Medicine From The Trenches

Experiences from medical school, residency and beyond.

We have a mess here…

I settled into an evening of reviewing my lecture for the next day. It is a lecture on the early recognition of the signs of shock, a topic that is “near” and “dear” to most surgeons. This lecture is one of my favorite topics because I deliver this information in a “user-friendly” manner that I wish I had received in medical school. It took years of training in graduate school, medical school and residency/fellowship for me to “make peace”, read comfortable, with early recognition of signs and treatment of shock. Once the peace had been exchanged, I worked out what experience has taught me and my colleagues and pass that on to my students.

As I tweaked a slide here and there, the emergency tone on my phone sounded. Odd, I thought, for me to get this call on this day because I was not even on back-up duty. I called the number and heard the voice of one of my colleagues who is a trauma surgeon. “I have a young woman; shot multiple times in the upper torso and neck”. “Can you come in because we have a mess here and I need another pair of hands?” Of course, I would come in if called, without hesitation as one of the sheer joys of what I do is the old surgical mantra “A chance to cut is a chance to cure”. Besides, if I had made the same call to any of my colleagues, they would be at my side as soon as they could.

I drove my 1997 rusty gold Toyota Corolla through the sheets of rain that were falling as I made the 20-mile trip to the hospital. If I had been on call, I would have stayed at the hospital but since I wasn’t, I had to drive in. The rain pounded my wind screen in the early evening darkness. Why do these  types of situations happen on cold, rainy and foggy nights? Even my chihuahua would not venture out on a night like this. (I left my heated throw on low for her to snuggle into as I left my townhouse). ” A night that is not fit for man nor beast.”

I arrived at the hospital, parked the car and headed in through the emergency department. This was the quickest way to get to the operating room and would allow me to check out the radiographic studies before I headed upstairs. I scanned all of her films with the radiologist on duty and headed up the four floors to the main operating room. “They are in Room 6”, the desk clerk said as I removed my wet coat and entered the women’s locker room.

I changed into scrubs and grabbed my headlamp from the top shelf of my locker. I piled my wet hair on top of my head, pulled on a scrub cap, shoe covers and then placed my headlamp; tucking the cord into my back pocket. I peeked into the room where my partner,covered with blood, winked at me as a sign of relief. I  grabbed my surgical loupes from their wooden box, already placed on the circulator’s table, and said I would be right in as soon as I finished scrubbing.

The surgical scrub is where I take the time to center myself and get into the ritual, the mood of beginning a case. I always say a prayer for God to guide my brain and hands and to guide the hands of those who will operate with me. This has been my brief meditation as I scrub since medical school. I take the time to relax my arms, shoulders and breathe slowly, deliberately before I move into the operating room. With all of the tension of the drive, the rain and the run up four floors gone; I am ready to get to work.

I never want any surgical case to be mindless. I want to be mindful of every step and every event that will unfold. For the patient on the operating table, nothing about what I do is ever routine and will in all likelihood, be a sentinel event in their lives. Once something is cut, it’s never the same as before the cut. No, there is no mindless routine for me or for the patient but for me, there is a sense of compulsive perfection to get it right and to get it done.

The patient had been shot multiple times with wounds in the neck, upper torso, abdomen and shoulder. She had been standing outside her house with a group of friends when a car pulled up and multiple shots were fired. A policeman, was present in the operating room to take all bullet fragments that we would remove. As I donned my surgical gown and gloves, my partner motioned for me to take over the shoulder vascular repairs that he had been working on so that he could move to the abdomen. From training and experience, get control and make the necessary repairs and move onto the next task.

My partner had completed only a tiny portion of what needed to be completed in this complex wound. The bullet had shattered two bones in its trajectory but the vascular damage was immense. I completed a couple of repairs to larger vessels and proceeded to take care of some of the smaller vessels. It was going well and she would have a good blood supply around this mobile joint.

I moved to the upper arm as my orthopedic surgery colleague moved in to do his part with this case. The bone repairs needed plates and screws. Not great to put hardware into places where filthy bullets had been but there are techniques to avoid infection. Most of the tissue that had been in direct contact with the projectile had been removed because it was not salvageable.

The upper arm wound was a clean pass-through which I explored and closed. This would need broad spectrum antibiotics but not a major vascular repair. My trauma surgery colleague had started to explore the abdominal wounds assisted by a resident as I completed the upper arm repairs. The anesthesiologist said that she was holding well and wouldn’t need any further transfusions. We were getting ahead of the damage one “mess” at a time.

“I am going to run the bowel and get out of here”, my trauma surgeon colleague said. “How’s things going up there?” , he asked. “We are almost done,” my orthopedic surgery colleague said. I looked at the neck wound which had amounted to a superficial graze with no penetration of the platysma, a sign the residents had not missed on their initial exploration in the emergency department. The torso wounds had been superficial largely, because of the angle she stood from the shooters.

I helped the orthopedic surgeon close above his work and then turned my attention to helping my colleague close the abdomen. In all, there were seven people around this patient, a diminutive young woman of 19 years. She would not remember those of us who worked on her that night in that operating room but she would bear the scars of being in the wrong place at the wrong time. She would live with some loss of range of motion in her left shoulder but she would be able to live a relatively normal life.

What would she change about her life after this event? Even more important, who is she and why was she in front of 8 bullets on a cold, rainy and foggy night?  Who was so cruel that they inflicted this on this woman who was approximately 25 feet from the car when she was shot? This woman is 19-years-old and just starting adulthood but could have been dead from this event. I would receive answers to some of these questions in the coming week after this case but some of the answers will never be known.

There is no “ego” to making these repairs and doing this work. There is a compulsion, on my part, to try to get the best outcome possible for every patient. I see damaged vessels and try to affect the best repair possible for restoration of their function. The wounds have to be explored, evaluated and repaired. There is no value judgment on these types of wounds; only repairs and restoration of blood flow. Get control and get the repair done as safely and as completely as possible.

This young woman is an honor student today with a passion for the study of literature. She has almost completed her undergraduate degree and is poised to enter graduate school. She is mindful, contemplative and readily shares her story with those who have a life of violence either by choice or not. She was visiting her grandmother the evening of the shooting and had just arrived in our city. She didn’t know any of the young people in the car, that shot her.

 

 

 

27 December, 2015 Posted by | medical school, on-call, practice of medicine, surgery, trauma, vascular surgery | | Leave a comment

Christmas in the Hospital 2015

I always readily volunteer for duty at the hospital during the Christmas season. My church celebrates one of our biggest services on Christmas Eve (I can usually get coverage for this) but I always spend Christmas Day covering for my partners who have families and children on this wonderful day. I am happy and grateful to have these duties.

On past Christmas Days, I have sometimes seen tragedy, loneliness and despair but I always see a joy in those who are working with me. We generally try to discharge as many people as possible for the holiday but we often have a smaller staff even with less patients to care for. This means that there is a wonderful “pitching in” by all of us, no matter what our jobs might be.

I have gladly transported patients to radiography humming along the way. I have gladly greeted all who are working on this day that is usually a welcome rest and get-together with family and friends. My Jewish colleagues always find great Chinese food to share, my Christian colleagues have brought in more food and goodies that I should be allowed to see in one place. (I am happily snacking on grape tomatoes and carrots).

The weather has been unusually warm for December for most of the country. This is welcome for us because we have not been dealing with the cases of hypothermia that sometimes fill our unit when winter sets in. We have seen an uptick in gunshot violence which is disheartening but in any urban area, this is something that we have come to expect regardless of warm weather.

For many young people, shooting another human being with a gun is an answer for presumed slights and many other problems. I have asked many of these young gang members, “Why?” because I just want to understand why they choose to kill, hurt and carry these acts with them for the rest of their lives. Too often, they can’t answer because they don’t survive; another grieving family who has lost a child.

On Christmas, I have tried to remind each of my friends and colleagues that I appreciate their role in my life. Some have been a lifeline for me this past difficult year and some have just been a joy because they are simply in my day to day life and breathe air. My partners have been a wonder and an education at times but always I am thankful for their knowledge and professionalism.

As the year ends and a new year comes in, I am looking forward to more challenges. Each year, I want to “push the envelope” of experience and knowledge. As medicine gets increasingly more scientific, I challenge myself and my students/residents to make medicine more human. I challenge them to take the time to listen and appreciate the wonder of another human being who has put their health and trust in your hands.

The wonder of medicine is that we are privileged to enter the lives of our patients and their families, many times, under raw and painful situations. It is up to us, as physicians, to bring as much comfort, skill and humanity to these difficult situations. I find that as I have aged in this profession, I cry more and feel more; not less. I never want to become immune to the humanity and suffering of my patients.

I also, as the leader of the health care team, want to continue to be mindful of the feelings of the first responders and the others on my team. We all have the same sense of despair when we find that despite our best efforts, a 14-year-old dies. We all feel that same sense of grief when a Mum cries out in pain after being told that her 14-year-0ld son did not survive.  I encourage all members of our team to share these feelings and feel them fully.

As I sit here in my office on this misty, foggy and rainy Christmas Day of 2015, I am thankful for this profession that I love. I am thankful for my life, colleagues and friends but most of all, I am thankful that it’s Christmas Day and the joy, lights, sounds and smells are everywhere.

25 December, 2015 Posted by | medical school, on-call, practice of medicine | 4 Comments

A Wonderful Christmas Present

I have been fannying about the hospital, home and church doing all of my duties for the Advent holidays and so forth. I have a wonderful internet friend (New Zealand) who writes some of the most beautiful words that I have the pleasure to read. Here is a Christmas treat that applies to physicians, physician assistants and all who need to just stop and take a close look at all of the wonder around us. Medicine is magical especially at this time of year but everything is magic; so enjoy! How I See The World

21 December, 2015 Posted by | medical school | | Leave a comment

End of the year reflections

At the end of each calendar year, I try to reflect on what I have learned and what surprises me. After some years of teaching and medical/surgical practice, one would believe that there is nothing surprising out there for an old surgeon but I have moments of amazement and wonder every day. This is the nature of my practice of medicine even today.

This past year, I have become more comfortable with my extreme connections with my patients and students. I see the greatness of their humanity and in the case of my students, I have had some moments of disappointment in their lack of humanity. In the case of my patients, I see more humanity because I spend more and more time with those who have cognitive, intellectual and physical impairments.

My patients with cognitive impairments often communicate without words. For me, this is the greatest gift that I have received from them and I am fortunate to be able to stop and make those connections. From a wonderful colleague (Daniel C. Potts MD; his blog is linked to this blog), I have learned to be more mindful which has enabled me to stop in the moment and appreciate all that this group of patients has to say and wants to say. These relationships are pure gold for me.

My patients with intellectual impairments show me the wonder of human achievement daily. Most of this group of patients thrive on having a physician that connects with them and not their caregiver or the person hired to accompany them on visits to the physician’s clinic. It takes a bit more time to make that connection but the relationship here is as rich for me as for the patient. I am thankful that I make and take the time to give these patients what they crave no matter how much it falls outside of the time constraints.

My students have been the greatest surprise this year; not always in a rewarding manner. Many have shown an unwillingness to meet goals in the professionalism that the practice of medicine demands. I know that it is my job, as professor, to make sure that they have the tools for practice but this year has been a challenge for me in many ways.

Many of my students have a fixation on comparing themselves to others. My mantra for countering these comparisons is to say that the only person with whom one can compare, is yourself. Every day, or every second for that matter, is a chance to change your thinking. What another person does or does not do, has no bearing on what you can do for yourself. I constantly remind my students to use social media for information but evaluate that information and surely do not use what is posted on Instagram, Snapchat or Facebook as a means of comparison with others. You have to be the best person that you can be and not compare yourself to what you believe others are.

The lack of appreciation for the humanity of those who would be the future patients for my students is also a challenge for me as their professor. I was fortunate to have mentors and professors in medicine and surgery who reminded me of the privilege of practice. My professors spoke often of the extreme trust that patients place in physicians. We earn that trust by mastery of our craft and by humility because we are not the healers; we are the instruments of healing. To practice medicine/surgery for ego is a straight line for burnout and exhaustion because of all professions, medicine will destroy an ego very quickly.

I am grateful for being able to climb onto the roof of my hospital (14 floors up) and just meditate in the early mornings. In the predawn darkness, I can hear the traffic below, smell the fuel of the helicopter as it lands and I can take a few moments in the stillness of that place to center myself. I can see for miles on some mornings but on others, I am surrounded by rain and fog which is equally comforting. My days of sailing have taught me to love the moments before the sun rises and appreciate the ever changing colors of each new day.

As the Christmas holidays approach and the first semester has come to an end, I try to take some moments to appreciate my wonderful friends. They are a source of wonder and discovery. This year, one very new friend has been a “touchstone” for me in terms of validating what I always knew in terms of the spiritual nature of medicine. His friendship has been truly inspiring and affirming. Though we are totally opposite in just about every aspect of our lives, we are in total agreement in terms of how we approach medicine. I am very grateful for all that I learn from him on a daily basis.

This year has been one of change for me as I have achieved many of my goals in terms of physical and mental conditioning. I have made running and weightlifting a significant part of my lifestyle. I was a varsity athlete in college but moved away from regular conditioning as I navigated graduate and medical school. I have reached many of my physical goals, being able to play rugby again but I am working on getting stronger and stronger.

This year, I learned to kayak (my new means of exploring nature) which has added a different range of being able to appreciate being outdoors. Being solitary in nature for me, has always meant hiking, again so that I can be alone with my thoughts and meditations. With learning to kayak, I have been able to explore rivers and two of the Great Lakes (Erie and Superior). Being on the water alone in a kayak is to perceive much in terms of spirit renewal. I strongly recommend finding some means to get away with your thoughts and enjoy what is around even if you are only able to take a walk in a nearby park.

This year, one of my extreme experiences was to spend a week hiking Joshua Tree National Park in the California desert. There is no location on earth like this magical place. The desert was magical, spiritual and allowed me to appreciate each grain of sand that surrounded me along with the huge stone formations of Joshua Tree. The Joshua trees were amazing in that no two are alike but all are like friends with arms outstretched in fellowship. I loved each spine on each cactus plant too. The desert, the surrounding mountains and the Joshua trees gave me a great sense of place in humanity.

As this semester ends for those who are in medical school, those trying to gain admission to medical school and for those who are in some stage of medical practice, I would hope that you strive to see your place in humanity by any means that you can. I would also hope that you enjoy the spiritual and connective nature of the profession that you have dedicated yourself to. There is pure magic in what we do on a daily basis and I am very grateful for the privilege to see that magic.

 

 

17 December, 2015 Posted by | academics, medical school | , , | 3 Comments

Some wisdom for every physician, physician assistant or anyone in medicine

A very wise and gifted colleague of mine, Daniel C. Potts MD FAAN published this piece a few days ago on his blog. It is about communication. It’s one of the best-written pieces I have encountered on this subject. Please enjoy this writing as it is worth several reads. Mindful Listening: Learn to Communicate Without Words With Your Loved Ones

6 December, 2015 Posted by | academics, medical school | 1 Comment