The Kindness of Surgeons

IT'S BEEN ONE OF THOSE YEARS. The kind where so much goes right that you stand to lose a lot when things inevitably go wrong. And if you aren't careful, you could look back at the whole darned thing as a Pretty Bad Year.

By last May I had lost at love - hard luck that came fast on the heels of what I'll call a fortnight-long hiccup in my job as a medical student. There were moments when I felt I was losing my sanity, questions I asked myself that threatened my integrity. And worst, I lost confidence, and even some self esteem.

Just as the tiny pieces of all my expectations (Ah, Third Year!) were floating around me like ash, I began SUR-430.

Surgery is the tough rotation. The job of the medical student is one of deference and - if you can manage it - stoicism. Legend has it that in some places the medical student is pushed to the point where it feels like torture: bleary eyed, red eyed, bone tired and broken down, she attends her rounds, crams through the night, retracts abdominal flesh until her muscles cramp to stone.

The consensus at UCDMC is that things here are "benign." One resident told me, as we stood in the elevator on our way to that almost bizarre middle of the night cafeteria hour, "The real malignant stuff is back east, man. You all have it easy here."

I have also been told that students either love surgery, or they hate it. This may be true, but I no longer believe our ultimate attitude rests simply on our predilection for that which defines the specialty. Sure, if you're comfortable setting the alarm for 3:45 a.m., it helps. And yes, it makes a profound difference to be healthy, able in body (quick up the stairs in clogs, arms like a meerkat's for hours).

You like to work with your hands, perhaps. Or you're good at knots. You coveted all things anatomical, and remember them. Strong stomach. Adrenaline junkie.

One attending confessed, "I like to wear pajamas to work."

For me, it was peanut butter (jars sit open and staked with plastic knives in the OR break room) and graham crackers (a sea of single packages populate a drawer near the espresso machine.)

It was the sound of the automatic double doors opening when I punched the silver square on the wall, and the shade of orange drawstring on my scrub pants - not the new ones; the faded ones, the many-times-washed ones.

Those rubber bubble-foot thingies that dispense soap. The feeling of walking to work in the dark-kind-of-morning, and returning home in the light-kind-of-morning.

I liked getting better at suctioning smoke from the cauterizer, and the beeping sound the cauterizer made. Come to think of it, I liked that cauterizer (it has two modes, and a foot pedal).

I loved how it felt to press the gentle curve of a scalpel into skin, and how the subcutaneous fat unfolded with tiny, shiny spots of capillary blood, reminding me of flowers blooming, while the fascia - thus revealed - conjured up what it was to dissect a dolphin so many years ago. (Their aerodynamics depend on fascia, you know.)

I liked all those questions asked of me: never Sports and Leisure for the orange pie, or that vile pink for Entertainment. Better questions - exciting questions - about life, and death, and the way things work. Names of things, places in the human body…like the Artery of Adamkiewicz. (I got that one wrong, but doesn't it sound like a magical place?)

Still, in the end, I suppose those details are special simply because they remind me of surgery. And while it is a funny thing to look forward to nostalgia, I do. I am banking heavily in fact, on the day when those smells and sounds and colors will, instantly, remind me of those eight weeks, and what it was to be…

Maybe, a Surgeon?

Mr. Q was obese. The kind of obese which earns him a "Big Boy Bed" and stymies the placement of IVs while a minimum of three people lift the generous pannus of his girth for a physical exam. The kind of obese that lends itself to a quiet growing of yeast, between rolls of fat, fat which is stiffened by time, puckered by the strain of it all.

When his name popped up on the Trauma Gold Team patient list, I recognized it immediately. During a previous stay, Mr. Q's inpatient care had been somewhat of a production, exposing me to that which can transpire outside of the patient's room. Conversations. Protocols. The way things work, my role as a medical student. "Reality," some might say.

It was during those weeks that I considered leaving medical school for the first time.

Quitting didn't take, though, for either of us. This time around, he was a "surgical consult": a name and room number inserted into a list of 25 other patients scattered all over the hospital, all of whom needed to be seen before 7:30 am.

We agreed it would be necessary to roll him.

Of course, it was more than rolling. It was some kind of origami-unfolding-turning-positioning kind of maneuver. He was seated much as one would be in a barber shop, requiring us to adjust the bed and stand there quietly as one person pressed the teensy button while another filled the silence, waiting for the hum of the mechanical recliner to do its job.

Once he was supine, we tacked around him like human fence posts. Shoulder to shoulder, belly facing belly: ready. Some donned gloves. Eyes met. We grabbed the sheets, crumpled them up in our palms. We seized his night gown, his arms, his hips.

And rolled him.

Rolling someone who weighs 400 pounds is not the same as rolling your average Joe (though statistics on obesity in the US indicate that the average Joe generally looks between his toes at a hefty 193 pounds, that 65.2 percent of adults in the U.S. are overweight, and that 30.5 percent - that's 60 million people - are obese¹). This was one time when I was glad our Trauma Gold Team could field a soccer game; i.e., do not imagine that we counted 1-2-3, grunted and it was done. The tactic required dialogue, "Watch out for his shoulder!" Attention to detail, "Don't let his back slide along the mattress!" Communication, "Switch your hand with mine…no…put it here…that's better." And all the while, our attending looked Mr. Q in the eye. "Tell us if you are in pain…Don't worry, we won't let you fall, we do this all this time." (Though there is the option of calling ahead for a troika of linebacker-sized, walkie-talkie toting, all-business hospital employees sporting black T-shirts that say, "LIFT TEAM.")

On his side, Mr. Q stared into the railing of the bed, eye-to-eye with the volume control for his TV. One of the residents crouched towards him, offering a human face for nameless voices and hands.

"Careful with the tape - don't let it pull on his skin," my attending directed, then bent over to our patient, "The less discomfort the better."

The lumbar portion of Mr. Q's girth was thick with flesh. Still, I could discern that The Ulcer was located exactly at his spine and supposed that if I put both fists into the giant gaping hole, the knuckles of my second finger would nearly touch the spiny bones of his vertebrae, and my pinkies would rudely find a groove in his Latissimus dorsi.

It was horrifying.

It doesn't matter how much stuff you've seen. It doesn't matter how gnarly it's been. You could be seasoned, or you could be green.

The fact was, I could nearly see this man's spine through a crater of gaping flesh that was rotting from inadequate blood supply due to prolonged immobilization secondary to his body habitus and various comorbid conditions.

And it was 7:19 a.m.

The inspection itself was brief but accompanied by my attending's benevolent narrative. "Mr. Q, you are going to feel some pressure as we remove the packing. Please let us know if you'd like more pain medication." He walked around the bed, hooked a finger under the sheets. "Can someone go get us some fresh sheets?" I turned and jogged down the hall. "And some new pillows! And another blanket!" His voice trailed after me as I tried to remember which floor we were on and where the linens were kept.

When I returned, everyone was busy. My fellow medical student cleared away a plate of jello-gooped dishes, an intern corralled two stray chairs, our attending supervised the careful removal of the former, wrinkly sheets, and a resident delicately supported Mr. Q's feet in his arms, querying, "Do you need another pillow? How about one under your legs? Hey, someone get me another pillow!"

Are they kidding? I thought. And then, Why would I think they are kidding?

In any case, no one questioned the rigmarole. No rolling eyes, no glancing at watches. Even when, in one unlikely moment, our attending double-checked the corners of the bed where the fitted sheet always slides up. I felt moved, overwhelmed and - what is it? - Verklempt. I had to turn to the window as my eyes brimmed with tears, the square vista of trees north of the hospital softening to a blur.

White noise. Distant voices. My mother holding her Frommer's Guide to Sacramento, exclaiming "Did you know that your new town is home to more trees per capita than any urban city in the entire world except Paris?" A flash of Mr. Q in the ER two months ago, then later on the floor as his heavy fists grabbed the hard poles of his bed as he tried to hold himself up, breathing so hard and with such effort I agonized about paging one of my dog-tired interns to ask, "Wasn't there another kind of Big Boy Bed which would maybe make it easier?"

Back in the room I realized the team was off again. I scurried down the hall, around the corners, down the stairs, grabbing the railings to make the hairpin turns faster as we descended flight upon flight, some rushing off to the OR, others back to the Trauma Nursing Unit.

I stopped somewhere - I don't know where - to gather myself. I put the heel of my hand to my breastbone, absently kneading the place where I feel things.

I will write about this, I thought. I will write about this, and I will call it The Kindness of Surgeons.

I loved surgery and, to my utter and somewhat sheepish delight, passed soundly. I still have four rotations to go, and plan to submerse myself in each one, but know that my experiences on the second floor of UCDMC were, in many ways, inimitable.

If I can take the peanut butter and crackers to every rotation, I will. So too, the constant demeanors of my fellow medical students, who often fetched charts at every floor when I was too afraid to lose the team on rounds; the scrub nurses who manage to guard the lives of our patients with their fastidiousness and vigilance - I promise I'll never let my hands drop too low again; the tireless surgical residents who unfailingly took time to teach me at all hours of the night; and, not least, lessons from each attending. I promise not to forget all that you taught me-especially the stuff that seems hard to change.

elven@ucdavis.edu

1. Centers for Disease Control and Prevention. "Health, United States, 2004." http://www.cdc.gov/nchs/data/hus/hus04.pdf.