“So, what are we looking at?” She asks this question with the insouciance of a child, but her gown and gloves, the heavy black loupes in front of her eyes, her eyes themselves render the demeanor of Dr. Alethea Papadopolous anything but cavalier. The incongruity is menacing. In turn, it is absurd to think of this woman as intimidating. For God’s sake, she is five foot nothing, a hundred pounds wet. She is “Dr. P” to the nurses, she is a girl named Al. Then again, she is the chief resident and writing my evaluation.
It is a posterior fossa lesion. That much I know. But I faithfully ape the radiologist’s preliminary read, which I had been fortunate enough to obtain just prior to entering the OR: a ring-enhancing lesion on the T1-weighted post contrast images, located in the anterior superior portion of the right cerebellum, it’s fairly large, about 3 cm all around.
“And what does that mean?” It is Greek to me.
To those who speak Greek, like Dr. P, it means that this previously healthy, 50-year-old right-handed man with acute onset of left hand tremor and difficulty speaking of duration one week, would in all likelihood soon be dead. Or would require a lengthy course of antibiotics. Or perhaps a lengthy course of rehabilitation. Like I said, I don’t speak Greek. I do, however, suppress a pang of guilt as I once again hear another’s words passing between my lips. The differential for this would include a tumor or possibly an abcess. It’s not likely to be a bleed.
“Good,” she replies. Another flash of guilt, quickly swallowed by panic as she continues: “Which is it more likely to be?”
The lesion is at the gray-white junction, a common location for metastases. This would also be the most common brain tumor, a met from somewhere else. I say so. She remains unflappable in the face of my cunning logic.
“But an abscess would likely be at the junction too. Come on, not good enough.”
More guilt; I am missing something. I stare at the light-box. One of the films slides smoothly from its holder, dropping to the floor, and the light-box abruptly darkens. Epiphany! Salvation! And it’s from the patient history: acute onset of symptoms. As I retrieve the fallen film I prepare for triumph and Lo! Behold! just in time, the realization that neither an abscess nor a tuor would explain that symptomology. My agony is evident, as is my ignorance.
“You’re about to cut this man’s head open and you don’t even know what’s in it. That’s not good, right?” Her voice is soft and unassuming.
Guilt is the most effective tool in medical education. Having coined it, the chief resident is quite fond of this particular platitude and puts it in practices regularly among her residents. With my recent addition to the neurosurgical service, I too am subject to this rule. Guilt is induced through judicious questioning of the learner. This is known as the Socratic Method or pimping. The logic behind it is as follows: as incorrect answers and unanswered questions accumulate, the student is overcome with feelings of inadequacy and remorse; he or she is thus stimulated to redouble his or her efforts with respect to the subject at hand. The attending for this particular case, on the other hand, favors a method he calls “tutelage through cruelty.” Luckily, he ignores rotating students.
During the case, my education continues. I get lucky with the muscles in the neck. I nail the external landmarks she will use to guide her saw as she creates a bone flap. When she passes the drill across the midline and a dark torrent of blood spills across the drapes and onto our shoes, she calmly asks which sinus she has damaged, and I am ready with the answer (she is below the inion, landmark for the confluence of sinuses, therefore she has nicked the occipital sinus – no big deal). Of course, I learn nothing from answering questions correctly. Ideally, each correct answer would result in two questions to be answered, the topics to read for tomorrow would accumulate slowly, and my education would proceed apace. But, after all, this is brain surgery, and we should not be wasting time. Guilt will have to wait.
Then she asks me about the possible complications of this surgery. As she does so, she is pushing the bipolar cautery in and out of the patient’s brain. It is distracting, and I am unable to think, and I realize that I am bone-tired. The clock, which I cannot see, do not look at, says it is now 10 pm. I am post call. I was awake all night and will have to be back at the hospital in less than 8 hours. I do not want to be here. I cannot answer this question. Then she knowingly asks what the deep nuclei of the cerebellum are. I name one, the dentate. Inadequate.
“You have this man’s head open, and you don’t know the possible complications of the operation. That’s not good, is it?” She delivers the blow in a low, unaffected tone.
But I am innocent! I could not possibly have known about this case, I could not have read ahead of time. And she knows this. She knows because this particular patient was admitted only late this afternoon, and I have been in the OR with her since this morning. But the shame is energizing; humiliation, as it were, wakes me up. And, with the undeserved guilt I feel comes the knowledge that I can fix this deficiency. I will simply have to read up on the cerebellum. I will learn the deep nuclei; know sequelae of damage to each; I will read and tomorrow I will know because today I did not. After all, positive motivation, the desire to advance, to impress, to be, for lack of a better word, good – it can only take you so far. Insofar as it is a reflection of desire such motivation exists only as long as desire exists. Negative reinforcement, such as fear, guilt and shame, will continue ot exert their power long after desire cools. I do not want to read tonight. But guilt would drive me from the bed in any case. It is potential energy, a rock atop a hill. What did my innocence buy me?
Guilt is power, innocence is impotent.
Suddenly, pus is pouring out of the man’s brain; a fetid odor briefly circulates and disappears as a large sucker is placed in the wound; grey-green ooze colors the hose. I am now privy to the fact that the man’s death sentence has been rescinded: this is an abscess. Had I looked at the diffusion-weighted images on his scan, it would not have been a surprise. I learn this after I leave the hospital, after slinking out of the OR, numbly accepting the chief’s final words.
“Good work today,” she says. Her voice is self-effacing, humble.
Two nights later, we get a transfer from Palos Hospital, a 60-year-old obese, right-handed man with history of hypertension, now with the worst headache of his life starting that morning, admitted with headache and a stiff neck and no focal deficits, CT with hyperdensities in the ventricles and the left Sylvian fissure. We admit him as a subarachnoid hemorrhage, Hunt-Hess1, Fisher 3-4. The outside hospital does not have a neurosurgeon and so I find myself alone in his room at 2 a.m., hoping the sweat on my brow will not contaminate the field as I prepare to stick him again in the chest with a very large needle, hoping that this time I would be able to hit the subclavian vein, hoping that, in my earlier attempts, I had not stabbed him in the lung. I had placed the arterial line in his right wrist just minutes earlier; it was a piece of cake. Again, I point the needle at his collarbone, slide it through his skin. I feel the tip grate against bone and turn it toward the notch at the base of his neck. I pull back on the syringe, I push the needle down, slide it forward. Nothing. The man grunts and shifts his arms against the restraints.
I should not be doing this. I really should not be doing this alone. On any other service, I would not be doing this. So why am I doing it, again? a wave of guilt washes over me as I reposition the needle, and I try not to think of what is lying underneath the bloodstained drape, the man’s face, no doubt screwed up in pain, fear, perhaps he is frowning, as I am, in frustration, perhaps it is tranquil under the large dose of midazolam I had asked the nurse to administer, perhaps he would like some morphine. This is a good though, and I ask the nurse to give him some morphine.
I am stunned by a sense of freedom. I am guilty that I have this license, or for lack of a better word, power. Perhaps ability would be a better word. Capacity or faculty, they would be better words.
Where does it come from? I think that I know, and the thought makes my hands shake. I am stirred by self-reproach. It is merely because I am here, because I am on call tonight. It is because I chose this rotation, this profession, that I am privileged to perpetrate what otherwise could only be called attempted murder.
But I do not succeed in murdering this man. The contours of his neck are hidden beneath rolls of fat. I have to push the needle deep, further than I thought. As I stitch the tubing to his skin, sweat drops from my forehead and mixes with his blood on the drapes.
Freedom is culpability
I am the only one in the room, after all.
Andrew Ko, Class of 2005
Please Breathe for Me
“I would like my doctor to understand that beneath my surface cheerfulness, I feel what Ernest Becker called ‘the panic inherent in creation’ and ‘the suction of infinity’…My friends flatter me by calling my performance courageous or gallant, but my doctor should know better. He should be able to imagine the aloneness of the critically ill, a solitude as haunting as a Chirico painting. I want him to be my Virgil, leading me through purgatory or inferno, pointing out the sights as we go.
“My ideal doctor would resemble Oliver Sacks. I can imagine Dr. Sacks entering my condition, looking around at it from the inside like a kind landloard, with a tenent, trying to see how he could make the premises more livable. He would look around, holding me by the hand, and he would figure out what it feels like to be me. Then he would try to find certain advantages in the situation. He can turn disadvantages into advantages. Dr. Sacks would see the genius of my illness. He would mingle his dæmon with mine. We would wrestle with my fate together…”
~Anatole Broyard, Intoxicated by My Illness
It was about three weeks into my time on the anasthesia service as a medical student. Most of my time was spent in the operating room, assisting with the induction of general anesthesia under the watchful eyes of both a nurse anesthetist and an anesthesiologist. After the first couple of days, the unfamiliar strangeness of gently lowering patients into unconsciousness and back out had become almost routine. While it’s far from what I savor as a career, it was a welcome break to have my interaction with patients consist of the solely technical – assessing their airway status, monitoring thir oxygenation, watching their cardiac activity. In some ways, it’s entirely the opposite of what I love most about medicine. The opportunity to interact is transformed into something approaching a laboratory experiment – without the experimentation, of course.
One morning, I teamed up with a particular nurse anesthetist who was a good and encouraging teacher. I looked over the list of patients for that room and saw a name that looked familiar, but it was common enough that I brushed it off as a coincidence. We got ourselves started with the first case, and before long I was busy with the routine monitoring and necessary paperwork.
We got to our third case of the day, the gentleman with the familiar name. The staff rolled him into the room. He looked like he might be mildly familiar, but at the same time, I have a thouroughly lousy memory for faces; it takes a couple of encounters for me to remember someone, and if I see them out of context, it’s even harder for me. (This is another reason I couldn’t work in an operating room long term. Everyone is dressed in scrubs that look almost the same, have their hair covered, and in the ORs themselves, have masks on. Couple that with the fact that many people don’t wear their IDs in the OR or have their IDs covered by their surgical gowns, and it’s all but useless for me to figure out who’s who. But I digress.)
We got ourselves started with getting him set up, helping move him over to the operating table, hooking up monitor leads. He seemed fairly tense, and I can’t say I blame him. The surgery he was about to have was a fairly common procedure, but even the most routine operation is anythign but routine for the patients themselves. I did the small kindnesses we try to do to mitigate the unpleasantness (warning about the cold EKG pads we’re about to stick on, etc.), but I didn’t feel like it was my place to do much more; as I said before, we don’t really have much interactive contact with our patients on anesthesia, and we also had to get busy drawing up medications and getting ready to begin inducing. Yakking with patients was not particularly highly valued on the anesthesia service.
I placed the mask on his face with some oxygen flowing while the nurse anesthetist administered the induction agents. This meant that the patient was, within seconds, unconscious and paralyzed – this reversible paralysis meant he wouldn’t unconsciously fight our attempts to intubate him or breath against the ventilator later. I tilted his head back to ensure his airway was open, made sure the face mask was squeezed tight to his face now that he was unconscious and began to “bag” him, providing breaths to his lungs via the rubber bellows on the ventilator. Some patients are difficult to bag – it can be for a variety of rasons – but sometimes it’s just hard to get a good seal against their face. Luckily for me, this one was pretty easy. I was watching his chest rise and fall with each breath, adn the end-tidal carbon dioxide detector was verifying that the air coming out was from the lungs. Good.
The anesthesiologist had come in at some point and was reviewing the chart with the nurse anesthetist. From behind me, I heard him say to the anesthesiologist:
“Oh, yeah, and this one is a doc here.”
“Yeah, he’s in peds, real funy guy.”
“He’s a doc here?”
I looked back down at the patient and realized that I hadn’t been wrong – this was exactly who I thought it was. He looked so different – the white coat gone, lying on a table clad in the standard-issue hospital gown. So vulnerable.
At this point, I fully expected the anesthesiologist would do the intubation himself – docs tend to be protective of “their own.” To my surprise, he let out a sigh and said to me “Okay, go ahead.” I gave him a few extra breaths to “pre-oxygenate” him, and then removed the mask. I grasped the laryngoscope in my left hand and slipped it into his mouth, pushing the tongue up and away. Unfortunately for me, I had a difficult time seeing the vocal cords, which is what we pass the tube right in between. I heard a quick “Well?” from over my left shoulder, and I awkwardly said I was having difficulty seeing the cords. The nurse anesthetist quickly taped my shoulder and told me to pull out. I let out a quick sigh of relief adn put the mask back on to breath for the patient again. It was only a few seconds, of course, but you want to make sure you minimize the time spent. While I was a bit annoyed with myself for not being able to see the cords, I was also being more gentle than I probably should have; the last thing I needed to do was to accidentally break a doctor’s teeth with the laryngoscope. I’d probably end up doing a residency in northern Siberia if that happened.
The nurse anesthetist stepped in to intubate. To my surprise, he couldn’t get it either. Finally, the anesthesiologist, who was not known for his patience, told us both to get out of the way, he’d do it himself. I was secretly pleased when he looked in there and gave a surprised little sound – he wasn’t able to do it either. Something about this man’s anatomy was just a bit off, making it difficult to do this. The anesthesiologist declared we’d have to do a fiber-optic intubation, which from a learning perspective was good for me, since I hadn’t seen one yet. (From the surgical team’s perspective, it was a necessary pain since they were all ready to go and just waiting around for us.)
At this point, I had the mask back on his face and was giving him breaths via the bag. The anesthesiologist went to get the fiber-optic unit, and the nurse anesthetist was busying himself with getting things prepared. He tapped me and said “It’ll take a couple of minutes to get this set up. Remember, he’s paralyzed, so you’re breathing for him.” Of course, he was quietly keeping an eye on absolutely everything I was doing, and I knew and appreciated that.
Usually, when doing all this, I have very little time to think much about anything else. As I said before, we don’t really know these patients at all, so there’s very little connection between us and them as individuals. On top of that, I’m very focused on performing the technical aspects of the procedure correctly. At this point, however, I was just standing there bagging him and occasionally glancing at the monitors. There was nothing else to watch since the surgical team was waiting for us.
I looked down at his face, unconscious, eyes closed.
You’re breathing for him.
My left hand was grasping his jaw and the mask, pulling them tightly together to ensure a seal. My right hand squeezed the bellows, rhythmically pushing each oxygen-laden breath into his lungs. My eyes periodically flickered over the monitors, watching his body systems, making sure a reading didn’t stray too far. His chest rose and fell in response to the motions of my hand on the bag.
You’re breathing for him.
I looked down again at his face and remembered the last time I had seen it.
* * *
It had been almost two years ago when we had been trying to adopt a child. My wife’s recent bout with breast cancer had meant pregnancy was on hold for a few years at least, if ever. Through a friend, we had found a young woman locally who was pregnant but didn’t think she would be able to parent this child. As you can imagine, there were the usual emotional ups and downs one would expect.
She had given birth on a Saturday morning and we received a call from the hospital telling us that. We stopped by in the middle of the day to see her and hold the baby. This is a profoundly strange situation to be in; under state law, she can’t sign a surrender until 72 hours after birth, so this little girl was both mine and not mine. And while we never had a reason to believe that she was stringing us along, there’s always a risk that she may change her mind – and we knew that. After a while, we went back home – she needed to recover and to deal with this complex emotional situation. We had planned to come in the next day.
We came back on Sunday, and went to her room. She was sitting there with some of her family members, and the first words out of her mouth were:
“There’s something wrong with the baby. They’ve taken her to…I don’t know what they called it.”
My heart elapt into my throat. “The NICU?”
“Yeah, that was it.”
If my heart hadn’t already been there, it would’ve leaped again into my throat. “Did they say what was wrong?”
“I don’t know…something about being dehydrated…the doctor didn’t…I don’t know!”
It was obvious from her face that she was scared and frightened. Having a child sent to the neonatal intensive care unit is not good for anyone. But for those of us in health care, in some ways it’s worse: all of our paranoid thoughts are rooted somewhere in reality. I asked a few more questions, but it was fairly obvious that they had no idea what was going on. I was just ask scared and frightened, but I didn’t want to show that to anyone else in the room.
I felt trapped now. As a pediatric physician assistant, my first instinct was to go look at the chart. However, that wasn’t an option here; I had never worked in this hospital, and I’m not in the role of a health care provider anyway, I’m…I’m…I don’t know what I am. I’m a parent. But I’m not. I’m caught, somewhere between the moments.
I did go and ask at the nurses’ station, but was told simply, “the doctor will come down and speak with you in a moment.” So all we could do is sit and nervously wait. I tried to ignore the grim procession of specters marching through my head, those neonatal anomalies which don’t declare themselves until a day after birth.
Finally, he showed up. Tall, distinguished-looking, the prerequisite white coat draped on his frame. He appeared in the doorway, and we all looked at him, hungry for information. Perhaps now I’d find out what I needed to know.
Unfortunately, it wasn’t much. To this day, I can’t remember exactly what he said, but he delivered it in several short sentences without even coming into the room. All he told us was that there was some vomiting and dehydration and the NICU staff would let us know when we could go see her. He turned, but I pressed him gently, asking what he thought was wrong, but he repeated his previous statement and then left abruptly. I still remember him right then just before he turned to leave, that image seared in my mind. Standing in the doorway, an almost annoyed look on his face. Was he having a bad day? Maybe. But I was having a worse one. I felt thrice-rejected: rejected as someone who cared for this child, rejected as a parent (because I was-wasn’t one), and rejected as a health care provider. I could’ve caught up to him and told him I was a PA as well as a first-year medical student. But, you know, it shouldn’t have made a difference. You don’t treat people that way.
Maybe he genuinely didn’t know much more, but it wouldn’t have hurt to discuss the possibilities, instead of leaving us there, floating in a sea of worry, anxiety…and now pain. It wouldn’t have hurt to come into the room and sit down for even half a minute with us. Or even to say you’d come back after attending to something else pressing.
Just give us a brief moment in which we know we’re the most important ones for you to be with, that this is the only place you should be, and helping us is the only thing you could imagine doing. Kindness and care are to the human psyche laid vulnerable what oxygen is to stressed cells crying out for relief. Please breathe for me doctor. Breathe for me, if only for a moment.
* * *
Before long, we were able to go back into the NICU and get some answers. And, to make a long story short, she ended up doign fine in the end, but the adoption fell through at the last possible moment, leaving us more hurt than we had ever been in our lives. Things did work out in the end – but that’s another story, for another time.
* * *
I kept on breathing for him; this was my specific job to do, and as my patient he was the most important one for me to focus on. Soon the fiber-optic equipment arrived, and he was smoothly intubated and the surgical team could start their job. Everything went smoothly from there on, and he had an uneventful surgery. I saw him in the hospital making rounds a couple of months later, so presumably he had recovered well.
Life is strange sometimes. Just remember to breath for others, because someday, they may be breathing for you.
“I cannot create life, but I can breathe on the reamining embers. It may work.”
“But I can hope.”
“Hope is all we have.”
~”Whatever Happened to Mr. Garibaldi?” Babylon 5
by J. Michael Straczynski
Dipesh Navsaria, Class of 2006, UICOM-Urbana