You can't run, you can't hide

I'm on my second month of visiting rotations in surgical specialties, and while the experience has been mentally and physically demanding (as my family can tell you from all my complaining), it has also been tremendously rewarding. I truly love surgery, and just like most other milestones in life, what was initially a pipe dream is shaping into something more perfect than I could have ever anticipated.

I was always drawn to the surgical field, but it's only after several weeks of being on service that I'm starting to realize why I love it so much. Surgery, particularly vascular surgery, is intense. It's like a sport: you train for it, hone your skills, go out to battle, and continually analyze your performance to improve. Every doctor develops the practice of introspection to increase his competence. However, in surgery, it's not only knowledge but technical excellence. And the course of events for a patient changes so acutely with the surgeon's involvement that perfect action is even more crucial.

I'm on vascular surgery right now, and we've just had a couple of tough cases with major complications, including death. Each of these times, the patient had a potentially fatal, surgically curable disease (both, in fact, were AAA's). One of those patients is no longer alive (iliac vein injury), and the other does not have a duodenum (we cut through it). Both of these are major, predictable complications of AAA surgery. However, at the end of the day, they walked into the hospital well, and in our hands, suffered more than they were helped. The transaction is clear; we hurt those patients more than we helped them. Nowhere to hide.

One of those cases will certainly be discussed at Morbidity and Mortality conference next week. The chief resident will stand up in front of the entire surgery housestaff to go over the case with a fine-tooth comb and offer up our actions to critical minds. We will bear witness against ourselves and take responsibility for ourselves. This is what I love about surgery: nowhere to hide.

In surgery, you can't help but be honest. You can't help but be compulsive, hardworking, caring. If you see a little bleeding before you close the fascia, you don't wave it away assuming it will stop on its own. You go back and explore, you remove hard-earned sutures if you need to, because you know that bleed will declare itself as a hematoma later on if you don't. On an exploratory laparotomy, you run the bowel meticulously looking for injury, knowing that if you don't, the patient will develop colonic necrosis and decline rapidly. There's no way around doing your very best for the patient.

That's what I love.

Each year, the AMA has an essay contest on a burning question in ethics. There's a handsome prize for the winner: $5,000. I'm not really a fan of the field of ethics; while I recognize its usefulness in medicine, I don't enjoy arguing about heated topics with opinionated people when there's no right answer except the one you feel in your heart. But I have to admit, the prize money was a draw.

The topic was whether or not medical schools should use social networking sites like Facebook as criteria for making admission decisions on applicants. And while I didn't write the essay, I thought it was an interesting question because, at its core, it asks a deeper question about a physician's role in society.

As much as I used to roll my eyes at people who claimed this, I now understand why good medicine is not just another 9-5. We all want to believe we are special, putting ourselves out there for the world to appreciate. It's not a terrible thing; it's the human condition. If we don't believe we are special, what's the point of living?

But a good physician IS special. A good physician spends extra time with anxiously waiting family members to explain how the surgery went. A good physician translates the pathophysiology of disease processes into more digestible elements so his patients can participate in their own care. A good physician listens patiently to her patients' worries, even when they are unfounded. A good physician struggles to suppress judgment and objectively advise a patient whose health problems are clearly attributable to his own poor choices.

A good physician is someone who, after interacting with her, leaves you feeling better. It requires going above and beyond the call of duty. Doing the right thing, all the time, not because someone is looking over your shoulder, but because you are taking the responsibility of someone else's health in your hands.

This kind of person is not acting from 9-5. This kind of person just is.

What does this have to do with Facebook? I don't know the answer to the AMA's ethics question. I know many golden-hearted people who have what would likely be considered character-compromising material on their social networking pages. They are professional when they need to be, and unprofessional when they want to be. What's the problem?

My dilemma is a little different. I'm a nondrinker, so you won't find pictures of me on Facebook in various states of drunken revelry or undress. But as a medical student who, this time next year, will have an MD behind my name (God willing), I find myself wondering how I am going to be a good person and a good physician at the same time. Yes, one necessitates the other. But they also conflict.

My sister, unlike me, is in the family-making phase of her life. She just had a beautiful baby boy, a little brother to her other beautiful 20-month old child. My parents, who came to this country at my age for medical residency, worked harder than I can imagine and made their wealth by God's grace, are growing older. I play an important role in my family's life, and that role is only growing. Not in a duty-bound sort of way, but in a loving, part-of-the-fold way. We are a nuclear family and stick together, helping each other solve problems, be good, and do good for ourselves, each other and when possible, others. When I was growing up, my parents always emphasized my studies. My job in life, as I understood it, was to go to an Ivy League school, attain a graduate degree, and become a working professional making lots of money (not for the sake of greed, but for the sake of respect) and living an honest life.

Well, three out of four ain't bad.

I went to Cal, got my graduate degree (x 2, almost), and am, I pray, living an honest life. I don't care how much money I make but as a physician, it will most likely be a respectable amount. But even though I am still a student, there's one criterion my parents forgot to emphasize when I was growing up: I am a person first, and a student second. Yes, my studies will get me that contributing role in society. But I cannot respect myself unless I am a contributing member of my family.

And that is a tall order. As I develop my personality as a physician, I have taken pride in actively listening to patients, involving myself emotionally enough to go the extra mile for them, but not so much that I incapacitate myself to give good care. I want to be a resource, a giver, a source of hope for my patients, God willing. But what about my family?

A person has only so much to give. A good physician gives a lot to her patients and their families. But what about their own? Are a professional giver's priorities skewed? How is it ok to spend those extra ten minutes at the end of a long day with a patient's family rather than your own?

So it seems that I don't have the answer to my own moral dilemma, either. All I know is that I'm incredibly grateful for the opportunity to be a physician, but also that it is only one role I play in life. I can only pray that my role as a good family member will make my role as a physician more complete. That the two will be synergistic in some way, perhaps in the preservation of some sense of humanity that seems to be buried in weathered professionals. And weathered people.

And that I have the wisdom to leave it entirely up to God.

Reflections on the psych ward

As I come up on the last few of days of my psych rotation I find myself already missing it. Tomorrow I will write my last soap note on a psychotic patient. My subjectives will go back to being dull and uninspired, recording bowel movement consistency and skin turgor rather than colorful quotes or behavioral quirks. My morning rounds will involve conversations about passing gas instead of the latest visual hallucination. That is not to say that the field of psychiatry is one big party--on the contrary, some of the most dramatic, challenging and emotionally charged moments of my third year occurred on thus rotation. But when you are dealing with human behavior as your disease, the neat line between black and white that other fields draw so meticulously to protect their scientific practice often blurs to a chaotic gray. I would argue that this happens in other fields, too; it is just that psychiatrists are necessarily more comfortable navigating the nebulous territory of raw humanity.

I never thought that I would leave this rotation filled with, of all things, hope. Nowhere in my life have I witnessed in such detail the utter unravelling of an otherwise functional human being. However, also nowhere else have I participated so intimately in the process of healing the mind, and, or so it often seemed, the soul. Of course, I would be as deluded as my first schizophrenic patient if I thought we fix people. We play a brief role in a tiny sliver of their lives; for a moment in the grand scheme of things we share our existence and the goal of finding truth and clarity. Then the patients go on their way, back to mobile homes, group homes, or, rarely, families. And we move on, too, to the next crisis. Our next learning experience.

Daisy was a middle aged, stocky woman with piercing blue eyes and heavy features. When I first met her, her face was locked in a resolute grimace. She was muttering to herself and could barely acknowledge my existence, let alone carry on a conversation. How am I supposed to report on this patient’s status if I can’t even communicate with her, I wondered. For the first few days of her stay, my daily report went something like this: “Daisy is a 52-year-old Caucasian female with a long history of chronic paranoid-type schizophrenia brought in by police after she was found running away from her parents’ home convinced there was a bomb on the porch. Collateral information was obtained from her parents who state that the patient was stable on her treatment regimen until she was found catatonic in her apartment after calling 911. No known significant events or stressors preceded this episode. Overnight, there were no acute events. The patient slept three hours, anxious about a bomb under her bed. This morning, she continues to mumble to herself, responding to internal stimuli. She exhibits thought blocking and paranoid ideation, unable to complete sentences and perseverating over a knife she believes was placed in her abdomen against her will. The patient endorses abdominal pain secondary to the knife and requests a pelvic ultrasound. Legal status: she is on a 14-day hold for grave disability. Overall, her thought processes, hallucinations and delusions have improved from admission but she still exhibits debilitating symptoms and would benefit from continued inpatient care at this time. Disposition planning: the patient will be discharged to her apartment where she lives alone. Her son, who previously lived with her, refuses to participate in her care after receiving a disturbing call from her in which she pleaded with him to release her from the hospital because "Hell's angels are raping me here." Her parents are elderly and unable to provide support at this time but are willing to call Daisy each day for phone support."

This same distant patient, whose personality was initially such an enigma to me, slowly emerged from her psychosis to reveal a sweet, pleasant woman with a bright smile who loved to go on walks and listen to music. In her second week on the ward, Daisy began to style her dirty blonde bob and wear her own clothes. She looked lovely. One day, she came up to me and tugged on her shirt. “You like it?” she asked, her words slightly slurring together. “My parents brought it for me. The color’s called rust. It looks good on me. It’s hard to find.” I looked at her, amazed. It was one of the first conversations we had had about anything other than the voices in her head, the bomb under her bed, or the comb in her belly. It was Daisy, unplugged. Or plugged, rather. Another afternoon, I found her swaying in front of the radio to a Frank Sinatra tune. “You like music?” I asked her. “Yeah”, she said, her eyes glued to the radio. “Sometimes, when I’m at home, I turn on some oldies but goodies, close the curtains and dance.” She leaned towards me, shrugged her shoulders and smiled like a child indulging in guilty pleasure. Again: meet Daisy.

Another patient of mine, Lenny, had his first manic episode ever while I was on the ward. Lenny was a 33-year-old stockbroker with no prior psychiatric history who recently lost his job and was experiencing severe psychosocial stress. He had four children under the age of 5 and one on the way, as evidenced by his wife’s very pregnant belly the night of his admission. He was deeply religious, and in the past few weeks had become convinced that there was a bloody battle between good and evil being fought, and that the end of the world was near. He was so convinced of this fact that he initially eloped from the emergency room, anxious an earthquake was about to occur marking what he called “the end of times.” The first few days on the ward, Lenny kept to himself. On the surface, he appeared normal; he smiled appropriately, followed the rules, and was never agitated. I would learn of his delusions from the nurses, from my daily conversations with his wife--only occasionally did he let his anxiety loose with me. When I asked him if he missed home, he politely inquired whether I was asking about his home in Orange County, or his home in heaven. He refused to do yoga because he suspected it was a form of pagan worship. Several days after admission, when he was coming out of his manic episode (an occurrence that automatically earned him the diagnosis of bipolar disorder), he told me that he initially refused to let the phlebotomists blood drawn from his right arm because he was afraid it would leave the “mark of Satan.” Over his ten days of inpatient care I was able to witness Lenny lose nothing short of body, mind, and soul, and then slowly collect the pieces of his shattered self. Each day, just as Daisy’s delightful personality awakened just a shade more, so did Lenny’s insight into his delusions about the devil. “I don’t know how things got so intense”, he told me one morning during rounds. “It seemed so real. I really thought the world was gonna end.” This was the same man that sat in front of a judge during his 52/50 hearing and swore beyond a shadow of doubt in front of his wife, family friends, physician and me that he was right about his apocalyptic predictions. Who, as his colleagues were doing their pagan yoga stretches, launched a self-imposed 20-minute run around the milieu as “penitence for my sins”. By discharge, Lenny was asking about therapy to help him deal with stressors in a more productive way. He acknowledged that he had been depressed for months, maybe even years. He planned to change careers as he was finally able to admit that he had never felt comfortable playing the stock market. His wife filed for short-term disability for him so he could fully recover and help with the new baby. He understood the importance of taking his antipsychotic medications. He was in it for the long haul. Broken, yes. But in a brave, strong way. The way that forces you to reach into your insides and see what they’re made of. And then decide what you want them to be made of. I had faith that was Lenny’s path when he walked out of our ward, carrying his few belongings in plastic bags, wife in tow, eager to get home to his children and reinhabit his world.

Not every patient has a happy ending. My last patient Gina was in isolation when I first met her. She was crouched on all fours in the corner of the room, picking at invisible objects on the ground in front of her. She would occasionally try to lift herself up, only to flop back onto the floor. This would prompt her nurse to enter the room, trying to coax her back onto the bed. “34509!” she would scream, or some other combination of numbers. She complained of thirst, biting her lips until they bled. We offered her water; she opted to mold her hand into a shaking fist and bring it up to her mouth as if it were a glass. This was delirium.

Delirium tremens (DT), more accurately. Gina had a long-standing history of polysubstance dependence. She was a binge drinker brought in by her father after he found her walking naked on a street near their home. It was unclear whether her psychiatric disorder was organic or substance-related; she had never been sober long enough to figure it out. We sent her immediately to the main hospital for alcohol detox; she needed IV fluids, soft restraints, and Librium. 24 hours later, she came back to us, sensorium clear, personality disorder in full swing. She yelled, cried, sneered, blamed, and pleaded. It was disturbing behavior, but nothing even remotely resembling her delirious state on admission. She was unapologetic for her condition. “Why am I in here? I’m confused 24/7,” she would sneer, as if to say that crawling around the floor on all fours was all in a day’s work for her. Classic borderline: past suicide attempts, difficulty forming or maintaining any relationships, splitting (people were either the best or the worst, and her judgment changed on a whim), deliberate manipulation. She alternately kicked you away and drew you in: “You think this is a joke? Do you enjoy seeing me like this? Leave me in peace!” and literally two seconds later, when you walked away to give her (and yourself) a break, “See? You always just walk away! You don’t even care about me!” Despite Gina’s nasty behavior once she came out of DT, I found myself rooting for her. She would show flashes of kindness interspersted with her outbursts of agitation, thanking me profusely for my help while the tears from her last tantrum were still rolling down her cheeks. Drawing me in.
Gina left the hospital in this state, as there is nothing a hospital can do for a personality disorder except manage acute episodes. But what is fascinating to me I s how different a person she was from the Gina who was admitted five days ago, licking the furniture and trying to climb the padded walls in solitary confinement. The power of the human mind over the body and soul is overwhelming. As the delirium melted away, the real Gina came back, demanding the right to live her life. I knew well that alcohol would probably get the best of her again, and that she might end up in our ward or somewhere similar soon enough. But the transformation was amazing to witness nonetheless.

The power of the human mind. During a manic episode, patients feel like there is nothing they can’t do. They are up for days, minds racing, deluded into thinking they can solve the world’s latest crisis. Depressed patients won’t leave the house, incapable of experiencing any pleasure. Addicts mold their whole lives around their next hit, letting families, friends, jobs and hobbies fall by the wayside. Schizophrenics are tormented by voices often taunting them, or commanding them to hurt themselves or others. I know this now not because I read it in a book, but because I’ve gotten to know people with these illnesses.

Some people say that psychiatry should be an optional rotation in med school. The field has a reputation for being laid-back, so much so that many students and physicians in other fields don’t treat it as a medical specialty. I was one of those people until my rotation. But I was wrong. If there is an organic disease out there with medications that work to ameliorate its symptoms, a physician must know about it. I’m grateful for what my patients taught me, and for those precious moments where we met minds in their time of crisis to come to a better place.

Hands

I believe without a doubt that we all have a path in life, and that path is to God. In that respect, my future career as a surgeon was always inevitable, literature major or not. But as far as this worldly life is concerned, it's fair to say that I am in medicine in large part because of my father's hands.

My father's hands. Big, gentle, gracious, useful. Just like the person.

I cannot express the kind of security a child--particularly a young girl--feels growing up in a world tethered by a father's love. 27 years into my life, I am still coming to appreciate how my father's support has buoyed and shaped me. Forget the early morning coffee sessions, the bailing me out of trouble in high school (ok, and long after high school), the countless hours philosophizing about life. That's all extra. I'm just talking about the sheer knowledge, every day of my life, that I have a dad. My dad.

And what is a dad, anyway? Problem-solver, answer-giver, plumber, doctor, builder, you name it, my dad will do it. He can fix a car, a toilet, a TV, a table. He can build a fountain, pave a road. He can coax a lamb out of a sheep's womb, cajole peppers out of well-toiled soil. He diffuses tense situation with thoughtfully placed words, makes you feel at home whether you have business here or not, and treats you like you're human according to your humanity, not your wealth.

And that's not even the half of it.

My father is a surgeon. A vascular surgeon, which I never thought made much of a difference until my vascular surgery rotation this past month. I thought the specialty was all about old people who smoke and have bad arteries or varicose veins and multiple medical problems. And a lot of it, to be honest, is about that. But there is also a terribly elegant art to it.

In its simplest description, the human body is a 5-liter bag of pipes filled with blood. Of course, there are also the airway apparatus and the plumbing systems, but without the sheer volume of liquid pumping through this bag of skin (thanks, heart), all the rest would be functionally nonexistent.

So when you're talking about giving someone blood thinners for peripheral arterial disease, or obliterating someone's veins for varicosities, or, more dramatically, reinforcing an aneurysmal aorta (literally the lifeblood to the lower half of the body bag), it's kind of a big deal.

Of course, the fact that my dad does surgeries that tinker with this lifeblood in astonishing ways never mattered to me. He's just my dad. For me, he's never been a hero for repairing an aorta or saving a limb. He's special for many other reasons. The kind of reasons you keep to yourself sometimes because they're so ardently pure, so defiantly unaffected that you ache to keep it that way.

A picture tells a thousand words, but I'm not a photographer--paragraphs are my snapshots. So here goes:

One: I'm standing outside the house near our makeshift barn in the freezing cold at 5:30 am. My dad is with me, kneeling to inspect Catarina's mangled foot. She is shifting her hind legs, unable to bear weight after a run-in with some barbed-wire fencing. It's a bad sign. My dad cleans up the wound with the garden hose, putting his thumb over the spout to deflect the force. He pulls out a tube of betadine he always keeps in the house in case anyone gets hurt. While he cleans, he talks. "You see," he starts off, "horses are very sensitive animals." Catarina shuffles her feet in discomfort, lending quiet agreement. He waits patiently, then wraps the foot up in gauze and goes back to stroking her, continuing his lecture on horse psychology. We do this until the wound heals.

Two: On another visit home, I wake up early to go to Starbucks and hit the gym. I feel a guilty twinge as I see my dad, up early too, sipping coffee from a mug and tending to his grape vines. I should be spending time with him. I get my coffee fix, do my forty minutes on the treadmill, and go home to join him. By now he's moved on from the vines to the vegetable garden. It's a humble effort, historically threatened by gophers and infection, but my dad insists on growing food as part of an experiment in sustainability. Most people would give up and go to Costco. Not my dad. Instead, he tilled and fertilized a plot of land and planted cauliflower, eggplant, broccoli and lettuce. A few years later, our first successful harvest yielded two fistfuls of buttery greens and a single crown of broccoli. Ever thoughtful, he triple-washed them and gave the whole lot to my brother-in-law to take to his mom.

Three: It's the last week of my surgery rotation. I'm at the VA cutting out devitalized tissue from a veteran's gangrenous foot as he lays in his bed watching Maury Povich. He's almost deaf, so when I enter the room, I yell into his ear, "It's time for our date, Mr. Miller! We gotta stop meeting like this!" He smiles pleasantly in my general direction. I tell myself we have a special relationship, though I'm not sure he comprehends much of what's going on. I take off his protective boot and unwrap the dressing to expose our putrid villain. His ulcer is so severe the entire heel bone is exposed, but he can't feel a thing. I take my scissors and forceps and slice away. Something makes me remember my dad, perhaps Catarina's injury or a more distant memory. I kneel next to the malodorous wound, thinking of my dad nudging his glasses up the bridge of his nose to examine the health of a rosebush. "You have to remove all the dead leaves," he'd tell me as I watched him purposefully snip away hard-earned branches. "It will grow better this way." I return to the task at hand, thinking of the fresh pink tissue that will appear tomorrow if I do my job well.

When you say you want to be a surgeon, people take notice. Like every other profession, there are preconceived notions about what it means to be someone who cuts people up and puts them back together. But the rules of engagement are the same no matter what endeavor you choose to pursue. An unwavering commitment to the preservation of life and dignity is required, whether your subject is a horse, a rosebush or a human being. It's not something you can learn from reading a book or hearing a lecture. It's something that comes from the heart. I learned this from my dad. Not in the OR, but in the garden; not as a surgeon, but as a veterinarian; not by his lectures, but by his living example.

I hope my hands do justice to their precedent, wherever they find themselves.

Labor and delivery

Labor and delivery—what a ward. It’s the happiest and saddest place in the hospital. When things go right, a new person is welcomed into the world. When things go wrong, lives are devastated. Always, always, two healthy lives are at stake, hanging in the balance. Anything can happen to either at any moment. For the patient and her family, it’s one of the biggest days of their lives. For the physician, it’s another stressful, restless day or night.

I am not a mother. I do, however, have 27 years of personal experience with a mother’s love—my own. For 27 years, I have been on the receiving end of pure, undying, unconditional, unrequited, undeserved love—this is a mother’s love. I am awed, humbled, perplexed, overwhelmed by this love. If God’s love is more than a mother’s—and I know it is—my mind cannot even begin to fathom it. A topic for another time.

Flashback to a couple months ago. As a treat after two stress-filled weeks of labor and delivery, I treated myself to a pedicure to soothe my raw, blistered feet. The pedicurist, a friendly young woman with a heavy Vietnamese accent and perfect English, chatted me up. She asked me what I was reading, where I lived, where my family was from. I put my Case Files down and decided to have a human conversation for a change. I asked her where she lived, where she was from. She had arrived in Orange County just 9 months ago with her husband and two children, 4 and 5 years old. Why did she come, I wondered? She had a good job back in Vietnam, she told me. She was manager of a department of a prominent software company. I asked her why she didn’t apply for a similar job here? I did, she said. They’re not hiring people with no work experience. Apparently, her Vietnamese corporate experience didn’t count. So she went to beauty school and started doing pedicures and manicures full-time, 6 days a week. But again, I asked, if her family was doing so well in Vietnam, why did they give it all up to come here and start over? The education is better here, she said. I lost my opportunity, but my kids will find theirs here.

I wondered if her kids, who were probably now waiting for her to come home for dinner, could ever fully grasp what she had given up for them. Would they ever work hard enough at school to do justice to her sacrifice? To make her days full of scrubbing strangers’ calluses and painting flowers on their toes worth it? How could they possibly understand?

And what about me? Sure, my parents came to this country with residency positions already secured, ready to be molded into surgeons. They forged a new path purely for themselves, not for their parents or children. But sacrifices come in different packages that are no more and no less poignant for their differences. The force behind them is one and the same.

My mother always used to tell me that I could never love her the way she loves me. That it was virtually impossible for me to reciprocate her love. That I would only understand it when I had my own children. I hated hearing this, and always vowed that she was wrong. I couldn’t bear the thought of her being right, because the imbalance seemed so unfair. But after 27 years, I have come to realize that as much as it shames me to admit it, she’s right. A mother’s love is inexplicable, unmatched; deep and complex yet, at the same time, simple and naked.

I guess that’s one of the things that amazes me the most about labor and delivery. The raw humanity of hope, expectation, joy, love and pain are all mixed up together in those moments of laboring. There is the mother who in excruciating pain screams "voy a matar a mi bebe!"--(i'm going to kill my child!)--and is, minutes later, cooing happily at her newborn as we suture an angry perineal tear. The pregnant teenager who comes to the ER pathetic, crying and vomiting, and leaves days later, proud and strong, body language transformed by her ordeal. It's a mother's love: exquisitely simple and impenetrably deep, and bears testament to the incredible relationship between parent and child.

Brief musings on a weekend off

It’s a gorgeous sunny So Cal day today. The air is sweet and there’s a slight breeze. It’s perfect tennis weather, reminding me of the old summer days when I would wake up in the morning, swing my racket bag over my shoulder and mentally prepare myself for a day on the courts. It’s been years since my last official tennis match, but I still can’t step on a court without remembering the sweat, the nerves, the excitement, the churning stomach.

These days I get my kicks not with topsin, angles and deftly placed serves (or so I liked to think), but with battling disease. Now it’s a pager, a stethoscope and a scalpel (on a good OR day) replacing my racket. Now I fidget by popping my pager in and out of its holder on my hip rather than rearrange my strings between points. The smell of a fresh can of tennis balls is replaced by the odor of cauterized flesh. But the sweat, joy, devastation and nerves are all too familiar, and after years of being holed up with basic science textbooks, I revel in the nostalgia.