Rock and a Hard Place

November 25, 2018

“You should be a surgeon, because you’re always telling me what to do during surgery. That confidence is good! Say hi to your mom for me.” The words were kind, but his cold eyes undermined the false compliment. They were hard with thinly veiled anger behind the twinkle in his voice. Fleetingly, I regretted admitting my moms’ identities to him when he asked about my last name. They had been OBGYN residents under him when he was a young attending. Fresh out of the OR and tired from a procedure that had taken nearly four hours instead of the scheduled two and a half. My teeth ached from the protracted time that I had spent biting my tongue to keep from speaking out of turn. The most recent willpower challenge had been to stay calm and quiet, nodding meekly while he explained that all the stem cells in our body resided in the bone marrow and each month those stem cells migrated from the bone marrow to the endometrium in order to create the fluffy, blood-filled uterine lining that was then shed during menstruation. The blood thrummed in my ears, and by focusing on the pulsating tempo, I refrained from mentioning that I had just completed my Ph.D. in embryology and stem cell biology. Accuracy was not important at this point. Speaking out of turn has insidious consequences, and most of the time the best strategy is to just grin and bear the errors and injustices.

A few hours ago, under the baby blue drape that marks a sterile operative field, the little white shadows had remained stark against the soft pink tissue of the patient’s bowel serosa. The delicate vertical lines were like fingerprints, marking them as the bites of a laparoscopic Maryland grasper. My voice is muffled by my surgical mask as I venture, “Should we be using bowel graspers to hold the bowel? One of my other patient’s just had to have a repeat ex-lap for a suspected bowel perforation.” Like Don Quixote, the blunt trunk of the laparoscopic suction had been battering away mercilessly at an immobile adhesion that had cemented the left ovary to a portion of the patient’s bowel. Counting my breaths had kept me quiet for a good half hour now as I held the laparoscopic camera motionless and watched the merciless bird’s beak of the grasper tugging on the shining intestine like an egret wrestling with a particularly large, stubborn eel. The futility was overwhelming.

“She didn’t complain of any pain with defecation?” Dr. Lancelot asked incredulously, turning to the Dr. Angel, the patient’s OBGYN. As he turned, the fallopian tube flopped like a fish out of water, the most recent of his Maryland’s conquests. “Nope. She was just seeing me for a fertility consult. She didn’t complain of any pain at all.” The ovary lay defeated at the bottom of the circular picture on the screen. When he had prodded it open, the viscous fluid really had looked like Willy Wonka’s chocolate river as it flowed out of the gravid endometrioma in a rich, velvety gush. Endometrioma excised, the ovary lay forgotten like a discarded paintball capsule as he turned his attention to the peritoneal implants of endometriosis, the metallic bird’s beak leaving bright red ribbons of blood in its wake.

Another awkward, carefully phrased question peeked out of my mouth, “If we’ve already removed the endometrioma, isn’t that all we should do to improve fertility? I thought that removing implants was primarily to address pain and didn’t have much effect on fertility.” Fuck. Once it was out in the sterile OR air, that question didn’t sound quite as careful as it had while it was still safely inside the confines of my head. Lancelot volleys my question back with the reflexes of a tennis player, “Well, if you had read the comprehensive metanalysis by …. [some dude]… in 1997, you’d know better than to ask that. If you’re going to follow your moms’ footsteps, you’d better look that up!” True, my ignorance exposed… I had not focused my time reviewing articles that were two decades old. Mums the word, but I could’ve sworn that the ACOG bulletin on endometriosis had mentioned something about how pointless the last hour of blasting away at implants was. I glanced over at Dr. Angel, but she was just gazing at him with big doe eyes as though he was some Lancelot, who came riding in on his geriatric steed to save her from the chocolate-spewing endometriosis inside our patient’s belly. Any concern she had was carefully tucked away behind the faintest of dimples between her eyebrows, hardly visible if one didn’t look carefully. Blood is oozing in the left corner of the screen. Dr. Lancelot blasts away with the accuracy of a deadly Stormtrooper sniper, until the flesh looked like the corner of a rack of ribs forgotten in the BBQ for far too long. The bright red ooze persisted, coating the charred tissue like cherry mesquite BBQ sauce, as the scent of cauterized flesh filled the OR. The oily carbon scent coats your tongue and reminds you that you are playing god inside another human’s body. Normally, it’s an exhilarating privilege, but right now, it tastes like shame at my failure to protect my patient. What kind of doctor will I be, if I’m willing to stand by and watch weak-kneed as Dr. Lancelot mashes through the patient’s belly as though she were a Mrs. Potato Head doll?

We never did find the bleeder in the left corner. Eventually, Dr. Lancelot gave up, and coated the entire abdomen in hemostatic Arista powder, turning it into a winter wonderland and obscuring the ooze from view. I wished that Arista could repair the damage of my incautious blunders as easily: I would pay for the few objections I had raised. He pimps me with sharp and increasing intensity as we clean up after the surgery. With the ACOG practice bulletin fresh in my head, I answered the first few salvos with ease, so the intensity increased, “What gene is associated with proliferation of endometriosis in extrauterine locations?” Guessing a common cancer mutation, I lucked into the answer he was looking for, “p53?” “What chromosome is it on,” he rapid-fired back at me. Inwardly thinking, “fuck if I know…,” I guessed, “chromosome 21?” “Nope!” he crowed, “Guess again.” “Chromosome 17?” that was the right answer. Both the anesthesiologist and Dr. Angel looked at me in surprise. He pressed onward, determined to stump me. “I don’t know,” I admitted as he pressed me for the seventh and eighth theories for endometriosis pathogenesis. His eyes narrow, “Guess anyway.”  “These are really advanced questions,” Dr. Angel interjected, trying to buffer me with an encouraging smile behind Dr. Lancelot’s back. He pressed on undaunted.

I continued to profess my ignorance as the surgical tech and anesthesiologist avoided looking our way. Grin and bear it. “Where do endometrial stem cells come from?” My territory at last… “I believe they are in the endometrial tissue in the stem cell niche.” “Wrong!” I was confused. Maybe he was asking about embryologic origin? “Do you mean what embryologic tissue are they derived from?” “No. Where are the stem cells located?” “I am pretty sure they are in the endometrium, because when the endometrial layer is scraped away too vigorously it causes Asherman syndrome, with scarring, amenorrhea and infertility.” He didn’t seem to hear me. “All your stem cells are in the bone marrow,” he explained carefully as though I was a little slow. My jaw dropped open, imperceptible under my mask…but thankfully no sound came out of my mouth. My head nodded mutely as he launched into his explanation.

The medical student call room is a good place to hide your shame when you are too impotent to speak up and protect your patient. Tuck it away in the corner behind the bed, so that when you emerge, you are ready to face the residents and attendings, fresh-faced and bright-eyed. Just a few minutes, sitting in the dark would help me decompress and let go of my frustration. It was inky black when I walked in, but then the motion-sensitive lights flicked on and Kristy bolted upright in the bed. A few seconds later, Mick walked in too. So much for that plan. Talking through the surgery with the other medical students, helped vent my frustration. We discussed what to do when you see things that aren’t right. Medical students are privileged because we get to work with many attendings, without any burden of liability. Do we speak up if we see something wrong? The conclusion we came to was that, for now, it’s better to keep your head down for now. If you speak up, your disillusioned head gets chopped off and then the world will be short one more good doctor. So, for now, you will be the keeper of my memories—that’s the whole point of this book. Holding it all in, will just make me forget caution and open my big mouth someday. Remember the end goal.

There is cowardice in the caustic mantra that I use to help myself stay quiet: Keep your head down. You are not here to learn. You are not here to take care of patients. Your only job is to look proficient in the eyes of all the people who are always watching you and judging you. Do not ever make your attending look bad. Do not ask the difficult questions. Do not under any circumstances stand up for what you believe in if it is counter to the thoughts and proceedings occurring around you. Your only job is to learn key words and become proficient at talking yourself up during feedback sessions with the residents and attendings, because (honestly) they hardly have time to remember your name, much less how you performed on the rotation. It feels like bile in my throat.

By the time a medical student reaches their third year of medical school, he or she is an incredibly valuable investment for the community. Countless hours and thousands of dollars have been poured into that mushy grey brain matter. The better teachers understand this and are cognizant of their role in shaping the philosophy and skill set of these nascent physicians. Other attending doctors merely see you as a convenient installment to attach a retractor and uphold their ego. These doctors do not see the value of an individual medical student. We slide through their ORs as faceless as the disposable gowns that we wear to scrub in. Unless you speak up. Do not give a voice to the faceless gown. Do not threaten the investment that so many other people have devoted to you. One wrong move and you will go out in a blaze of futile glory. Remember your future patients. You can do this for them. Remember, remember this day in November.