The Switch

“Who are you?”

I’m walking next to the gurney, transporting the patient from the emergency department to the OR, when I hear this dreaded question. Rarely have I experienced a positive reaction from a patient when you explain that there is a medical student *gasp* scrubbing into their surgery, so I try my best to avoid disclosing that fact whenever possible.

“I’m Tessa,” I smile and keep walking.

“And you are a….”

I sigh, “I’m the medical student working with your surgical team.”

“Will you be there for my surgery?”

“Yep!” I attempt to stay upbeat despite it being 4 AM and I’d been working all night, “but don’t worry, the Attending will be doing everything, I’m just there to make sure they don’t do anything too crazy.”

He laughs, which surprises me. This man is supposed to be really sick, that’s why we were heading to the operating room in the first place.

We’d received the consult at around 3 AM, I had been sitting in the OR watching a rather laborious laparoscopic cholecystectomy that my fellow medical student had scrubbed in on, when the Intern had requested my help with this particular patient. He was a 55 year old man with cancer who had recently finished a course of chemotherapy and had presented with acute onset abdominal pain. Not super exciting on it’s own – but the CT scan peaked our interest.

“Free intra-peritoneal air” said the preliminary read. I remember trying to contain my excitement – this meant I was getting a surgery tonight.

When we approached his room I could see from outside the glass that this wasn’t looking good. His blood pressure reading 85/50 and heart rate in the 170’s, before we even entered the room the Intern sent me to call up to the OR to inform our Attending.

We started a fluid bolus, got a quick history and I started working on the H&P that would need to be done before we went to surgery. When our Senior resident and Attending arrived I followed them into the room. Even after the administration of 2 liters of normal saline his blood pressure had continued to drop to 75/40. I listened to their conversation while my eyes stayed pinned to the monitor, half expecting him to crash any moment.

“It looks like you may have perforated a part of your bowel.”

After allowing the patient a brief moment to finish the string of obscenities coming out of his mouth, the Attending continued:

“This can sometimes happen after undergoing chemotherapy, or it could be due to your malignancy itself. Either way, we’re going to need to take you to surgery to remove the damaged piece of your bowel.”

“What are the risks doc?”

“Well, you’re very sick. There are always risks to undergoing a procedure, but even more so with your co-morbidities. I have to be honest with you, the prognosis doesn’t look very good. This very well may kill you.”

He takes it in for a few seconds, “how long would I have? Weeks? Months?”

There was an uncomfortable air that settled over the room.

“No,” my Attending clarifies, “I mean that this could kill you tonight.”

I could see the flurry of emotions cross his face like a blizzard turning him a paler shade of white and I was struck that even a man carrying a terminal cancer diagnosis could be surprised by his mortality.

“Is there someone that we can call for you? Does anyone in your family know that you’re here?”

“There’s my daughter, but she doesn’t know I came. I’ve been in the hospital so much recently I figured she didn’t need to know.” He checked the clock, “It’s the middle of the night, I can’t call her now.”

The intern and I were left to consent him for the operation, and I was given strict instructions not to let him out of my sight. I took my post at his bedside as the operating room called for us to bring the patient upstairs.

“I do hope you get to learn something at least, since you have to be up in the middle of the night for this.” He’s smiling kindly at me and I reciprocate. He continues on, “Tessa is a very nice name, where is it from?”

“It’s Dutch,” I respond, prompting a conversation about Europe, his military service that took him to Germany and the bitterness the Dutch hold against the German soccer team. I ask him about what he did in the service and about his family. We arrive outside the main OR board and wait for anesthesia to arrive. He’s telling me about his daughter who he believed to be about my age. I don’t know when, but sometime along the ride up the elevator I had ended up holding his hand.

We’re silent for a moment and as I look at him I feel a sudden rush of emotion. There was something about him that personified my own father. The words my attending had spoken just a half hour before rang in my ears: this could kill you tonight. 

“You really should call your daughter.” I urge earnestly, “she would want to know.”

His eyes meet my own in a moment of shared desperation, he nods his head.

I help him get to his phone and wait, desperately trying to hold back the tears as I listen to this man leave his daughter a voicemail verbalizing the direness of his situation, his unconditional love, and how proud he was of her.

By the time he hung up, Anesthesia had arrived. I take hold of his hand again as we’re rolled back into the OR.

Normally, at this point I am assisting the nurses in getting the patient connected to the SCDs, correctly positioned, and grabbing my gloves and gown for the scrub tech. But this time I just stand there holding his hand, his unrelenting grip capturing me in place.

At this point my Attending comes and stands next to me. I wonder what he’s thinking of me – this useless medical student just standing there, being of no help to anyone. I fear he can see the tears welling in my eyes. We stand there in silence for what felt like years as the Anesthesiology Attending arrives and initiates the induction of anesthesia.

When he’s finally asleep, I let go of his hand and glance towards my Attending. He considers me for a minute, and I half expect him to kick me out of the OR and tell me to go get my emotions in check.

Instead, he simply nods and states, “I think we’re going to need some music for this one, don’t you?”

So we performed the operation while blasting Shakira and Enrique Iglesias.

This experience demonstrated to me the dichotomy of what it means to be a physician, and especially to be a surgeon. It’s a balancing act. We must be human, we must feel and connect deeply with our patients. We also must be able to turn it off, put our heads down and charge forward at the top of our game.  Both roles are required in providing complete patient care.

If I had been the lead surgeon, I never would have been able to be objective and thorough in that operation if I had spent the entire time worrying about the daughter who may not get to see her father again. But I also wouldn’t have been able to facilitate this man’s calm journey to the operation if I hadn’t embraced my humanity and made a connection.

So we have to develop the switch – the one that puts a pause on our humanity and turns on the well-oiled-machine that is the experienced surgeon. We turn on some 80’s rock, latin pop or EDM and fix the problem.

I think this is essential in nearly all areas of medicine – to have the ability to suspend our emotions and do what needs to be done. It’s healthy and it’s required.

But what happens if we forget to flip the switch back once the surgery is over or we’re finished running the code? When the outcome is bad, isn’t it just simpler to leave it off? We have more patients to take care of, more surgeries to do, more lives to save. So yes, it’s easier to remain disconnected. I’ve seen examples of that happening throughout this past year on the wards. But I’ve also been shown amazing demonstrations of courage, vulnerability and compassion when physicians have purposefully made the decision to flip the switch back, to embrace their humanity and with it, their humility.

On my pediatric rotation this last month an Attending of mine reminded me that sometimes I need to rein in my intensity to a level that my patients can handle. To read the room, take a step back, and make a connection before I rush into my plan for their care. I think that fits well with this concept, because in the same way as I consciously decide pump the brakes when it comes to my level of directness with my patients, it is also a conscious decision to lay down the suit of armor that is medicine and meet our patients and their families where they are.

I hope that moving on in my career that I can continue to remember the importance of this decision and fight against the lazy temptation of disconnection.

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