White Spots and Black Holes
The man’s arms and legs were shrunken, atrophied from disuse, and his hands were twisted and stiff, curled into rigid fists. He moaned in pain on the long, white stretcher. Cringing at the sight of his wasted, deformed body, I could hardly believe he was once a soldier. His story, his image, would haunt me for years to come.
“This is a fifty-nine-year-old male with a history of multiple sclerosis and hypertension,” the second-year surgery resident reported to the senior fifth-year resident in his typical robotic fashion. “He developed acute, lower abdominal pain earlier today associated with vomiting. Exam reveals abdominal distension and diffuse tenderness to palpation.”
“OK, so what’s your diagnosis?” Matt, the senior resident, asked the second-year, his usual bored arrogance replaced with mild interest.
“Well, obviously intestinal obstruction, uh, probably volvulus.”
“Sounds like it!” Matt exclaimed, his voice now eager at the prospect of operating.
Volvulus – an abnormal twisting of the intestine back on itself – can cause a log jam in the abdomen, blocking the passage of waste products and sometimes causing severe tissue damage, infection, and death. It was a bread and butter general surgery diagnosis, but in the weeks since starting my rotation, I had only read about it in my textbook.
Katy and I, just a few weeks into our required surgery rotation at the Veterans Affairs (VA) Hospital in Houston, looked at each other in despair. We were two women in our second year of medical school, assigned to this team of five men: young resident doctors training to be surgeons who were also charged with training us, the lowly students. But while the residents were celebrating another surgical opportunity, I looked at my watch – 11:12 p.m. – and sighed, resigned to my dismal fate. Katy and I, indentured servants for the month in our matching green scrubs, would have to stay up with them, running to find a nurse, medical records, or even a paper clip if that’s what they needed. After a day that had started at 6:00 a.m. with hospital rounds followed by hours of watching two hernia repairs, a splenectomy, and a longer vascular bypass procedure to improve blood flow to an ischemic (oxygen-deprived) foot, I was ready to collapse.
“Oh, God, please help!” our patient cried out.
“Yeah, hey, can we get him some more morphine?” Matt ordered a nurse nearby. Then he turned to us, “Hey, students, did you examine this guy?”
I didn’t want to cause further injury, so I approached our patient cautiously, annoyed that Matt was calling on me to put him through another uncomfortable exam.
“Hi, Mr. Sloane,” I whispered, gently touching the man’s shoulder. “I’m Lisa, one of the medical students. I’m so sorry you’re hurting. We just need to check your belly once more.”
“Oh, owww!” he moaned again, but he rolled onto his back to allow me to examine him.
Katy stood behind me. “The nurse is getting more pain meds right now,” she assured him.
“Come on, ladies,” the second-year resident interrupted. “We’ve gotta get this guy to radiology.”
“Sorry, Mr. Sloane,” I said, trying to ignore the resident, as I placed my stethoscope on the patient’s abdomen, listening for bowel sounds. The familiar little squeaks and gurgles, indicating a healthy and active intestinal system, weren’t there. I then pushed down slightly, pulling back my hand as the patient winced.
“Absent bowel sounds. And he’s got guarding,” I whispered to Katy, referring to the abdominal tightening I felt when I applied pressure.
“Seems like an obstruction alright,” she replied.
“Come on! What are you doing? Hustle, hustle!” the resident said, waving his arms as if to push us aside.
I jumped out of the way, thankful to see the nurse injecting more morphine into the patient’s IV. Within seconds, he relaxed a little.
Katy and I followed behind as a hospital orderly wheeled the stretcher into a large elevator to take us to the basement radiology department.
I had correctly guessed that I would not enjoy this rotation, but all medical students were required to spend three months in the surgery department. Each day, standing under bright lights as the smell of burning flesh from the cauterizing pen polluted the stale air, we watched for hours as the surgery residents sliced open abdominal walls or directed small laparoscopic tools to remove diseased gallbladders or colons. On a particularly exciting day, we might be asked to hold a clamp or put in stiches to close someone’s abdomen after an operation. Standing there for hours, I had plenty of time for internal debates to determine whether surgeon or nineteenth century coal miner was the worst imaginable profession.
During surgery, the residents grilled us on our knowledge of anatomy – never my strong suit – and laughed in our surgically masked faces when we didn’t answer correctly.
“What’s this artery?” the resident would ask, lifting a thin pink cord with the tiny laparoscopic tool during a gallbladder surgery, his harsh voice muffled by the mask.
“The hepatic artery?” I’d guess.
“God, no! It’s the anterior branch of the cystic artery. Remember Calot’s triangle? How many times have we gone over this?” he would say.
I was almost as exasperated with myself as he was. No matter how many times I reviewed the illustrations in my textbook, I often couldn’t identify the arteries, veins, and other anatomic structures during an operation.
“So, students, is there a connection between this guy’s MS and a volvulus?” the second-year resident asked, once we arrived in the radiology department, while the techs started preparing the patient for a procedure – a barium enema.
“Yes?” I answered, hoping I was right.
“Correct. And what are the other risk factors?”
I was grateful when Katy jumped in, “Older age, constipation, other neurologic and psychiatric conditions.”
Wow, she had been reading her textbook! The resident nodded and then glanced over his shoulder when the patient shouted out again in pain as the orderlies moved him onto a special table. The resident looked back at us, unconcerned. His annoyed expression reminded me again that, in addition to teaching me the basics of surgery, these resident physicians were teaching me about the kind of doctor I did not want to be.
“Yeah, so we’re gonna do the enema procedure first to confirm the diagnosis. Sometimes the enema itself will straighten out the twisted intestine, but he’ll almost certainly need surgery after that to keep it from happening again.”
The residents were practically gleeful about this new case, which, I was grateful to learn, at least would be delayed until the following day. “Every operation is a good operation. Remember that,” the third-year resident had told me during my first week at the hospital.
Katy and I stood in the corner watching as this broken man, with his mangled body, was helped into a fetal-like position on his side while a tube was inserted into his rectum. I imagined that once, decades before, he had fought in Vietnam. Then he came home, eventually received a diagnosis of MS, and his body had forsaken him.