Saturday, August 24, 2013

Things handed down

It was a difficult night. A 20 year old had come in as a referral from an outside hospital with the following story: Several years ago she had had a cesarean section, and was now pregnant at approximately 22-24 weeks. She had gone to an outlying hospital where they diagnosed an intrauterine fetal demise, and started an induction. A week later, she still hadn’t delivered and was septic. By the time we saw her, she had "the look." ("The look" is how I have come to describe the appearance of a woman who is close to death and knows it. It is in her eyes. It is a brave look. And it is also a look of resignation and sadness. There are never any tears, and there is always a profound silence). Her abdomen was soft and she had some guarding, and the fundus of her uterus was not readily palpable. The ultrasound showed a fetus—but not clearly in a uterus. I took her to theatre and found her 24 week baby outside her uterus, and a placenta that was attached by adhesions to her small bowel. Her uterus had ruptured days before and was not viable. And so, at 10 o’clock at night, I found myself doing a hysterectomy on a 20 year old.

The next morning, I received a call from my intern. We had gotten another transfer—this time from a very remote area, with this story: She is a 32 year old mama with four children. She had delivered all of her other babies at home—but this last delivery did not go well. She labored for days, finally made it into a district hospital, and was diagnosed with obstructed labor and a fetal demise. She underwent a cesarean section. At the time of her operation the doctor thought her bladder was necrotic. They sent her home on post op day #3. She returned several days later with hemorrhage and purulent vaginal drainage, along with urinary incontinence. She got antibiotics, and a week later was transferred to us septic with a hemoglobin of 4. When I went to her bedside, she too had "the look." She was hypotensive, tachycardic, febrile, and breathing 40 times a minute. Her wound was pouring out huge amounts of foul drainage, and she was bleeding. Her exam was consistent with a dead uterus sitting in her abdomen, and also for possible early necrotizing fasciitis.

And so, a hard night devolved into a harder morning. An hour later, I was in the theatre—and this case was much, much worse, because the patient’s uterus and upper vagina, along with some fascia and muscle, were necrotic and gangrenous. The smell was horrific. After two hours, we had gotten her uterus out, her vagina resected, and her pelvis debrided.

Both of these women survived surgery. They both have a long way to go towards recovery.

This afternoon I am sitting beside an open door, listening to crows calling, looking out towards the Poinsettia and Jacaranda trees full of bright little birds, feeling the soft breeze blowing through my curtains and onto my skin—I am tired and I am thinking about my patients. I know about the anatomy, the surgery, the physiology. I know how to approach their care—in the operating room and postoperatively. I know they are both not out of the woods by any means —the human body is just not meant to undergo this type of prolonged insult. But I also know that they can survive, they now have a chance. So, I know a lot of things—but I have realized out here that it is not enough just to know a lot of things.

I grew up the daughter of a physician who was a general practitioner turned child psychiatrist. My childhood and early adult years were spent beside him, soaking up everything he could teach me about being a physician—but more than that, a physician who practices out of a call to help and minister to the body, soul and spirit of a person created in the image of God. Many times I find myself thinking, feeling and sensing with my patients, the way my father did, and sometimes the feelings can be so strong I have to step away.

Yesterday, standing beside that second patient who had suffered so much and had come from such a remote place—I became momentarily overwhelmed by her pain. But I could not step away. I was the Gynecologist who had to open her abdomen and try to begin to fix what was terribly broken. She needed a Gyn surgeon at that moment—but she also needed something more. She needed someone to see beyond her broken body, beyond the anatomy, the surgery, the physiology. She was alone, quite possibly facing her final moments of consciousness this side of eternity. No one spoke her tribal language. Her family was not around. Strange people in masks were standing over her. The lights were very bright.
It was at that moment I saw "the look" come into her eyes. But wasn’t I the surgeon? Could I feel with this woman and do the things I needed to do to save her life? At that critical time, it had to be about the anatomy, the surgery, and the physiology, didn’t it? Could I let myself become vulnerable, right before I started hacking away the gangrenous tissue filling her pelvis and abdomen?

She was looking at me then. I grabbed her hand and we stared into one another’s eyes. I tried to tell her without words that she was not alone. She held my hand tightly and I looked down to see our hands grasping one another: one hand freckled, pale fingers entangled with her beautiful, dark and work- worn fingers. In the next few minutes we induced anesthesia and began surgery.

As a missionary doctor in Africa, I confront many challenges —the surgery is difficult, the diagnoses can be illusive, and the suffering of my patients often extreme. The emotional and physical toll is great. Yet in the midst of this, I am rediscovering what it means to be the kind of physician that my father was. Yes it is about medical knowledge, technical proficiency, and experience. Yes, it is about empathy, even personal vulnerability. But it turns out that the whole is far greater than the sum of the parts. And knowing a lot of things does not make you a good physician—although it might make you a good technician. There is a sacredness about what the physician does: ministering to a hurting, perhaps profoundly damaged person, created in the image of God. And it calls for something that cannot be outcome measured in electronic health records, or counted off in shift hours or time cards. It cannot be defined in terms of patient safety acronyms, or equated with teams of administrators administrating. It is what my father knew after nearly a half century of the practice of medicine.

And it is what I am coming to know, and perhaps beginning to understand, in the middle these difficult nights, in this hard place, holding onto the hand of my patient.