November 23, 2018
The third year of medical school is a special kind of lonely. My alarm begins its persistent, plaintive tone at 3:30 am. Reflexively, my forefinger hits the orange snooze button in the middle of my screen and I huddle deeper into my warm, fuzzy blankets. Before the next call to arms, I tap on the light on the bed stand and groggily roll out of bed. I read a novel in the bath for about 10 minutes while the water runs. Ideally, this morning’s schedule would include meditation and flossing, but my phone has been snoozed too many times to allow such personal luxuries. My eyes are red and raw from too little sleep, and the hydrogen peroxide hasn’t had a chance to fully dissolve into bubbly saline around my contacts before they are slipped into my eyes. It stings but fades after a few minutes.
The scent of eggs frying on the stove makes my mouth water. Unfortunately, it’s a mere memory of a morning with more time. Today is not a day with time for cooking eggs. Shoving three meal bars and two 5-hour energy bottles into the pocket of my backpack, I’m on my way to the hospital. Yesterday I had a parking ticket on my windshield when I got to my car. Parked within 10’ of a fire hydrant. Figured the risk was worth it to avoid paying the $28 it would take to park in the hospital parking lot. Medical students aren’t worthy of parking passes, so we spend an extra 30 minutes in the morning cruising and looking for a viable spot. The ticket was $35, but the experiential knowledge was valuable too.
The money seems so insignificant. Two days ago, I volunteered to scrub in on a surgery. The patient was a minor. The surgery was penciled in as an add-on at 4 pm and was expected to take two and a half hours, far past my obligatory hospital time. The attending physician was a wizard in surgery, so I elected to stay. The patient had moist, dark brown eyes, her pupils were rimmed with white and an occasional tear slid down her face as I introduced myself. “My name is Erica, and I’ll be the medical student on your care team. How are you doing today? During the procedure, the doctor will do an exam, which the medical students and residents normally participate in. Is that ok with you?” She nods dumbly. “Do you have any questions?” Bilateral tears track down her face, and I want to flee to escape the awkward lump in my throat. “We’ll take good care of you,” is the phrase that propels me out of the room.
The trocar twists—10 o’clock to 2 o’clock—boring through connective tissue with alacrity that Elon Musk would applaud. On the screen, yellow globules of fat scurry out of the spotlight as the surgeon burrows gently through the abdominal wall. The scene cuts to a new landscape as the cavernous abdominal space stretches away beneath us. The intestines lie quietly under a field of glistening goldenrod omentum and the vaulted ceiling stretches out of the field of view. The hissing gas makes everything inside stretch beautifully and tightly. Internally, we are an architectural miracle of evolution that surpasses the most elegant gothic cathedral. A few spots of blood from the incision drip down on to the friendly golden embankment below, but no one sees. The upper left quadrant of the camera is obliterated by a massive hunk of tissue that resembles an oatmeal cookie. The lighthearted banter dies like a candle in the wind. The camera pans and we watch in silence as the abdominal wall passes us, covered in malignant growths with feathery vessels helping each one to establish an empire. A grossly distended sphere looms like Jabba the Hut, hulking in its extravagant distention. The second peeks in uninvited from the right side of the screen, equally profligate and equally unwelcome. Their magnitude is impressive but it’s the smaller growths, scattered like corn at planting time that make the hair on my arms stand up. She’s only a kid. Still in high school. She likes paddling. There’s cancer everywhere in her belly. She will die of this, soon. I wonder what she was like. Was she popular? Mean? Valedictorian? Cheerleader? Tomboy? Bully? What will her classmates think and say when they learn that she’ll be dead before they graduate?
Never eat an oatmeal cookie. Blood is running down the pebbled surface from the miniature alligator bites of our instruments. Ascitic fluid looks like shimmery green dragon scales as it mixes with chocolate lava and bright red blood—the cyst bursts and the biopsies bleed languidly. Pulling the instruments out, we stich the incision sites closed. Nothing to see here. A good doctor acknowledges futility, and some lives are not meant to be saved. There’s an itch inside my mind. Guilt, I think, clawing at the edges of my consciousness. I’m already a decade older than she will ever get to be. The presumption. I drive fast that night. The needle hits 110 mph as I’m thinking about the cars that she will never drive. The speeding tickets that she will never receive. The taxes she will never pay. The love that she will never know.
The loneliness is crisp tonight like an autumn evening. It comes bright and early, buffeting me as I walk through the door to my beautiful, wretchedly empty apartment. Jaeger has been gone for nine days now, and the echoes of his strangely long toenails on the faux hardwood floors as he wriggles over to greet me is fading into a memory again. There’s numbness in my bones and in my heart. The girl will die. No one knows why, but that’s ok. To be a doctor, you must make peace with the unknown and the unjust. The lack of emotion weighs like lead on my ego. In the OR, it seemed like the attendings and residents were warily watching me to see whether I would melt into a puddle of tears at the Shakespearian tragedy unfolding before us. My face was controlled and dutifully held the emotions I molded onto it. The corners of my mouth downturned with grief. My eyebrows raise and pinch together in the middle—empathy. A tear rolls leaks out of the cracks of my china doll façade as I sit with Dr. Gandalf breaking the news to her mother. Sympathy. The emotions of the rest of them seem feigned. The gestures at 80% sincere but there’s nothing in their eyes. Do I look like them? How does one learn to be so conscientious? This is a crucial part of my training, and I’m behind the curve. I go to warn the pediatric attending about the magnitude of the tragedy that she will be dealing with in the morning. It’s a bombshell that deserves some warning, and I adore Dr. WonderWoman. I want to be just like her when I grow up. She is the best role model I’ve encountered by far this year. My face is brave as I wait for her to finish with a student, and I talk with Dr. M, another attending that I worked with. A patient of hers went into freefall today, and her tears are contagious. By the time I talk to Dr. WonderWoman I’m a wet mop and can hardly gasp through the phrase, “It was everywhere.” “What did Dr. Gandalf say?” She probes. “She’ll die of this. And soon.” Verbatim. There is the same emptiness behind her eyes, and it helps dry my tears. “Yeah, anyway, I just wanted to let you know.” I finish weakly and leave awkwardly.
The base thrills through my bones as I whip through cars on the highway and the lyrics make my feet dance on the pedals. The velvet darkness of early morning is exhilarating because it is mine, and I stalk through it like a cat in the night. I see my patient during morning rounds, but in my mind, I’m conversing with a dead person. I have to stop doing that. What is wrong with me? Leave it all behind. Drive fast and forget the things that weigh you down. The day moves quickly.
Dr. Bubblegum reminds me of an anole with lanky brown arms and a sharp, but whimsical gaze. On the schedule are a series of rapid-fire D&_’s (C or E). I don’t know the difference yet. I ended up drawing the first and third of his cases. D&C first. D&E third. For your information, D&C means “dilation and curettage.” In this case, the curettage will be an abortion procedure. I go to meet the patient. She’s half a decade younger than me, lying calmly in the pre-op bed. “My name is Erica, and I’ll be the medical student on your care team. How are you doing today? During the procedure, the doctor will do an exam, which the medical students and residents normally participate in. Is that ok with you?” “Yeah. I just want to get this over with,” she says with a hair flip and preen. Unconcerned. The bad taste in my mouth is judgement, a new one for me. I swallow hard and go to find a chaser.
T is for teacher. The fellow, Dr. T, is brisk and cheerful. No-nonsense, but caring. “Sit here and take the speculum. Grab the cervix at the top so you can manipulate it. Get a good bite. Inject this at 4 o’clock and 7 o’clock. That way you miss the vessels. Good. Now this is a dilator. Put your hand on mine, so you can feel the resistance. That went in easily, so we’ll go to the next one. Great. Now we’ll switch places, so you can watch how it’s done.” She picks up an innocuous plastic tip attached to some surgical tubing and inserts it gently through the dilated cervix. Her hand spins the plastic handle clockwise. “Always clockwise until it doesn’t spin anymore,” she explains. The blood is so bright red that it looks fake inside the plastic tubing. I don’t ever see the fetus as it’s sucked away. I was joyful because I’d had another person in the OR that interacted with me, a first for this rotation. A great teacher. She cared. I had participated in the procedure. I exuberantly described the learning opportunity to my classmate, AC, in the hall as we traded places for the next surgery.
An hour later, AC and I tag team again, passing each other as I head into the OR. Her eyes were wide, but tired and I didn’t understand. There’s a bounce in my step as I ask, “Did you like it?” “Yeah,” she said weakly looking as though she’s about to faint. Perhaps she just doesn’t like surgery, I think to myself. My feet tripped happily down the hallway to greet the patient that would be occupying OR 4. “My name is Erica, and I’ll be the medical student on your care team. How are you doing today? During the procedure, the doctor will do an exam, which the medical students and residents normally participate in. Is that ok with you?…”
“…I don’t …. speak….. English.” Her smile was tired and sad around the edges.
Ok… damn…, I think internally.
A few minutes later, we’re both waiting in tense silence for the Marti translator to pick up. “My name is Erica, and I’ll be the medical student on your care team. Is it ok with you if I participate in the pelvic exam during the surgery?”… “Yes.” “Ok great. Thank you.” We end the call with the Marti translator.
On pelvic exam, this patient’s uterus is much larger than the last one. Dr. T seems confident in my skills and she has me dilate the cervix by myself, until I “feel resistance” inside. Dr. Bubblegum is manning the ultrasound and there’s a new anesthesiologist. They are making jokes that seem forced, and I tangentially wonder what the dynamic between them is. There’s a nervous tension here that I can’t quite put my finger on. Then I feel the resistance against the dilator. Dr. T takes over, and I stand by the patient’s right knee, watching the ultrasound. It’s a perfect picture of the fetus, as if from a movie, curled snugly in its cozy womb. The arms and legs are moving and there’s a smirk on its face. Almost cute.
Before the procedure, Dr. T “spontaneously” brought up the laws on late term abortions. They disproportionately affect women who want to have a child but are struggling. Older women. The ones who are predisposed to have babies with chromosomal abnormalities like this one. By the time they learn there is an abnormality that is possibly incompatible with life or with normal function, their desperately wanted pregnancy is already at 18 weeks. By the time a thorough work up is done, they are nearing the 20-week cut off. This one is only 16 weeks. It’s vivacious, and the mother’s despair is palpable even under anesthesia as we bore into her womb with cold metal to tear out the hope growing inside. I’m slow to realize what’s happening. The fellow and the resident switch places and the forceps in the resident’s hand show up as bright white loops on the ultrasound screen. They grab an ankle and pull but slip off. The fetus kicks weakly. On the next pass, the cold loops reach higher, near the knees and when they emerge, the bottom drops out of my stomach. A tiny leg drops into the plastic bucket. The right foot has perfectly formed little toes and delicate pink skin. The fetus is still on the ultrasound. The tongs make a few more passes before the left leg joins the right. Then there’s some placental tissue. The spine shows up as a bright, notched line on the screen and when the cruel loops grab it, they emerge with a bloody mess of intestines and musculoskeletal tissue. Now the arms and shoulders. They aren’t recognizable when they come out, or else I miss them in my wide-eyed horror. Just the head left now. It still has a face. A round skull etched in white. The tongs slip off of it repeatedly. Finally, they find purchase, crushing it a little. I try to watch the ovoid come out, but it’s unrecognizable. A final chunk of placenta and some suction, and the procedure is over.
Standing dazed in the middle of the room. Everyone moves around me efficiently as if I wasn’t there. The fellow is gently drying off the feet. She colors them with marker and asks me to hold the card flat. She presses the inky footprints onto the paper and they leave streaky purple-black impressions on the expanse of white. She covers it with tegaderm. The only remnant of a life that the mother will have to treasure and weep over.
Abortion is divisive. Now, I have to decide whether I care enough about a woman’s right to choose to go into OBGYN because of that or if I dislike abortions enough that I will not go into the field because I would feel an obligation to perform them and they are incredibly unpleasant. For the first time in my life, I did harm to a potential human being.
On October 27, 2018, Robert Bowers shot 11 people and wounded six others at the Tree of Life Synagogue in Pittsburg. At least three of the doctors and nurses that cleaned and dressed the shooter’s wounds were Jewish, and they did their duty even knowing what the man had just done. The Washington Post wrote that, it was a “radical demonstration of humanity in an era increasingly marked by naked partisanship and tribalism,” but really, it wasn’t. They were just dedicated professionals doing their jobs. (https://www.washingtonpost.com/health/2018/10/30/im-dr-cohen-powerful-humanity-jewish-hospital-staff-that-treated-robert-bowers/?noredirect=on&utm_term=.1ac9e7e642af)
There are people in this world who avoid unpleasantness. People who are comfortable looking away from an ugly situation or leaving a mess for someone else to deal with. The doctors that perform this service are not people that turn away from ugliness. Dr. Bubblegum may seem lackadaisical and odd, but there is something steely under his nonchalant façade. The women who need late-term abortions are devastated. In their presence, the sadness seeps into your bones. There is a reason that this pregnancy could not go to completion. What kind of doctor would turn away from a patient in need, just because the procedure was hard and unpleasant?
My soul hurt as I walked on the broken sidewalk outside the hospital. Instinctively reaching for my phone, I opened Messages, scrolling idly and trying to decide who to text about it. My thumb swiped a few words that seemed immeasurably insufficient, before I deleted them. It wouldn’t do to cheapen the life that was lost today. There was a numbness hanging around me like a cloud. The necessity of it was clear, and I was grateful to have been forced to watch it with so little prelude, because in the end it was a life-altering experience that somehow didn’t matter.
Have you ever taken a life? Have you ever felt the moment when all energy drains from a still-warm body? That was what I had experienced today, but it wasn’t the first time I’d felt that: I eat chicken, unapologetically. I buy breast meat from Costco and usually bake it. Because I eat chicken, it seemed important to know how to obtain those glistening breasts and thighs for myself. To subdue a chicken, take firm hold of the base of the wings from behind. Once it calms, fold the wings in, pinning the body under your arm and stretching out its neck with the hand attached to said arm. With a sharp knife, cut across its throat horizontally through the cartilage and tissue until you feel the blade scrape against the bony surface of the spine. Do not cut through the spine. Continue to hold the neck outstretched as the blood drains out. You will see the light leave its eyes and feel the vibratory tension fade from its feathered muscles. Wait a little longer, a cautious homage, lest you move too soon, and it begins a mindless flapping that spews fine red mist everywhere. Then scald, pluck and eviscerate before packaging and freezing the meat for future use. It’s not a pleasant task, but it is necessary. The skilled knowledge is valuable. I think that this is humility. Being willing to learn knowledge that may not immediately benefit you and being open to doing unpleasant things because someone needs to do them. Knowing someday you may be the only person who is willing and able to step forward and shoulder the burden. Medical school is full of a special kind of loneliness.