He asked the senior resident, but she had no idea. There was no real therapeutic plan. Without having come up with a good script, we knocked on the door and walked into the room.
It was late at night, and with the blinds drawn, the room took on a ghostly atmosphere. The boy’s mother looked at us through the sliver of her veil. There was no telling what her face was expressing, much less what she looked like. I could only guess whether she was hopeful or upset or resigned, given their six-week stay with no clear or optimistic end point. The patient’s little brother was also there, smiling and grabbing hold of his mother’s leg, conspicuous in his normalcy. The mother approached us like many patients’ parents do: as if the arrival of the doctors was really going to help her son somehow. The way she moved toward us and toward her son showed that she had hope left. But looking at the boy, I could tell that there was going to be little time, and that keeping him comfortable was the only medicine left.
He was a tiny thing, barely three feet long, and dark, as if he had been living in a cave for weeks. He was cocooned in a fetal position, with a ma
chine blowing air in and out of his chest. I thought about how cruel the natural world could be. I didn’t get the sense that he was in pain, but it did seem that his soul, a full human soul, was suffocating in a congested, ravaged body. He didn’t speak, or it may have been that he was too sick to speak, or that he was unable to understand English. But I was glad that we couldn’t talk to him; if I were in his place, I wouldn’t want to talk to anyone. I would be wondering why the doctors were keeping me alive. What the hell was all this—the doctors, tests, blood draws, genes and receptors and sequencing, what could it all mean? From his perspective, it must have been a sick game. I wondered what was actually going through his mind as his eyes met with each of ours. I hope it was nothing at all, that it was only numbness. It was clear right then that we were dealing with a human being, but I didn’t want him to feel like a human must have felt at that moment.
We were no longer in the vacuum of the laboratory, and the intellectual excitement that I had previously felt drained away as we took in the child’s misery. It was a stark and uncomfortable realization. He was both a gift and a curse to medicine: A gift because we could learn about his missing gene and its function in immunity. A curse because his suffering was as terrible as his mutation.
The Last Prayer
Joan S. Hu
MY FIRST WEEK OF OB-GYN. I am thrown into gyn-oncology right away, and the rotation is fast paced. Our team is always racing somewhere: OR, floor, “the Tower,” OR again, then back. Fifteen patients on the floor, and an OR schedule packed from dawn till long past dusk.
The scoop today is that we are planning a total exenteration for tomorrow a.m., exenteration being the Greek for “to scoop out the bowels; to eviscerate.” Pleasant thought.
Our star patient is Ms. S.—thirty-three years old, married, with a two-year-old baby boy at home, beautiful brunette, young and tan, who looks as if she could be on the cover of a magazine. Except that she has cervical cancer that reappeared only months after total abdominal hysterectomy, chemotherapy, and radiation therapy. She had apparently gone to Bermuda or somewhere for homeopathic treatment in the interim. Her cancer has now invaded the bladder wall and the colon, according to an MRI taken two weeks ago. The total exenteration will remove her bladder, the involved colon, and her vagina, and she will get a new plastic bladder, a reconstructed colon and rectum, and a 50 percent chance of survival. Without the procedure, her survival amounts to a whopping 0 percent. But first we are going to biopsy her nodes and pelvic walls to make sure the cancer has not already metastasized. Because if it has, there will be no exenteration, and there will be no life.
I am thrilled about the prospects of seeing this surgery, so complicated that it is expected to last anywhere from nine to twelve hours. I copy the elaborate chapter on the procedure in a surgical text with the intent of fully memorizing it for the next day. I am going to watch her surgery, since scrubbing in is an impossibility for a medical student on a surgery that is literally done only once a year at this premier tertiary care institution, if that. All the residents want to watch, and both fellows are scrubbing in, along with a general surgeon, a urologist, and our attending. This is going to be the surgery of the year.
I introduce myself to Ms. S. and her family as they wait in pre-op, thinking that it might help her to see a familiar face once she’s in OR. In a few minutes, the surgeon and anesthesiologist also show up, and just before we are about to roll her into the OR, the family wishes to gather around her, including us, her caretakers, to say one last prayer. As her husband says the first words, “Our Father, bless us,” his voice cracks, falters, breaks. “Give our daughter, our sister, our wife, the strength to survive this ordeal. Guide the hands of her surgeons so that they may rid her of this disease. May God bless her nurses, who are so caring and careful; give them and give us the strength to help her, our daughter, sister, wife, survive. Guide us, bless us, forgive us, and have mercy on us.”
And all the while I am thinking, Will this be her last prayer? Are we, feeble as we are, uncertain as we are about whether we can save her at all—are we her last prayer?
I am standing around in the OR, wishing that I might have scrubbed in. Hoping to help in any way. The first thing we will do is send specimens to the frozen lab for surgical pathology. Para-aortic lymph nodes, left pelvic-wall biopsy, superficial left pelvic-wall biopsy, left presacral pelvic wall, third left pelvic-wall biopsy. And I run down to the path lab, hoping for a negative answer. The path resident is rushing around in the small room, freezing, writing, slicing, mounting, washing and rewashing. The wait seems torturously slow, yet I know she is working fast as lightning. And the pathologist, gentle and incisive, says, para-aortic nodes are negative. Hooray! We are one step closer to the fabulous, fantastic exenteration. And I wait a little longer. Left pelvic-sidewall biopsy, positive for metastatic carcinoma. Superficial left pelvic wall, positive for metastatic carcinoma. What do you mean? Metastatic. Aren’t we still going to do the exenteration?
I rush back to the OR. Dr. B., our all-knowing, gentle-voiced, all-curing attending, are we going on with the exenteration?
No. The answer is no. It will be impossible to obtain clean margins, now that she has pelvic-wall involvement, and without that, nothing we do now can save her.
So it goes, I am slowly learning; the worst answer one can ever hear in a hospital is the word “no.” No, she has no more chances; no, she is not going to get surgery; no, she is not responding to therapy, treatment, whatever. “No” is the last finality.
They do a little more, they resect a big chunk of the cancer in her colon, but they decide not to touch the main mass fungating on the top of her vagina, because it is firmly entrenched, “frozen,” as they say, into the pelvic cavity, clasping in its death’s embrace the bladder and surrounding ligaments. So what will she have? A few more months, at the most.
And she wakes up from anesthesia, much too soon. What happened to scrubbing in for a straight ten hours? I had used the restroom, eaten a big meal, prepared for a long watch, everything. We started at 10:00 a.m., and now it is only noon. As she is waking up, she murmurs a prescient, “That was so fast,” still drowsy from sleep. And I wonder if she knows. We say nothing. All of us, the nurses, the anesthesiologists—all we can do is look at her, with a silence too unbearable, with a sadness that strangles the depths of my gut. All we can do is look at her and pretend to smile, rub her hands and her legs, and tell her that the surgery is over. I have never heard the OR so silent and so sad, and the air is stifling, rife with disappointment, disbelief, and the excruciating pain of knowing.
The word is that her family took it badly. How else could they have taken it? And the nurses and resident ask whether it might have made a difference that she spent those months in homeopathic heaven in Bermuda. The fellow says sullenly that it doesn’t matter now; there’s no need to mention that, because it makes no difference now.
Yes, her and many others. The two other patients that I scrubbed in on, Ms. T., a lovely elderly Vietnamese woman so small and frail that you might mistake her for a child except for her wispy gray locks, with a face so beautiful that you think she must have been a gorgeous little thing in her younger days. Ms. T., who has metastatic ovarian cancer, did not get an exenteration per se, but we did scoop out some of her bowels, to put it crudely. But her cancer was so extensive, extending to the diaphragms and deep into the bowels, that our “radical cytoreductive operation,” aka “debulking” of tumor, was dismally “suboptimal.”
And Ms. H., a sweet elderly lady who presented with pelvic masses and bloating, who also has metastatic carcinoma that is probably ovarian, had four liters of malignant fluid in her abdomen on the afternoon we opened her up. And staring at us were large white masses of cancer perched on top of her bowels, right over the omentum, draped luxuriously like kings. And as soon as we touched the cancer, as soon as we started dissecting and cutting just a little bit, blood began pouring into her abdomen, like a crimson flood. Where was it coming f
rom? And we scrambled to stop up the blood, to find the arteries that were leaking. But alas, it was her cancer. Thirsty for blood, unquenchable and unforgiving. And the surgeon could not help but shake his head time and again, all the while muttering that this was a mess, this was just awful, this was a dirty, nasty business.
And this whole week, I have been wondering: How much can we take out? Can we remove Ms. S.’s pelvis to save her? Can we take Ms. T.’s and Ms. H.’s bowels all out? How much of them must we take away to preserve the meager bit that is left? How much of them has the cancer eaten and devoured, engulfed and swallowed up whole? It seems to me a monster of a demon. The white ghoul that gnaws and devours from the inside out. And we are the exorcists, the demon chasers, the high priests, the wise men. And we cut and cull and slash and sew, scoop and slay, we eviscerate and extirpate, in the hope—vain hope!—that a prayer and a chant, a magical wave or two of the miraculous sterilized wands of our armamentarium, will exterminate the demons forever. But inevitably, they come back. It is so hard to believe, even when the sea of purple cells are staring me straight in the eyes, that this is her fate, as it might be mine. To see ourselves eaten away by such … invisible fiends of fate. And what good was the prayer, the last prayer of all? Guiding our hands to extinction.
I heard the Twenty-third Psalm on the radio today, and I wrote it down for safekeeping. I think I might read it to a dying patient one day, if she likes. I think I know now why we say prayers.
The Lord is my shepherd; I shall not want.
He makes me to lie down in green pastures,
He leads me beside the still waters.
He restores my soul.
He guides me in straight paths for His Name’s sake.
The Soul of a Doctor Page 9
