bypass

They tell us to look for patterns in medicine, in the way diseases work and in the way we treat them. One of our favorite things to do is to bypass. When a vessel supplying blood to the heart becomes blocked, we use other vessels to go around the blockage. Same idea with a block in the vessels supplying the small intestine. And when you don't want food going to the stomach, you bypass it by cutting off a point where two points of the stomach connect and reconnect the stomach to the small intestine instead. It all works pretty well, perhaps not quite as well as the anatomy with which we're born, but after the wear and tear of time and experience we cope the best we can.

Currently on my one month gastrointestinal surgery rotation, and have seen several gastric bypasses for morbidly obese patients. They were good surgeries to see; the abdominal anatomy is compact and clear. When the stomach is cut, you find the pancreas behind it. As you move horizontally to maneuver things, you find the liver and spleen flanking the stomach. And you follow the small intestine down to find the best place to cut, and to reconnect, saying hello to the large intestine amidst the surroundings along the way. Seeing things in real color (the spleen really is purple, and the pancreas off-white), and three dimensions makes for a pretty view.

Sitting in the back during a informational meeting for gastric bpyass patients also afforded an interesting view. Insurance typically covers this procedure once a person's BMI is greater than 40 (ideal being 20) and most of the patients I've seen run beyond 50. They suffer from an interaction between their physiology and their environment that makes it nearly impossible for non-surgical interventions to help. Interestingly, their internal anatomy is not so different from others. At one point, the surgeon giving the talk said all of our stomachs are the same size, "including that of my med student sitting in the back there." To my relief no one turned around to look at me, but I was grateful to be present. A secretary who'd had a bypass herself talked about the experience, the looking forward before she'd had it and the looking backward now that she had, while emphasizing that the process was never over. The surgeon went into detail about what the procedure entailed and what it demanded of its patients. People listened and asked questions.

Medicine so randomly throws you into the stories of people you might otherwise never consider, and being literally dwarfed in a corner of this room made me feel it pretty strongly. Seeing one bypass after another in the operating room fools us into thinking the stitches signify an end and numbs us to the change that's happening or will happen. But hearing an acknowledgment of the anticipation leading to this surgery and hearing the patients be told the long course of care that must happen after the surgery reminds us of context. There's a lot--a lot of work, thought, feelings--encased in a two hour procedure that for those in the operating room starts with an incision and ends with a suture. Up until then surgeries for us as students have been so open-shut, and part of why I feel out of place during the week is because I have nowhere to put what we see on a daily basis. Settling their organs and skin back into place still leaves a sense of intrusion that isn't fully reversed. From the room full of people hoping to become more by becoming less, I'm more able to place what I see back into the people themselves, and this isn't something we can afford to bypass.

surgery / pain

Coming back from break this past week, I started on my three month surgery rotation in the hospital. The first month is actually two weeks of anesthesia and two weeks of emergency medicine, before the actual surgery part begins. But anesthesia requires being in the operating room (OR), as they prep all the patients for their surgeries. And because most of the action happens in the beginning and ending of the procedures, I spend most of the day standing and watching the anesthesiologist monitor the monitors in said OR. In the simplest of terms an anesthesiologist keeps patients pain-free and alive during surgery. Which is a very worthy occupation. We spent much of the past six months thinking about people's pain; a lot of what influenced my experience and what I want my future experience to be, was about that.

This time around, literally taking away the capability for pain has me thinking about our own pain as medical students. This is not to compare at all to our patients, but maintaining relativity doesn't have to take away from personal subjective experience. Keep in mind that anesthesia is perceived as the easiest part of the surgery rotation, in terms of hours and exhaustion, and it has been. But it gives a glimpse of what's to come, and during the hours of standing, I can't help but consider the suffering we go through for this profession.

We wake up when it's still black outside, and at the height of freezing. I normally like short walks in the cold; your face warms up after a few minutes and the sharpness makes me glad for senses. But that early in the morning, destination matters and I don't look forward to going to the hospital, where the ORs feel as cold as outside. I hate wearing scrubs and how I have to layer up underneath. I hate the face masks and the fuzzy blue shower caps they call hats. An hour into surgery my shoulders ache, my lower back aches, my feet hurt. On surgery proper on most days the days are twelve hours long and you go home when it's as black as when you woke up. On surgery proper surgeries can be up to seven hours long, and there are no breaks for food or bathroom. Your sole purpose might be to hold an instrument in the same position throughout the surgery so that the surgeon can do his thing, and to answer questions I'm pretty sure I don't know. I feel inadequate in all ways, which is immeasurably worse than feeling inadequate in only a majority of ways. I can't pay attention for that long, I process things slowly, my fingers aren't nimble, I liked anatomy but am bad at it because I'm bad at spatial visualization, and I'm not good at learning motion from watching others. In surgery one of the few things we might be allowed to do is tie knots, and it took me about ten times as long as my classmates to learn this. Once I try on my own terms, it's fine, but as a med student your presence seeps away from you with each step to the OR. The one thing I felt decent at was talking to my patients, and I've spent a total of ten minutes doing that all week. I spend some time each day imagining how I'm going to do this.

And more so, why. Why do we do this? Besides from the learning, which I know there will be. But while this is a wide open avenue for education, to be melodramatic it is also elements of torture--slow, long, physical and emotional at once. Over break I read Murakami's memoirs as seen through his marathon running, and he talks about the pain of running too, and how the most important things are learned through physical pain. Sometimes I think of the process of becoming a doctor as a marathon. People talk about the uselessness of some of the long years of medical training--the requirements, the studying, the politics, the busywork, all the things that necessitate a type A personality and that physically exhaust us. No one thinks of a marathon that way, but really when you think about it, the purpose of both is to accomplish something, and it's really crazy when you consider what you're doing in the meantime. You just keep going for the sake of it. Sometimes people patronize that. But it's not mindless. For me it's a conscious decision each day.

But I haven't decided whether the will and strength that you develop makes the level of bullshit valid. Having hours at the hospital for mind wanderings is not that good for me. There are so many things I'd rather be doing--writing, talking to patients and friends, sleeping. I don't even spend this idle time the way I'd like to spend nothing time, time that I often pine for. I think about stupid things. Like how I would like really long hair again so that I could chop it off. And how awkward it is to be in an elevator with a group of pretty swimsuit clad girls and a college guy ogling them. I think about self-detrimental things. Like how I keep having vivid dreams with cameos from people I don't want to think about anymore. I think about things I want to do that I couldn't do even if I weren't in the OR, like travel and spend time with my family. And I think too much about how much I don't like this.

It all gets so mixed up that it's impossible for me to write coherently about it. I resisted using this reason not to write, because this is how it is.

I met with my surgery advisor today, who gave me the good advice to always look and see. And there is a lot valuable to be seen. I think one of the hardest things for patients is not understanding what's going on inside their bodies--how something so intimately close feels impalpable. I know that developing a view of this, and being able to describe it for someone, is valuable. The problem is that I don't see the nuanced differences between the tangled monitors tracking their blood pressure and temperature, or the differences in the tones of the multiple steady beeps in the background (or foreground) telling us how they're breathing. A sweet 87 year old undergoing a heart bypass said that at his age everything scares him. As I stood in the back of the OR, I thought about how at age twenty five, I sometimes feel the same way. As med students, we see a lot in the OR. We see a system of tools that are purely functional. We see the wall between us and the people whose bodies we see more closely than they ever can. What I see is foreign, and we're supposed to familiarize such that that goes away, but honestly, I'd rather not. I'll work for skills and knowledge, but not to wear away the foreign, because how then would we really know pain, ours or theirs.

physicality

Hepatic sinusoidal obstruction. Encephalopathy. Hypoglycemia. Sepsis. Hypotension. Lactic acidosis. Intubation. Multiple organ failure.

Prepositions strung these words together, a litany of the goings-on in her body and what ultimately took her life. Having a slight sense of what these mean, the words were bullets. Instead of blood, they drew salted water. It can never be as visceral as it is for a person whose physical life is slipping, but it reminds us that it is visceral, and today I felt that maybe that's part of what they mean when they speak of all this as a gift. We tend to polarize, sometimes focusing on the science and other times emphasizing the emotions, with elbows nudging us to meld the two. In between lies something less lectured, less considered, equally present--physical sensations, from which so much flows.

I started my neurology rotation today, and we began by observing neurological exams on a couple of patients. Neurology more than other disciplines draws quite a bit from the physical exam; you can often localize what part of the brain has been damaged by what part and side of the body can't move, or what the person can't say. The brain is the center of complex feeling and thought; it's also the source of tactile sensation and bodily movement, and to me this can often be the most touching loss.

One test requires a person to close their eyes. Without visual balance, one should still be able to center themselves. When our patient closed his eyes, I heard a gasp slide from the classmate behind me. When our patient closed his eyes, he swayed to his right side, and had we not known this to be a possibility, he would have fallen. One way to treat his condition, which causes vertigo because deposits in the inner ear dislocate and end up in the wrong place, is to rotate your head and roll your body in various directions, to shift the deposits back into place. We marveled at this cure, so simple beside the antibiotics whose names I can rarely remember and the surgeries involving anatomy I often can't visualize.

A bit later we observed our first stroke code, meaning the standardized protocol when a person is suspected of suffering from stroke. Aside from the acute event, she had a past medical history of HIV, hepatitis C, breast cancer with metastases to the liver, COPD, and obesity. The four of us, students with nothing to do but watch, huddled in the corner but there was no way not to be in the way. Red stained needles and whatnots fell to the floor inches from us and we were benignly smacked as people went to and from a corner of the ED made flimsily separate with shoddy curtain. As all this went on, a doctor spoke loudly in the woman's ear: Close your eyes. Open your eyes. Stick out your tongue. Say your name. Lift your arm, and hold it there. There is a point system that adds up a person's ability to follow these commands and thereby determines how dire the state of a person's consciousness is. There's no modesty, much noise, and carved out among this are the listless failures of a body to move.

For fatal cancer, for benign vertigo, for someone in limbo--it can be these everyday sensations that are stolen, and sometimes never given back. A friend of Natasha told us in Natasha's words how she felt about her cancer, and she said this when she had relapsed: lucky, without regrets or a wish to turn back time and eradicate the experience. Because of it, she felt beyond what she called earthly, and I believe that must paradoxically be some kind of sensation too. We talk a lot about feeling happy, what seems a communal and obvious and ever elusive goal. It seems to me that between the innate and fragile capacity to feel the "earthly," and the "beyond" that we acquire and earn--there lies the most honest, coveted desire to merely feel.