Monday, August 22, 2011

Residency vs Life After - Part One

How are residents supposed to prepare for real life as a surgeon if they can’t even work twenty-four hours straight now?

I hear this complaint about once a month from a someone trained in the Golden Age of hazing. Outside of anecdote, we’ll never know if surgeons are better trained now or twenty years ago, or fifty. But it’s too painful to imagine every-other-night-call wasn’t of critical importance.

Residency resembles the real life of a surgeon in important ways, but working thirty-six hours straight all the time isn’t one of them. You pick your lifestyle after residency. The frequency of your thirty-six hour days is determined by this choice, not by the commitment you made as a third-year med student.

Besides the work routine, other pleasant surprises awaited me after residency. The first was a return of cognitive function. The second was the freedom of choice. Third was that a surgical career was not like managing a patient factory.

Part One - My Coma

For me, chronic under-rest was like living with a head injury. The bits I recall went like this:

Chief, grabbing unfamiliar chart on rounds: Who’s this patient? Porter, did you admit Mr Jensen?

Me: Nope. Must’ve been the off-service intern.

Chief, pointing at admission note in my handwriting: Isn’t this you?

Me: Uh, yes. Hold on.

I’d pull a half page of scribbled notes on Jensen from my pocket to jog my memory. Still nothing. I’d read straight from my notes for three minutes, having no independent recollection of the two hours I’d spent with the man.

I’d walk in the room with the chief, see the patient’s face and boom - oh yeah, this guy. He’s the owner of the Chili’s on Woodward. His wife is worried he’ll miss his thirtieth class reunion. Every time he gets a lab draw somebody wants to work him up for polycythemia vera, which was ruled out at Mayo in the eighties.

End of the day, our team is reviewing our patient list.

Chief: Porter, anything new on Jensen?

Me: On who?

Chief: The diverticulitis patient you admitted, that you couldn't remember this morning.

Me: That must’ve been the off-service intern...

Later, I open my Schwartz textbook to start a chapter I’d been meaning to read. Finding yellow highlighter streaks all over, I wondered: Who the hell..? I turned to the cover page to make sure the book was mine. Sure enough. So I started again with blue highlighter. A month later, pink.

When residency mercifully ended, I spent two months doing no thinking whatsoever. For fun, I resumed my old college summer job as a whitewater guide. I’d leave my neomammalian brain behind at headquarters and we’d go out camping and splashing for a week at a time. There was absolutely no call for higher cortical function in the rapids of the Middle Fork of the Salmon. Brainstem, spinal reflexes, and some parahippocampal gyrus and you’re good to row.

When summer ended, I started my surgery job and hit the books in prep for boards. I felt like Charlie in Flowers for Algernon: I'd picked up about thirty IQ points over the summer. Not only did I recall having highlighted Schwartz the day prior, I remembered the topic and some of its substance. And my patient list was almost superfluous - I remembered admitting them, their names, their labs.

Can I do residency again, I wondered, in a better-rested environment? It would be nice to recall what I’d learned.

Wednesday, August 17, 2011

Thanks for Studying

Suffering excruciating belly pain and actively dying, the man appeared nevertheless to fully digest the scene: an operating room scurrying to ready for something serious, complex, and emergent. Plus, for him, this event was extraordinarily personal - intimate, even.

Thank you, all of you. For studying and everything; I mean it. And thank you, in advance, for doing your best.

This is what a man with a ruptured abdominal aortic aneurysm said as we shoved him from gurney to operating table. It’s the only time I’ve been thanked for studying. I like to pass the gratitude along to current students and residents.

Patients give out little thank you’s all the time. They’re not accustomed to being so dependent, after all. They ask many tiny favors.

Can you push that table a little closer? Can you shut the door please? Can I get a cup of ice water? Thank you, thank you, thank you.

Big thank you’s usually come during the post-op visit, after recovery. These are the sweet ones. The patient takes your hand then adds his/her other, making yours the middle of a hand sandwich.

Dr Porter, I just want to say thank you, for everything.

Only once did I get the big thank you before surgery. The man’s insight still strikes me. I thought about it a great deal during the days that followed.

I recalled certain nights I stayed home to study:

  • When a good friend called with Sonics/Jazz tickets. Self-absorbed in med school, I’d lost track of him. Didn’t know he was starting forward for the Jazz. 
  • When a roommate announced that Nirvana was playing a secret gig under a pseudonym at a local club. 

I recalled the test-every-Monday fourteen-week semester and falling asleep on the bus, passing my stop and walking home miles in pouring rain in a bad part of town.

In the late nineties, my siblings prospered ridiculously, started families, had every weekend off, gathered for holidays without me, and never got up before 6 AM.

The patient with the fifty-fifty chance of overnight survival was thanking me for these sacrifices.

He acknowledged everybody with sincerity. He seemed to judge he'd never been the focus of so much trained attention, so much expensive technology and inventory. He knew the seven masks surrounding him possessed the moxie to open his catastrophic abdomen. But he hoped even more, I'm sure, that we were the kids in the libraries on Friday nights, trading young years for the chance to one day staunch hemorrhage in a dying man.

He thanked us for preparing for this moment.

Friday, August 12, 2011

Natural Childbirth

The uterus was not my usual territory. It took a minute of gentle exploring to sort things out. I found the little scrunched face. I scrunched my own eyes closed, like the copycat game you play with babies. Instinct was to pull my hands out of the mess, but I resisted. I couldn’t open my eyes again though; I worked by Braille. I pulled. My hand slipped off. Gripping the tiny head more firmly, I felt the chilling wrongness I'd expected.

A surgeon's duty throughout training is to learn what feels like what. Every new texture and sensation is recorded deliberately somewhere in white matter. The fingers and brain teach and learn together: This is the smooth inflamed inner wall of mature abscess; this is dense, scarred adhesion; this is liver parenchyma; this is thickened appendix; this floppy one’s normal. The hands have to know: Can I pinch between these inflamed organs and separate them? Or, will they burst between thumb and finger, spilling disaster?

My hand only knew the auspicious firmness of healthy baby heads. My brain was recoiling, as this head was not that. Recoiling because this new texture, of a soft, yet swollen, collapsing ball, dense, but not firm, confirmed tragedy off the charts - an unfamiliar brand of tragedy for a surgeon accustomed to deaths nearer the other end of life expectancy. Death before birth was too much. I couldn’t look.

Worse yet, I couldn’t extract the baby.

He was a home birth, like 99% of South Sudanese deliveries.

Good luck, or science and public policy, had spoiled me. I’d taken for granted the public health moon-landing which brought us from Nature’s criminal childbirth statistics to the expectation of perfection for every mother and child.

In South Sudan, childbirth is a one-in-ten risk of death to the child, and one in a hundred for Mom. I’d forgotten - and it’s just been a few generations since American settlers faced the same statistics.

The baby boy I was delivering had come, at home, arm-first. Tribe midwives, doulas, friends, and family all failed in bringing forth anything but the little arm. Three days later, when Mom arrived by emergency air shuttle, the arm was a grotesque eggplant, dislocated but still connected to his shoulder by skin. Dead skin. His mother’s vagina was dying too, by my guess - that was the urgency, in fact. I’d seen plenty of obstetric fistulas. (Stories for another day.)

I’d made a C-section incision and gone through the usual steps, plus a three-inch incision in Mom’s bladder on accident. Her urethra was crushed closed with her swollen child’s arm and she hadn’t voided her bladder in three days. I confused the massive bladder for uterus and made a nice cut that demanded repair before getting back to the business of delivering a dead baby boy.

When I finally had head in hand, I pulled, slipped off, pulled, slipped again, etc. In a humid hundred-degree inflatable operating theatre, I was sweating through my cloth cap and gown.

I hadn’t looked at the little corpse in minutes. Having a one-year-old girl of my own at home, this was unbearable.



Grab his arm with both hands and push it back up the birth canal. Try to squeeze some of the fluid out of the arm as you go.

Working together, my eyes still closed, we loosened him up. He came free all of a sudden. Trying not to appear stunned to my new medical colleagues, I looked at the ceiling and passed him immediately to Esther, the Kenyan midwife who knew these terrors too well. I opened my eyes again, and began the pleasant simple business of sewing, fixing, repairing, restoring. Concluding a case. Getting her off the table. Curing. Healing. Saving. Helping - a little, maybe. Who knows.

South Sudan - Mabior's Scholarship