I was anxious to pass out. Surgery, my first rotation, begins on July 1, and I was glad to have the opportunity to feel the gruesomeness of the situation before I entered the more pressured atmosphere of the wards. I wanted to be desensitized.
So I was somewhat disappointed when our surgery preceptor arranged for us to watch a nonsurgical drainage of a pelvic abscess and a fiberoptic endoscopy. Though the abscess drained approximately 500 ml of yellow-brown pus, it did not have quite the drama of an open incision.
After this initial disappointment, our preceptor took us to watch the reconstruction of a breast after a complete mastectomy. In the procedure, the rectus abdominis muscle is removed from the abdomen to be used as tissue for the new breast. When we entered the operating room, the woman's face was hidden behind a steel blue curtain. Her abdominal muscle had already been removed, and the deep, rectangular crater left behind was packed with gauze. The layers of fat, fascia and muscle were visible at the margins. Three surgeons were carefully dissecting off the top layer of skin from the tissue that used to be her right breast. The highly vascular subcutaneous tissue now exposed was sweating delicate rivulets of blood.
Upon hearing that we were medical students, the surgeon offered a brief explanation. "This is really an excellent procedure. You can see how healthy the tissue is," he said. He scraped his scalpel against the denuded chest wall and demonstrated the ample vascular supply by milking a few more drops of blood. "But as you can see, this is quite involved surgery. It's not for everyone."
The gore of medicine has always frightened me. I cringe at the thought of reducing dislocated joints, stitching bloody wounds, and dressing gangrenous toes. The NBC-TV show ER parades the blood and guts on prime time in trauma after trauma. After watching every Thursday, my parents and nonmedical friends tell me, "I could never do what you are doing!"
I, too, thought that this was the horror of medicine. Yet becoming desensitized to the physical realities of surgery does not seem quite the challenge I had anticipated. Over time, the horrifying becomes commonplace, the gruesome mundane. As another surgeon told us, "The surgery itself gets pretty boring after a while. It's the human interest in the patients that makes this job interesting."
But it also makes the job more difficult. In my first two years of medical experience, I have found that dealing with the emotional pain is an even greater challenge. The suffering elicits a visceral response in me, and it does not go away.
Every Monday morning, we find a list of patients posted according to diagnosis on a specified door. These patients have agreed to let us practice histories and physicals on them. I was choosing between two patients, and I noticed that the small bowel obstruction was in the room with a patient whom I had interviewed the previous week. So, instead, I took the pancreatic cancer in the next room. Still savoring the last moments of my weekend, I entered the room expecting to find an elderly, sickly man. But Mrs. W was a young, blond, 50-year-old woman. In January, she had been diagnosed with nonresectable pancreatic cancer, which carries a particularly dismal prognosis.
In taking her history, I learned that Mrs. W had two children. She worked in a shop in Connecticut. She had never drunk or smoked. She had no personal or family history of cancer. Except for a large incision spanning her abdomen from her navel to her sternum, she was perfectly normal on physical examination.
She was hoping to go home on Wednesday. I asked her if she had made any plans for when she returned home. She looked at me, and she cried. After a pause, she replied, "I'm just going home to wait and see how long I have."
Another patient I met through my hospice work was dying of cardiac failure, and his lungs were filled with fluid. He sat bolt upright in his bed so the liquid would pool at the bottom of his lungs, leaving his apices clear for breathing. In the last hours of his life, his nurse said he was breathing so rapidly, trying to get the oxygen into his fluid-filled lungs, that he could no longer speak. And as he sat dying, tears were running down his cheeks. He was not yet ready to leave life.
After one of my Patient-Doctor sessions, I was walking through a dimly lit linoleum hallway in the deep recesses of the hospital, and I nearly bumped into a gurney sitting there. As I looked back, I noticed an older man lying in the temporary bed, patiently waiting his turn for a procedure. I found myself wondering what I was doing in the hospital. How could I have chosen this? I expected the gruesomeness of medicine. But I didn't anticipate the pain.
Yet I know I will survive the pain, and I know it will be hard. But even in my short experience, I have seen the beauty that exists in the relationships I form with my patients. The dehumanization of disease forges a powerful connection between patient and caregiver. And I feel honored to share the lives of my patients so intimately and deeply.
Editor's Note: Ellen Rothman is finishing her second year at HMS. Her column, "On Becoming a Doctor," appears in every other issue of Focus.
