General Surgery: the Fire and the Patient's Blessing

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The Fire

In medicine, and in clerkship particularly, it is so easy to get caught up in the hospital madness. I felt it most ostensibly during my general surgery rotation this past month: patients waiting, nurses hollering, the requests for consults beeping, beeping; running up the stairs, down the stairs, finish rounding on 30 patients by 7:30 am and rushing off to the OR; running up the stairs, down the stairs, checking labs, nagging interventional radiology and nutrition and physio and thrombosis (advocating for your patients, essentially), and at the end of the day, pre-ops for the next day (so that you can repeat it all over again). It is exhausting.

The fulfilling part is the patients. Seeing patients, talking to them, operating on them for sure! Goodness, I love the OR. It's a beautiful place where you see the beauty of God's work in the fascial layers, muscles, nerves and vessels of the human body. And then you cut and resect and stitch with love and fervour. Yes, with fervour. Does anyone realize how passionate surgeons are about their work? I have not seen that anywhere else so far. They know true love, really. They will not eat or sleep or pee (or care to complain) if they are operating.

But it's not just about the surgery -I found that they are just the 'passionate type', period. For better or for worse, they will aggressively advocate for themselves, their patients and their cause. They will walk into the ER for a consult, glance around at the beds of patients in the halls and angrily vociferate, "This is disgusting -it's inhumane! You'd think we're in the third-world here!" Some will flex the muscle of their reputation or hierarchy to turf colleagues out of the OR so they can operate on their own patients first. Certainly egos are huge like nobody's business, but they would also give their lives for the love of their work... and they do. They will review their mistakes and take themselves and each other to task so it doesn't happen again. They seek the tangible Truth, not mere theory. On our last day as clerks, we had breakfast with the residents, while engaging in passionate and witty banter about politics in the Middle East -it was fireworks, cynical, reality-checked humour. And yes, there are lots of innuendos, double-entendres and sexual jokes between colleagues. But they've got that Fire. They embrace it, they fight for it and they become it, for all its potential to provide warmth, destroy and salvage. Surgeons are like the warriors of medicine, with their fair share of villains and heroes, and the Iliad is in the OR.

I am so a 'surgical' type, I don't care what people say... whether or not I decide to become a surgeon, that's a different story, but am I the type? Absolutely, yes. I am all about the Fire.

The thing is, when you play with fire, you risk getting burned. And when the fire's all up inside you, you risk spontaneous combustion. Firstly, people forget that the warriors are still human. Odyssius sure was and so are surgeons. We had been in the OR for nearly 7 hours (of a 12-hour surgery) and the general surgeon, although he had given the resident and I breaks, had not taken any himself. So I asked him, "Doctor, are you planning on taking even 5 minutes of a break?"

"If I wanted to take a break, I would have taken one already, but you never know what can happen when you step out of the OR and if something goes wrong later, how would I know that it's not because of what happened when I left for a few minutes? So I prefer to just stay."

But I pressed, "Okay, Doctor, 'makes sense. But if you feel you want to step out for even just 2 minutes, I have a granola bar in my pocket, so you can eat something."

The surgeon literally stopped what he was doing for a moment in his surprise. The medical student was making sure that he was okay? Of course, I was. Isn't that the human thing to do? Someone is hungry, offer food; someone is tired, offer rest. And if the scrub nurses weren't rotating off every few hours, I would have offered them the same. He was so touched that someone should care for his well-being as a person. Not as a big-shot doc, but as a human who has basic needs, and who may function optimally if those needs are met.

And then it struck me that perhaps people get so caught up in their roles in the hospital that they forget each other's humanity. Nurses get frustrated with docs (sometimes rightfully so, sometimes completely uncalled for), so their tone can be rude and demanding (and they probably don't realize it). Doctors are perceived as gods by some and devils / assholes by others (the worst is when they buy into these delusions themselves). Orderlies are there to bring you stuff. Unit coordinators are there to be efficient for the floor. And all these egos clash and flail, slave and dominate. And unfortunately, if often becomes a survival jungle: everyone for themselves. People forget that if you show love and compassion towards your colleagues, and if in the heart of a fire, with flames licking your feet, you can show patience and humility, the blessing of that service to humanity comes back to you. In essence, you won't burn.

The Patient's Blessing

So anyway, I was burning in one of these fires at the end of a long, trying day, with everyone snapping and nagging all around me, for what I could recognize as nothing that I did wrong. But I have learned that when one reaches that moment of loathing and despair, despite this awareness (because really, how much can you take before, very humanly, losing your patience), the best thing to do is go see patients. Go see patients and remember that it's about them, it's not about you and count your blessings.

I had no choice anyway, the pre-op history and physical had to be done. So I did. The patient's wife was in the room and his two daughters as well. And you could literally feel the worry and anxious energy in that room. I sat down next to the patient's bed and went through my questions: you know why you're here, you know what surgery you're having, what are your meds, allergies, medical conditions, what symptoms are you having and not having right now; stop eating at midnight, drink this bowel prep, etc. And then came his questions. And oh, so many! So I would explain, smile, reassure, which obviously only led to more questions and sometimes, repeating the same question over.

It had been a very long day, and I was honestly at my wit's end. But then I reminded myself of what it would be like to be that patient, right now, not fully understanding why I need surgery again, not fully understanding exactly what will be done and scared shitless that something could go wrong or that I might need surgery yet again in the future. I briefly thought, "Really, I can't believe the surgeon didn't explain this to him! It's the least that could have been done!" But then I remembered all that medical anthropology, all that history of medicine, all those books I've read by surgeons and other doctors, all those anecdotes and testimonials from patients and from Physicianship in the early days of medical school. When people are sick and scared, they remember F-all. Most likely the surgeon did explain everything, but my patient had some fear-induced amnesia. It happens all the time. So my job was to judge no one and make no assumptions, but just calmly and patiently explain one more time, and perhaps, one more time after that.

I took a deep breath, smiled, put my hand on the patient's arm and explained again, this time, drawing diagrams on the back of my report. I reassured them about what I knew, looked up what I didn't know and came back to the room 5 minutes later to explain further and reassure further. I explained the reasoning of risk management that we do in medicine -what happened to you happens to a small percentage of surgical patients; the reason we are doing so much radiological imaging is because the benefit of finding stuff and then being able to fix it outweighs the risk of having too much exposure to radiation. And only once my patient was as satisfied as he would be, had no further questions and seemed a wee-bit calmer did I leave that room. 40 minutes later.

I realized that the reason they teach us about these scenarios and empathy in Physicianship is not because they think we're a bunch of cold, heartless dweebs and that they're going to "teach us empathy". It's because even the nicest, most compassionate people could easily become jerks under stress, or just become slightly less thoughtful, slightly more self-involved... basically, what came naturally before, may not come so easily under the high levels of stress we experience as clerks at the bottom of the medical food chain. By drilling all the official empathy diagrams and physicianship mumbo-jumbo into our conscious awareness, this program has essentially created a sort of safety valve so that when the unconscious, naturally-flowing compassion and kindness very humanly wavers under stress, there is a conscious secondary mechanism for empathy to kick in. And that is exactly what I used that day with that patient.

Two days later, post-op day #1 for my patient, during rounds after the residents had asked all the questions and I had scribbled them down as efficiently as possible in the patient's chart, I had smiled warmly at the patient and said "Good to see you're doing well, sir". I was about to leave the room and then he said "Wait, please come here". I approached his bedside. He took my hand in both of his own and looked into my eyes with his soul. "Thank you. Thank you so much for taking that time to explain everything to me that night." From the other side of the bed, his wife added "Oh, it made such a difference, you have no idea! You will make such a good doctor one day."

I looked back at the patient, "I'm glad I could make you feel better about the surgery -that's my job!"

"Well, it really helped a lot -thank you."

"You're happy, then I'm happy. Have a lovely day, sir -be strong, you're doing great."

It is our job. It is, and it feels wonderful to hear that you are doing your job well from the people who matter the most -the patients. In my ethnic and religious culture, we call this kind of feedback, in this particular way that it happened, the patient's du'a, or prayer. Appreciation or positive vibes that come from the heart. It's really only with the blessings of our patients that we can truly become good doctors, the only evaluation that counts for anything, in the end.

As I continue making my way through the fires of medical school, at times singed senseless, at times cremated and reborn, I am so grateful for each one of those blessings.