Spent Sunday's daylight at a waterfall in Woodbridge. A. brought curry he'd cooked, sliced pineapple, and cold clementines. I brought leftover rice recently reheated in the microwave. The short drive was spent becoming acquainted with silence, and living through the open windows and open sunroof. Entering the narrower roads, the fluffy green of spring, so light and nonchalant as the car wheels crunched along, made silence easy. I'd forgotten how green it gets. I'd forgotten the way you forget photographs from last year's trip across the world even though you spent weeks after that trip flipping through the same pictures over and over. Upon arrival, we surveyed the contents of his trunk: two chairs, a cot, a sleeping bag, and a wheelchair. "What do you think we need?" "One chair and a sleeping bag," I decided, for once making a decision.
It's a short walk and a slight descent onto the rocks, where the sleeping bag was spread, the chair placed still folded on another. We ate first, and bites through my fourth or fifth clementine I realized that I'd have to pee at some point in the day (twice, it turned out). He threw the peels into the water. It was still five or six hours until daylight would slip. The first hour was spent meeting feet with water. We saw a couple of frogs, and I looked down the creek for minutes. I cross-legged onto the chair with my book, which I finished late that afternoon; he laid on the rock spread with sleeping bag and hours passed. Somewhere in those hours I slept deliciously, sitting and thinking that it must be raining because the water was streaming by in steady slushes and waking up intermittently to the pleasant surprise of being dry, warm and sunned and closing eyes again. We woke to eat again. I walked along the banks, up on the slopes and down by where water made dirt mud, and spent a full two minutes blowing the fluff off a lone dandelion. I made it back to the parking lot and tried writing into a rock with another stone. When I made it back to our rocks he'd moved, and I took his spot atop the sleeping bag. I was closer to the water here, and it sounded different, just a few feet from where I'd been there before. The police woke me, to ask what we were doing; apparently it is unusual to find people sitting at the base of a waterfall and sleeping on a rock up the bank.
When they left, we began staring at each other. He had suggested this as an activity months before, and it'd recently come up in conversation with a stranger newly met, and I thought of it again, as something I'd now be ready to try. I only laughed for the first couple seconds. From watching him I understood we were allowed to move, so long as we kept eye contact; and the mosquitoes kept us swatting about and the rocks' edges kept us shifting legs and feet. I didn't imagine the activity as meditative; I imagined it as an interaction between people. So for a long time I was frustrated; I felt a barrier more than an entrance; I don't know any better what he was thinking or how he was feeling. I've often thought that not seeing is a result of not trying hard enough to look and see. But this made me feel that you can look and look so long and hard, and still not see. I only felt more strongly how much I didn't know, and once the frustration reached its peak, I slipped into a groove where I felt I could do this for a long, long time. It was then that I felt something give; the barrier remained the same, but I felt patience come. And I felt that the best I could do is be patient, to keep looking without expectation or return, and so a very long time did pass.
The day was slow and languid; when I look back I envision a movie montage with scenes moving from one position to the next, but the experience of it wasn't a series of clips. It was a natural flow of feeling a sense and letting it take its course. It's a little cove of elements, not a postcard or even a picture, but better; a space to fill and then leave, that gives without effort on anyone's part. Maybe it defies laws of physics or whatever, because I really don't think the reaction is equal in force, though its direction may be opposite; it is an insensibly generous thing when you are so still and things envelop you so hard.
Thursday, May 6, 2010
Saturday, April 24, 2010
childbirth
For the past three years we've spent most of our education considering things that harm, threaten or take life. Now on my ob-gyn rotation, for the first time in med school and really in my life, I've given serious thought to the birth of life. This brings to mind something I heard somewhere (okay, from Dawson's Creek) about how people think of life as the opposite of death, but really birth is the opposite of death and life has no opposite. I still think the latter part of this is true, but I feel now that the former is not quite so straightforward. Setting birth and death apart from life assumes that they're isolated events. But as medicine has showed me that dying is a process, ob-gyn has taught me the same for birth.
The process happens in so many different ways in so many different venues, and even the same kind of labor and delivery holds unique crevices. That the joys of fostering life can be so nuanced makes me think that Tolstoy's all-happy-families-are-the-same philosophy isn't true. I haven't minded observing deliveries several times over. Each baby is different by nature of being new. Besides that inherent change, every woman experiences this process in her own way, absorbs and gives in her own form. Even the same silence, or the same cries, can't be described quite similarly. It's the eyes and the lips and the hands clenched or open that I find drawn to, that I want to use to etch the outlines of those sounds that might sound the same but travel to the ear and register in mind in singular paths.
Then there are all the other places where life is considered and formed. At the fertility clinic, I watched a sixteen year old deal with premature ovarian failure and I watched a forty year old couple contemplate their options for having a child. Having failed in vitro fertilization three times, they would like to try again, and after that? Adoption, egg donation? I clearly remember the first time egg donation ever crossed my mind as any sort of thought, sitting at the freshman dining hall and glancing at a school newspaper advertisement for egg donations from tall women with high SAT scores. I don't think I've given it any sort of thought since then, until fertility clinic, where I realized that childbirth includes all that precedes it, the carrying and laboring. And this is why women choose to place within themselves someone unconnected to them, to take this process into their own hands and foster the connection with strength and desire and commitment. Later in the antenatal testing unit, where women receive ultrasounds during pregnancy, I watched twins float within a 45 year old woman, a phenomenon made possible by egg donation. In class we watch a video about home birth, and debate its use. Regardless of anything else, home birth pays attention to the labor of childbirth, and I find this respect for the process so important. Like most things, it's not something that happens to you; it's something you go through. I can't honestly say it seems easy or pleasant to bear all that pain, but I do believe feeling fully allows for a heightened awareness of experience and why settle for less of something so substantial?
Ob-gyn brings to the forefront much of what I've enjoyed in medicine, the broad range of experience and emotion, and the role of healthcare providers to connect to patients dealing with personal, sensitive, important issues. With each component of this field as a whole and of individual patients, it challenges us to confront things as continual processes with steps, thoughts, and consequences, immediate and far in time. I've really enjoyed seeing babies born, which is a given, but I'm thankful for the surprise of how the value of this moment comes so much from the before and after.
The process happens in so many different ways in so many different venues, and even the same kind of labor and delivery holds unique crevices. That the joys of fostering life can be so nuanced makes me think that Tolstoy's all-happy-families-are-the-same philosophy isn't true. I haven't minded observing deliveries several times over. Each baby is different by nature of being new. Besides that inherent change, every woman experiences this process in her own way, absorbs and gives in her own form. Even the same silence, or the same cries, can't be described quite similarly. It's the eyes and the lips and the hands clenched or open that I find drawn to, that I want to use to etch the outlines of those sounds that might sound the same but travel to the ear and register in mind in singular paths.
Then there are all the other places where life is considered and formed. At the fertility clinic, I watched a sixteen year old deal with premature ovarian failure and I watched a forty year old couple contemplate their options for having a child. Having failed in vitro fertilization three times, they would like to try again, and after that? Adoption, egg donation? I clearly remember the first time egg donation ever crossed my mind as any sort of thought, sitting at the freshman dining hall and glancing at a school newspaper advertisement for egg donations from tall women with high SAT scores. I don't think I've given it any sort of thought since then, until fertility clinic, where I realized that childbirth includes all that precedes it, the carrying and laboring. And this is why women choose to place within themselves someone unconnected to them, to take this process into their own hands and foster the connection with strength and desire and commitment. Later in the antenatal testing unit, where women receive ultrasounds during pregnancy, I watched twins float within a 45 year old woman, a phenomenon made possible by egg donation. In class we watch a video about home birth, and debate its use. Regardless of anything else, home birth pays attention to the labor of childbirth, and I find this respect for the process so important. Like most things, it's not something that happens to you; it's something you go through. I can't honestly say it seems easy or pleasant to bear all that pain, but I do believe feeling fully allows for a heightened awareness of experience and why settle for less of something so substantial?
Ob-gyn brings to the forefront much of what I've enjoyed in medicine, the broad range of experience and emotion, and the role of healthcare providers to connect to patients dealing with personal, sensitive, important issues. With each component of this field as a whole and of individual patients, it challenges us to confront things as continual processes with steps, thoughts, and consequences, immediate and far in time. I've really enjoyed seeing babies born, which is a given, but I'm thankful for the surprise of how the value of this moment comes so much from the before and after.
Sunday, April 18, 2010
surgery / strength
A few weeks ago I finished my two month surgery rotation. As with much of this year, and more so with this rotation that consumed more time and energy than any other, I felt the need for catch-up, a need never fulfilled because of the constant forward momentum that is med school. I don't think I'll ever do reflection full justice; it's gotten to be too hard to even just describe. I think a lot will be lost in time and memory, but so it goes. I keep saving it up for later, later; at the very least, next year I will put aside blocks of time for this later. It's my main consolation during this time, a time when as much as I want to put everything I'm experiencing down, I also just want to experience. Which is one of several things surgery taught me to do better.
Surgery seemed to me a lesson in survival--not just in the sense of getting through, but of gaining strength. On a concrete level, I learned to pay better attention to my body's basic needs. Eat at any chance, eat two breakfasts (when you first wake up at four in the morning, and then at the normal breakfast hour). Before a long surgery, hydrate and use the restroom. Running on graham crackers, peanut butter, and apple juice (consumed at each and every break) made me strangely aware of pockets of emptiness inside me and how they fill up.
Standing for most of the day also motivates movement. It was on surgery that I went from running a few times a week to every day. You'd think that you'd be too tired after a fourteen hour day in the hospital, but it was actually the one thing that gave me energy at the end of the day. I tried variations of running longer and faster, and everything felt good. It wasn't just counteracting physical stillness; it was battling the sense of having spent most of the day doing very little. No matter how it ends, time spent running is time well spent, and there is an individual sense of having done something. There's no particular goal other than to do it, which I could also say about days of work, but in this case it's solely my decision telling my legs what to do. Besides broadening things that were comfortable for me, I found it useful to try new things (squash, rock climbing), none of which I'm good at, but the topic of how I'm not good at most of the things I enjoy is for another time. The rigidity of schedule forced me to flex other parts of life, and being mindful relieves some of the sting of the numbness I slipped into during long hours of watching, not really seeing.
Despite this complaint, it jars me to think of how much there is to feel and say as a result of my surgery rotation. Because there were substantial things to see, and besides building up some inner muscle in fighting for life outside the operating room, I found myself with much admiration and respect for the strength of people. As usual it's beyond me to articulate in this venue, and is something I'm saving. Briefly, I think that transplant surgery (the most exhausting, and best, part of my rotation) sets much of the tone for what seeing organs can do for a person. Transplant surgery, which deserves many writings, was an amazing thing to see--to see people give to and receive from one another, with natural humility and generosity. To see the liver charred black as it's cut and burned, so that it can be given away, renders more sharply the outlines of what it means to donate. To feel the liver in a new body grow from cold to hot in your hands, as foreign blood warms it, made the idea of a gift something to carry and hold. A mother to her daughter, a young aunt to her nephew suddenly inexplicably ill, a fiance to his fiance. They seem like easy enough decisions, but they're not simply decisions in concept. They are procedures felt with scared tears preceding, and recoveries borne with tangible changes after.
Surgery seemed to me a lesson in survival--not just in the sense of getting through, but of gaining strength. On a concrete level, I learned to pay better attention to my body's basic needs. Eat at any chance, eat two breakfasts (when you first wake up at four in the morning, and then at the normal breakfast hour). Before a long surgery, hydrate and use the restroom. Running on graham crackers, peanut butter, and apple juice (consumed at each and every break) made me strangely aware of pockets of emptiness inside me and how they fill up.
Standing for most of the day also motivates movement. It was on surgery that I went from running a few times a week to every day. You'd think that you'd be too tired after a fourteen hour day in the hospital, but it was actually the one thing that gave me energy at the end of the day. I tried variations of running longer and faster, and everything felt good. It wasn't just counteracting physical stillness; it was battling the sense of having spent most of the day doing very little. No matter how it ends, time spent running is time well spent, and there is an individual sense of having done something. There's no particular goal other than to do it, which I could also say about days of work, but in this case it's solely my decision telling my legs what to do. Besides broadening things that were comfortable for me, I found it useful to try new things (squash, rock climbing), none of which I'm good at, but the topic of how I'm not good at most of the things I enjoy is for another time. The rigidity of schedule forced me to flex other parts of life, and being mindful relieves some of the sting of the numbness I slipped into during long hours of watching, not really seeing.
Despite this complaint, it jars me to think of how much there is to feel and say as a result of my surgery rotation. Because there were substantial things to see, and besides building up some inner muscle in fighting for life outside the operating room, I found myself with much admiration and respect for the strength of people. As usual it's beyond me to articulate in this venue, and is something I'm saving. Briefly, I think that transplant surgery (the most exhausting, and best, part of my rotation) sets much of the tone for what seeing organs can do for a person. Transplant surgery, which deserves many writings, was an amazing thing to see--to see people give to and receive from one another, with natural humility and generosity. To see the liver charred black as it's cut and burned, so that it can be given away, renders more sharply the outlines of what it means to donate. To feel the liver in a new body grow from cold to hot in your hands, as foreign blood warms it, made the idea of a gift something to carry and hold. A mother to her daughter, a young aunt to her nephew suddenly inexplicably ill, a fiance to his fiance. They seem like easy enough decisions, but they're not simply decisions in concept. They are procedures felt with scared tears preceding, and recoveries borne with tangible changes after.
Monday, April 12, 2010
experience
I wanted to do medicine for a strong desire for something vague--experience. I spent a good chunk of my life reading stories, thinking about stories, cooped up inside of myself. I wanted to see things, do things, understand things, as a means to reach outwards. I wasn't sure of the actual texture and contours of these endeavors, but I knew that I wanted texture and contours. And the main reason I love med school is that it has been just that. It's let me in on so much experience.
There's so much variety. We rotate through so many different areas of medicine that we constantly see people dealing with different aspects of life. A sudden heart attack, the realities of the deficits of a stroke, a long struggle with cancer, a steady adjustment to a chronic disease, recovering from the pains of a surgery, having parts of your body rearranged, having parts of your body removed, giving birth, terminating a pregnancy, battling mind with mind, losing movement, losing thought, recovering movement, recovering thought--so much can happen to a person, and each experience tells you so much about people and what's around people and what's in between people and what's independent of people.
A friend of mine recently mentioned an aversion for how a crowd of people tend to respond to things in the same way, stripping people of their individual qualities and interactions with things around them. Once you've chosen your path in medicine, it's easy to do this to people, by nature of seeing similar things over and over. But even within the same experience, there's depth and nuance. I saw four women give birth today and each one was different. Each person feels things differently; expresses in their own way; lives what happens to them as only they are fit to do.
In one day there were these experiences, for me to absorb and give back in some form. Today was a long day and I have to write quickly so nothing will be entirely accurate or remotely elegant, but at the least it's fresh. One of my top ten things is seeing people do things for the first time. Two women gave birth for the first time. Many sets of eyes saw the outside for the first time. I delivered my first baby, a six pound girl with curly black hair. I tried my hardest to hold it like a football but I probably forgot how because my memory sometimes fades in the presence of wonder. When pushed to do more, one woman immersed in pain continued to give more and more. Her friend of twenty plus years hung onto her leg and told her the baby was getting closer and closer ("you're lying!"). The father of one baby held tentatively to the mother's foot, unattached or unsure. A head popped from the abdomen (perhaps blossoming is more ethereal but popping is what it was); in another, the foot came first. These ones were purply gray, wrinkly, gross and so damn gorgeous it hurt you through your double gloved hands. He said his little girl was suffering from ET skin, so apt. There is a female camaraderie where certain things can be said in the open and cause laughter and comfort, as women just met share something momentary and lasting. There is a lot of endurance but only because there is a lot of pain, and it reminds you that you're here not for a blip but for the spectrum.
There's so much variety. We rotate through so many different areas of medicine that we constantly see people dealing with different aspects of life. A sudden heart attack, the realities of the deficits of a stroke, a long struggle with cancer, a steady adjustment to a chronic disease, recovering from the pains of a surgery, having parts of your body rearranged, having parts of your body removed, giving birth, terminating a pregnancy, battling mind with mind, losing movement, losing thought, recovering movement, recovering thought--so much can happen to a person, and each experience tells you so much about people and what's around people and what's in between people and what's independent of people.
A friend of mine recently mentioned an aversion for how a crowd of people tend to respond to things in the same way, stripping people of their individual qualities and interactions with things around them. Once you've chosen your path in medicine, it's easy to do this to people, by nature of seeing similar things over and over. But even within the same experience, there's depth and nuance. I saw four women give birth today and each one was different. Each person feels things differently; expresses in their own way; lives what happens to them as only they are fit to do.
In one day there were these experiences, for me to absorb and give back in some form. Today was a long day and I have to write quickly so nothing will be entirely accurate or remotely elegant, but at the least it's fresh. One of my top ten things is seeing people do things for the first time. Two women gave birth for the first time. Many sets of eyes saw the outside for the first time. I delivered my first baby, a six pound girl with curly black hair. I tried my hardest to hold it like a football but I probably forgot how because my memory sometimes fades in the presence of wonder. When pushed to do more, one woman immersed in pain continued to give more and more. Her friend of twenty plus years hung onto her leg and told her the baby was getting closer and closer ("you're lying!"). The father of one baby held tentatively to the mother's foot, unattached or unsure. A head popped from the abdomen (perhaps blossoming is more ethereal but popping is what it was); in another, the foot came first. These ones were purply gray, wrinkly, gross and so damn gorgeous it hurt you through your double gloved hands. He said his little girl was suffering from ET skin, so apt. There is a female camaraderie where certain things can be said in the open and cause laughter and comfort, as women just met share something momentary and lasting. There is a lot of endurance but only because there is a lot of pain, and it reminds you that you're here not for a blip but for the spectrum.
Sunday, April 11, 2010
playlist
I periodically lose my song playlists, which upsets me at the time because I spend some time putting them together based on various associations, and then they develop more associations as I listen to them. A few times now, they've disappeared from my iTunes and I'm left to start over (I've tried saving them but I don't do this often enough to encompass changes over time, so that the last ones I've saved are not the ones that were currently on my iPod when I lost them). A friend once told me that this might be good, to consciously change and renew, and I thought this was a good point. Sometimes, though, I remember the old and ache for it, like now--when I'm fully enmeshed in the third year of medical school which is also soon nearing an end, when I suddenly remember a song that was so definitively part of a playlist entitled "second year" and a handful of the songs on that list come back to me and though I can't remember all of them, I go back to the ones I do and remember so clearly the walks and study sessions and nothingness spent listening to those sounds, and more than that, how the feelings of the songs themselves get mixed up in how I felt back then, how those songs chose me and I chose them for that time and experience in my life, how suddenly the gap between then and now can simultaneously open up and close. It's a crazy, crazy thing.
Saturday, March 27, 2010
plastics / plasticities
I'm done with my surgery rotation: one month of general surgery and one month of specialties (two weeks of transplant surgery and two weeks of plastic surgery). There was a lot to consider and write about in these past couple months, but there was little time and energy to do so. Ideally I'd like to start from the beginning, but starting from there and thinking about how much has to be rendered, is a little overwhelming for me even after 12 hours of catch-up sleep. So I'll start from the end, where it's freshest and easiest to retrieve.
In the two weeks of plastics, I never once saw the same procedure twice except for two or three minor removals of moles. Every day the variety and creativity made me think of it as plasticity, the capacity of our imaginations and skin to move and stretch. Plastics in general is a very broad entity. I'm sure there's a technical all-encompassing definition of what qualifies as plastic surgery, in the little guidebook they gave the students but I'm bad with defined definitions and technicalities. From my short experience I think of it as making molds and shifts, for any combination of structure, function and appearance. I find this an admirable endeavor, because it takes both art and empathy, in addition to the anatomy and science of surgery.
To be completely honest, my surgery rotation took a lot out of me and I'm still recovering. So I find it difficult to write in any other way than by a sort of list and free reflection, but maybe that's the best way in this case.
Day 1: Hand surgery. The first case consisted of carpel tunnel, trigger finger, and tenosynovitis all in one hand. These all follow similar pathologies of compressed tendons causing pain or dysfunction, and the procedures were simple releases of the respective tendons, placed in different areas of the hand. Hands have the most amazing anatomy in my opinion; they are so finely controlled. There are eight bones at the base of your hand--eight! Then four for each finger, three for your thumb. So many for such a small space. There are different tendons for each separate movement of each digit, and they extend from your forearm into the hand, and when the surgeon exposes them in the wrist, he can tug on one and make a finger move exactly as predicted. Besides the anatomical elegance, hands are so important in daily function; think of everything you need them for and how detrimental it would be for them to have pain or lose function.
In surgery they place sterile drapes on everything that's not being operated on, so in hand surgery the only thing you see is the person's hand. Sometimes there's such contrast between a person's hands and the rest of them. A face can be so rough and a hand so delicate, or vice versa, and it makes you think that there's so much to know about someone. In any case the capacity and shape of hands make them all pretty damn beautiful, and I can see why they take on so much importance in some cultures. That's where part of the uniqueness of plastics comes in; it remembers how deep aesthetics run below the surface.
Day 2: Cleft palate, eye reconstruction. I love the cleft lip and palate cases, as they're kids, and their smallness is made fuller by the small space of the mouth. Kids born with these defects return throughout their lives until adulthood, to fix the multiple problems arising from the incomplete fusion of their palates. It's interesting and touching to fix a "defect" of which they are too young to be aware. The eye reconstruction for an eye injured while ziplining consisted of molding plaster to place underneath the eyeball to lift it up and match the other eye. The person had lost much of the vision in this eye, but people need more from their eyes than to look out from them. As the surgeons looked from every angle to strive for symmetry, I realized eyes are also looked into.
Day 3: Melanoma removal. From these and the removals of moles, I was surprised that when a small area of your skin is removed, you can pull the surrounding areas together to cover it, as though we were designed with a bit of excess just for the possibility of mistakes and misfortune. Many of these occur on the face, and the surgeons cut them in a particular arrangement such that when the surrounding skin is used to close the wound, the result is very natural. There are natural creases in the face, and the surgeons cut as to conserve these; the creases that we inflict are then sewn with such care that the inevitable scars are underwhelming. Small changes are always felt by the bearer of them, and while these can never be completely eradicated, I appreciate the surgeons' sensitivity to the nuances.
Day 4: Resection of squamous cell (skin) cancer of the arm. This was a sad case, as the cancer penetrated much deeper than we anticipated. Originally, the skin was to be removed and covered with skin taken from another area of the body. But it turned out that the cancer went beyond the skin deep into the muscle; the surgeon removed what he thought was reasonable to take at that moment and the rest of the case was canceled, to further investigate the nature of her cancer. Instead of being closed with a skin graft, the area removed was left completely open, wrapped and covered with gauze. The sight of that made cancer visceral, something I felt in my throat more tightly than when I learned about cancer or interacted with cancer patients. And the weak cries of pain from the elderly woman with dementia, who couldn't express fight as even a child would by pulling away, made me feel there's a lot we can't cut away so easily. See Day 8 for a follow-up.
Day 5: Breast reconstruction. Most of the breast reconstructions I've seen here are for mastectomies for breast cancer. One consisted of making an entirely new nipple, by raising existing breast tissue. I did not expect to be impressed by this at all, but I was. It isn't until you see something being made from scratch that you realize how much structure it contains. With my own limited capabilities I've tried to craft things, and know it's much easier in theory than in practice to make something you make resemble something natural (which is probably why most of my Halloween costumes are abstract). It also feels important, this attempt to give back something a woman has lost that she's probably never anticipated losing. Regaining a breast is a slow process, that often requires gradually expanding the space underneath the tissue you've injured by removing the cancer, before you can place implants or other means of reconstructing the breast. In one case I watched the surgeon transfer fat from the belly to the breast--how malleable we are, how much can flow from one space to another if we only think of it. I also saw a breast reduction, which was the bloodiest surgery I've seen thus far; who knew that space encased so much red?
Day 6: I can't remember...
Day 7: Skin flap, which means taking the skin and muscle of one area of the body to cover another. This was a long day, with the surgery ending at 9:30 at night. The patient had basal cell cancer, another skin cancer that doesn't spread to other parts of the body but does invade local areas pretty aggressively. It takes years and years to do this, so sometimes people ignore it until it gets to be quite a large area. In this case, it had gotten so out of hand that the ear nose throat surgeons had to remove her ear, facial bones, and most of the left side of her face including the nerves. I didn't enter the surgery until much of this had been taken, and I couldn't recognize anything to orient me to what exactly we were working on; it wasn't until I saw her exposed neck (her jugular vein and carotid artery were completely out in the open) that I could somewhat tell. To cover this large area, the plastic surgeons took a large flap from her thigh. It took quite a bit of effort to use the thigh's surrounding skin to close this new wound, and even more to contour the flap to suit its new location on the face. In the end, it looked like a face, her face.
Day 8: Resection of skin cancer from Day 4. They decided that they could take out her entire tumor; they'd go back and take out the muscle that it had invaded. They planned to take the skin and muscle from a muscle on your side called the latissimus. They cut away at one edge of the cancer while I pulled on the other edge, and at one point they'd made enough progress that as I pulled the entire thing came away from her body. I felt then that we were doing something. Later they moved to under her arm, where the cancer had spread, and found that the cancer had wrapped itself around the vessels supplying the latissimus muscle. If we wanted to get rid of the cancer, we'd have to sacrifice the vessels, and thus sacrifice the muscle that was to replace the gaping hole the cancer left in her already fragile arm. And so that's what happened. Though her arm skin was loose enough to be able to be pulled over the wound, the inability to replace the removed muscle left her arm thinner and without much function. This was disappointing to everyone, and harder than I imagined, to see her be twice cut away...the cancer removed but likely to recur, her body and function progressively lessening in character. It made concrete the idea of fighting cancer, something that had previously seemed to mean a conceptual and mental battle but that I now know is also a physical struggle that is fully felt by the person.
Day 9: Skin graft. In this case, only the skin of an area is removed to replace another damaged area; no muscle is taken as with a skin flap. This elderly patient suffered a stroke and fell onto a heater that burned her back and knee quite badly. The surgeon razed a thin layer of skin from her thighs, and ran the skin through a little machine that places little holes into it to make a mesh with more surface area. This was originally invented for burn victims, who lost more skin than they could replace with the skin they still had. It's procedures like this that make for terms like "donor" and "recipient," both of which refer to the same person. One part gives to another, and I felt lucky to have seen this connectedness, to see things come together that I hadn't even realized had been apart.
Day 10: Nasal fracture, mandibular fracture. These reminded me of having my wisdom teeth taken out, fully awake--I didn't feel anything, but the noises of cracking and screwing together bone terrified me. The first person had broken his nose in a fight, and the other had broken both sides of his mandible and I don't know how. In addition to moving things around, plastic surgeons are good at putting things back in place, but I hope I never have anything in me knocked out of its origin.
Over the course of two weeks of seeing things rearranged and created to make things of value for people, I find myself glad that people require so many views to see them. I'm not personally equipped to do what these surgeons do, and so I feel lucky to have at the least seen a small part of their work. Sometimes it's painful to know how easily we can be damaged, but I think the plasticity that makes that true is also what makes repair possible.
In the two weeks of plastics, I never once saw the same procedure twice except for two or three minor removals of moles. Every day the variety and creativity made me think of it as plasticity, the capacity of our imaginations and skin to move and stretch. Plastics in general is a very broad entity. I'm sure there's a technical all-encompassing definition of what qualifies as plastic surgery, in the little guidebook they gave the students but I'm bad with defined definitions and technicalities. From my short experience I think of it as making molds and shifts, for any combination of structure, function and appearance. I find this an admirable endeavor, because it takes both art and empathy, in addition to the anatomy and science of surgery.
To be completely honest, my surgery rotation took a lot out of me and I'm still recovering. So I find it difficult to write in any other way than by a sort of list and free reflection, but maybe that's the best way in this case.
Day 1: Hand surgery. The first case consisted of carpel tunnel, trigger finger, and tenosynovitis all in one hand. These all follow similar pathologies of compressed tendons causing pain or dysfunction, and the procedures were simple releases of the respective tendons, placed in different areas of the hand. Hands have the most amazing anatomy in my opinion; they are so finely controlled. There are eight bones at the base of your hand--eight! Then four for each finger, three for your thumb. So many for such a small space. There are different tendons for each separate movement of each digit, and they extend from your forearm into the hand, and when the surgeon exposes them in the wrist, he can tug on one and make a finger move exactly as predicted. Besides the anatomical elegance, hands are so important in daily function; think of everything you need them for and how detrimental it would be for them to have pain or lose function.
In surgery they place sterile drapes on everything that's not being operated on, so in hand surgery the only thing you see is the person's hand. Sometimes there's such contrast between a person's hands and the rest of them. A face can be so rough and a hand so delicate, or vice versa, and it makes you think that there's so much to know about someone. In any case the capacity and shape of hands make them all pretty damn beautiful, and I can see why they take on so much importance in some cultures. That's where part of the uniqueness of plastics comes in; it remembers how deep aesthetics run below the surface.
Day 2: Cleft palate, eye reconstruction. I love the cleft lip and palate cases, as they're kids, and their smallness is made fuller by the small space of the mouth. Kids born with these defects return throughout their lives until adulthood, to fix the multiple problems arising from the incomplete fusion of their palates. It's interesting and touching to fix a "defect" of which they are too young to be aware. The eye reconstruction for an eye injured while ziplining consisted of molding plaster to place underneath the eyeball to lift it up and match the other eye. The person had lost much of the vision in this eye, but people need more from their eyes than to look out from them. As the surgeons looked from every angle to strive for symmetry, I realized eyes are also looked into.
Day 3: Melanoma removal. From these and the removals of moles, I was surprised that when a small area of your skin is removed, you can pull the surrounding areas together to cover it, as though we were designed with a bit of excess just for the possibility of mistakes and misfortune. Many of these occur on the face, and the surgeons cut them in a particular arrangement such that when the surrounding skin is used to close the wound, the result is very natural. There are natural creases in the face, and the surgeons cut as to conserve these; the creases that we inflict are then sewn with such care that the inevitable scars are underwhelming. Small changes are always felt by the bearer of them, and while these can never be completely eradicated, I appreciate the surgeons' sensitivity to the nuances.
Day 4: Resection of squamous cell (skin) cancer of the arm. This was a sad case, as the cancer penetrated much deeper than we anticipated. Originally, the skin was to be removed and covered with skin taken from another area of the body. But it turned out that the cancer went beyond the skin deep into the muscle; the surgeon removed what he thought was reasonable to take at that moment and the rest of the case was canceled, to further investigate the nature of her cancer. Instead of being closed with a skin graft, the area removed was left completely open, wrapped and covered with gauze. The sight of that made cancer visceral, something I felt in my throat more tightly than when I learned about cancer or interacted with cancer patients. And the weak cries of pain from the elderly woman with dementia, who couldn't express fight as even a child would by pulling away, made me feel there's a lot we can't cut away so easily. See Day 8 for a follow-up.
Day 5: Breast reconstruction. Most of the breast reconstructions I've seen here are for mastectomies for breast cancer. One consisted of making an entirely new nipple, by raising existing breast tissue. I did not expect to be impressed by this at all, but I was. It isn't until you see something being made from scratch that you realize how much structure it contains. With my own limited capabilities I've tried to craft things, and know it's much easier in theory than in practice to make something you make resemble something natural (which is probably why most of my Halloween costumes are abstract). It also feels important, this attempt to give back something a woman has lost that she's probably never anticipated losing. Regaining a breast is a slow process, that often requires gradually expanding the space underneath the tissue you've injured by removing the cancer, before you can place implants or other means of reconstructing the breast. In one case I watched the surgeon transfer fat from the belly to the breast--how malleable we are, how much can flow from one space to another if we only think of it. I also saw a breast reduction, which was the bloodiest surgery I've seen thus far; who knew that space encased so much red?
Day 6: I can't remember...
Day 7: Skin flap, which means taking the skin and muscle of one area of the body to cover another. This was a long day, with the surgery ending at 9:30 at night. The patient had basal cell cancer, another skin cancer that doesn't spread to other parts of the body but does invade local areas pretty aggressively. It takes years and years to do this, so sometimes people ignore it until it gets to be quite a large area. In this case, it had gotten so out of hand that the ear nose throat surgeons had to remove her ear, facial bones, and most of the left side of her face including the nerves. I didn't enter the surgery until much of this had been taken, and I couldn't recognize anything to orient me to what exactly we were working on; it wasn't until I saw her exposed neck (her jugular vein and carotid artery were completely out in the open) that I could somewhat tell. To cover this large area, the plastic surgeons took a large flap from her thigh. It took quite a bit of effort to use the thigh's surrounding skin to close this new wound, and even more to contour the flap to suit its new location on the face. In the end, it looked like a face, her face.
Day 8: Resection of skin cancer from Day 4. They decided that they could take out her entire tumor; they'd go back and take out the muscle that it had invaded. They planned to take the skin and muscle from a muscle on your side called the latissimus. They cut away at one edge of the cancer while I pulled on the other edge, and at one point they'd made enough progress that as I pulled the entire thing came away from her body. I felt then that we were doing something. Later they moved to under her arm, where the cancer had spread, and found that the cancer had wrapped itself around the vessels supplying the latissimus muscle. If we wanted to get rid of the cancer, we'd have to sacrifice the vessels, and thus sacrifice the muscle that was to replace the gaping hole the cancer left in her already fragile arm. And so that's what happened. Though her arm skin was loose enough to be able to be pulled over the wound, the inability to replace the removed muscle left her arm thinner and without much function. This was disappointing to everyone, and harder than I imagined, to see her be twice cut away...the cancer removed but likely to recur, her body and function progressively lessening in character. It made concrete the idea of fighting cancer, something that had previously seemed to mean a conceptual and mental battle but that I now know is also a physical struggle that is fully felt by the person.
Day 9: Skin graft. In this case, only the skin of an area is removed to replace another damaged area; no muscle is taken as with a skin flap. This elderly patient suffered a stroke and fell onto a heater that burned her back and knee quite badly. The surgeon razed a thin layer of skin from her thighs, and ran the skin through a little machine that places little holes into it to make a mesh with more surface area. This was originally invented for burn victims, who lost more skin than they could replace with the skin they still had. It's procedures like this that make for terms like "donor" and "recipient," both of which refer to the same person. One part gives to another, and I felt lucky to have seen this connectedness, to see things come together that I hadn't even realized had been apart.
Day 10: Nasal fracture, mandibular fracture. These reminded me of having my wisdom teeth taken out, fully awake--I didn't feel anything, but the noises of cracking and screwing together bone terrified me. The first person had broken his nose in a fight, and the other had broken both sides of his mandible and I don't know how. In addition to moving things around, plastic surgeons are good at putting things back in place, but I hope I never have anything in me knocked out of its origin.
Over the course of two weeks of seeing things rearranged and created to make things of value for people, I find myself glad that people require so many views to see them. I'm not personally equipped to do what these surgeons do, and so I feel lucky to have at the least seen a small part of their work. Sometimes it's painful to know how easily we can be damaged, but I think the plasticity that makes that true is also what makes repair possible.
Tuesday, March 16, 2010
ellipse
We removed a mole from the scalp of a sweet little boy today (it has a low potential to become cancerous). They incised an ellipse around the area to be removed. A circular wound doesn't work, because when you bring the edges together to sew into what will be his scar, there will be areas that don't meet and cause a bump. To render it smooth, you make an ellipse instead (three times as long as it is wide). And with your hand, you have to stretch all the surrounding skin under the scalp, to release the tension. Tension doesn't bode well for stitching the wound.
For all the pains of surgery, it's pushed me to stretch farther than I imagined. And at the least and most, I've had many experiences, which is what I came here for. I'm looking forward to processing and stitching them up, into a scar whose pain is past but whose presence is palpable.
For all the pains of surgery, it's pushed me to stretch farther than I imagined. And at the least and most, I've had many experiences, which is what I came here for. I'm looking forward to processing and stitching them up, into a scar whose pain is past but whose presence is palpable.
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