journal entry made January 25, 2009
I imagine that every doctor could speak volumes about particular patients that have affected her, inspired her, changed her. I encountered one such patient before I even entered medical school while I was serving with Mercy Ships. Her name was Betty. Betty was 21 when I met her in the hospital wards on the third deck of the Africa Mercy. She was about half my size but had twice my spirit and spunk. Betty had been admitted for her second attempt to repair a vesico-vaginal fistula. Three years earlier Betty had been with child, (whether she had been impregnated by choice or by force I still do not know; both are unfortunately equally likely in Liberia) and when it came time for her to have her baby she was not able to push it out - perhaps because of her size or her age or some ill position of the child. Being far from medical care, Betty was stuck in labor for 7 days. The baby died, and she was eventually able to deliver it, but the pressure that it had put on her birth canal left her with a 3cm tear between her urethra and vaginal wall, providing a passageway for constant, uncontrollable urine leakage. Thanks to this fistula, she was sent away from the city to live with her aunt in the country. And this was where she spent her next three years – in exile, unable to attend school because of “the problem” as she called it. I do not know if she had a boyfriend or husband before the problem; if so, he had evidently not stuck around after. When I met her, Betty had actually already been operated on by our surgical team once several months before. Because of the size of her fistula, Betty’s first surgery wasn’t successful, and she was back with the hope that a second one would be. I only met her briefly the night before her surgery, but it was long enough for me to be impressed by her resiliency. That’s why I was surprised to learn the next day that her second operation, like the first, had almost killed her. On the day of her surgery the hospital lab tech asked me if I would be willing to donate blood to one of the patients who needed an A-positive transfusion – it was Betty. She had lost so much blood during the operation that she actually needed transfusions from two additional crew members after me, and she spend the next few days in isolation in the ICU while I spend the next few days violently ill with the worst fever I would have while on the ship. By the time I was well enough to visit her Betty was still in isolation, which meant that we were able to have more personal time than when she was back in the ward in the company of a dozen other fistula patients. I was able to talk with her more about her history, her faith, her ambitions. She told me that she hoped that God would make her dry so that she could go to school. I told her that we were sisters two times over – because of our shared faith, we were both connected by the blood of Jesus, and because of the transfusion we had the same physical blood running through our veins too. Eventually Betty was transferred back to the regular wards, and I enjoyed visiting her daily as she healed. One of the things that she seemed to value most was physical contact. She always wanted me to plait her hair, rub her back, or paint her nails. I can only imagine how starved her isolating condition had made her for human touch. After several weeks had allowed our friendship to deepen, Betty was well enough to be sent home. Unfortunately, her second surgery had failed – she was still leaking. Betty was told that she could come back to the ship for a third surgery. Before she left Betty and I exchanged telephone numbers so that we could keep in touch when I went back to the States. I told her that she could call me after her third surgery when she was dry so that we could say “Praise God!” together. Then she left with a small paper appointment slip and more hope than I could honestly muster.
Last fall I read an autobiography by Dr. Catherin Hamlin called “Hospital by the River.” It’s the story of how she and her husband, both Australian obstetricians, left their homeland in 1958 and set up a fistula hospital in Addis Abba, the capital city of Ethiopia. Dr. Hamlin writes in her book that upon arriving in Ethiopia she was warned by another missionary that “the fistula patients will break your heart.” I concur. I need only reflect upon the thousands of women with stories like Betty’s, and my own problems seem at once petty and insignificant. The lives of these women are just so tragic on so many levels that they would threaten to drive one to despair. In her autobiography Dr. Hamlin divulges her source of hope, which drives her onward. She shares,
"I have sometimes been asked if these tragic cases ever test my faith. I can truly say that, if anything, my faith has been strengthened and my soul more firmly anchored to Jesus as the only one to whom we can turn. Jesus never promised us a smooth or trouble-free passage through life, but he did promise to be with us to share the sorrow and the pain."
This same sentiment was engendered in me as I naively worked for only a short time in Liberia, and I am glad to know that such a confidence is confirmed by one much more seasoned than myself. Dr. Hamlin speaks with the wisdom of a woman who, though her husband and partner passed away decades ago, though she has already donated 51 years to her cause, though she is 84 years old, is still working with diligence and with joy to bring hope and healing to the women of Ethiopia.
Several months ago I received a call on my cell phone at 6:30am on a Saturday morning. I stumbled out of bed and across the room to tell unknown caller that they had dialed the wrong number. It was Betty. She was calling to tell me that she had been healed. She was dry. And we cried “praise God!” together.
The thought that I might one day be able to repair fistulas is the primary driving force behind my interest in obstetrics and gynecology. I know that I am just a first year medical student, and I know that most students change their chosen specialty throughout the course of their studies. I cannot say if my interests will weather the semesters of shadowing and rotations. I’ve recently learned of other pathways that could train me to repair fistulas; I could, for example, specialized in family medicine and choose a residency that permits me to take a year to focus on women’s health. Whatever my course, may I remember that I have been called to serve. I can only hope to achieve and maintain the resolve of Dr. Catherine Hamlin, who concluded her autobiography at age 77 with the following:
"There is still so much to be done for thousands of women who every year suffer the agony of obstructed labour and its horrific consequences. I could never imagine just living here and not working, it would be unthinkable. Unthinkable, too, to walk away when I know the problems would be even worse. I have therefore made no plans for retirement."
May my calling coincide with my life’s work and result in the same passion.
Saturday, May 9, 2009
On Callousness
A reflection on Clinical Anatomy
journal entry created October 26, 2008
We are now nearing the completion of our clinical anatomy block, and we have been working with our donors for many weeks. In an earlier entry I commented on how strange our donor’s body looked – so alive while dead. It’s interesting how accustomed one can grow to things that were once shocking. On my first day in the lab, a peak at her face was wholly disturbing, yet that was nothing compared to the grisly sights of more recent labs. Last week our donor’s cervical vertebrae were severed so that we could easily flip her head and lay it face down on her stomach in order to observe a posterior view of the esophagus. This week we skinned her face to observe the musculature and vessels beneath. I certainly would not have been able to handle such invasiveness during my first few experiences in the anatomy lab. It’s interesting how accustomed one can grow to disturbing situations. I think this idea of desensitization is applicable across the board - in medical procedures, in death, even when facing injustices. Over time we grow accustomed to things that once shocked us. I think it is self-protective.
I noticed that I myself became quite desensitized throughout my three months working in post-war Liberia last fall. While I was there it was undeniable that fourteen years of civil war had utterly devastated the country; nearly ten percent of the population had been killed in the conflict, the country’s infrastructure – education, healthcare, etc – had been destroyed, and eighty-five percent of the people were living in poverty. At first everything was overwhelming. During my first week there I remember meeting an emaciated man with desperate, hollow eyes on the shipyard dock who was looking for work so that he could earn money to feed his family. My coworker told him that our ship was not hiring but took his contact information just in case, knowing that there would be no offer for work. The hopelessness of that encounter and others like it at first haunted me for days. It was incapacitating. For my first two weeks in the country I often felt emotionally exhausted. Then over time I noticed a strange shift in myself. I became able to encounter desperate situations and remain for the time being unscathed. I could interact with broken families, starving babies and innocent detainees who had been imprisoned without formal accusations or hope of a trial, and I didn’t shed a tear. Not that I didn’t care about their situations, but I had become calloused.
I have taken several personality tests over the past few years, and consistently my strongest personality trait is compassion. By default, I tend to consider the situations of others, and I find myself very impacted by others’ feelings. This made the desensitization I experienced in Liberia rather unsettling. By the end of my time there I did not like my unsympathetic response to suffering. I remember wondering if I had been permanently roughened. I wondered if would return to the US with much more cynicism than I had left with. I departed from Liberia via a ship that set sail for the Canary Islands, and it was while at sea – two or three days removed from the Liberian coast - that I was finally able to process all I had seen. I sat alone on the deck of the Mercy Ship, I looked out over the ocean, and I wept. I wept for patients who never were healed, for the children who never were nourished, for the prisoners who were never released. It was cathartic. Emotion had returned to me, and I felt human again.
I’m not sure I know whether or not callousness is such a good thing. To what degree is it appropriate in medicine? What is the most beneficial to my patients? Do I connect with each one so deeply that their hurts become my hurts, their family struggles my family struggles? It seems that could burn a doctor out in a hurry. Do I wall myself off completely so that I see my patients as mere clients who pay for services rendered and have no bearing on me or my personal life, nor I theirs? It seems that would make it difficult to build a covenant relationship.
At this point in my medical career, having had limited clinical practice in the physician-patient context, I consider myself to be rather naïve, and I’m not sure I know the right answer. I want to be detached enough to remain objective in emotionally difficult situations, but I want to be engaged enough to feel sorrow when my patients feel sorrow and joy when they feel joy. The art of engaging is one of many things that I hope to develop as I continue on my medical school journey.
journal entry created October 26, 2008
We are now nearing the completion of our clinical anatomy block, and we have been working with our donors for many weeks. In an earlier entry I commented on how strange our donor’s body looked – so alive while dead. It’s interesting how accustomed one can grow to things that were once shocking. On my first day in the lab, a peak at her face was wholly disturbing, yet that was nothing compared to the grisly sights of more recent labs. Last week our donor’s cervical vertebrae were severed so that we could easily flip her head and lay it face down on her stomach in order to observe a posterior view of the esophagus. This week we skinned her face to observe the musculature and vessels beneath. I certainly would not have been able to handle such invasiveness during my first few experiences in the anatomy lab. It’s interesting how accustomed one can grow to disturbing situations. I think this idea of desensitization is applicable across the board - in medical procedures, in death, even when facing injustices. Over time we grow accustomed to things that once shocked us. I think it is self-protective.
I noticed that I myself became quite desensitized throughout my three months working in post-war Liberia last fall. While I was there it was undeniable that fourteen years of civil war had utterly devastated the country; nearly ten percent of the population had been killed in the conflict, the country’s infrastructure – education, healthcare, etc – had been destroyed, and eighty-five percent of the people were living in poverty. At first everything was overwhelming. During my first week there I remember meeting an emaciated man with desperate, hollow eyes on the shipyard dock who was looking for work so that he could earn money to feed his family. My coworker told him that our ship was not hiring but took his contact information just in case, knowing that there would be no offer for work. The hopelessness of that encounter and others like it at first haunted me for days. It was incapacitating. For my first two weeks in the country I often felt emotionally exhausted. Then over time I noticed a strange shift in myself. I became able to encounter desperate situations and remain for the time being unscathed. I could interact with broken families, starving babies and innocent detainees who had been imprisoned without formal accusations or hope of a trial, and I didn’t shed a tear. Not that I didn’t care about their situations, but I had become calloused.
I have taken several personality tests over the past few years, and consistently my strongest personality trait is compassion. By default, I tend to consider the situations of others, and I find myself very impacted by others’ feelings. This made the desensitization I experienced in Liberia rather unsettling. By the end of my time there I did not like my unsympathetic response to suffering. I remember wondering if I had been permanently roughened. I wondered if would return to the US with much more cynicism than I had left with. I departed from Liberia via a ship that set sail for the Canary Islands, and it was while at sea – two or three days removed from the Liberian coast - that I was finally able to process all I had seen. I sat alone on the deck of the Mercy Ship, I looked out over the ocean, and I wept. I wept for patients who never were healed, for the children who never were nourished, for the prisoners who were never released. It was cathartic. Emotion had returned to me, and I felt human again.
I’m not sure I know whether or not callousness is such a good thing. To what degree is it appropriate in medicine? What is the most beneficial to my patients? Do I connect with each one so deeply that their hurts become my hurts, their family struggles my family struggles? It seems that could burn a doctor out in a hurry. Do I wall myself off completely so that I see my patients as mere clients who pay for services rendered and have no bearing on me or my personal life, nor I theirs? It seems that would make it difficult to build a covenant relationship.
At this point in my medical career, having had limited clinical practice in the physician-patient context, I consider myself to be rather naïve, and I’m not sure I know the right answer. I want to be detached enough to remain objective in emotionally difficult situations, but I want to be engaged enough to feel sorrow when my patients feel sorrow and joy when they feel joy. The art of engaging is one of many things that I hope to develop as I continue on my medical school journey.
Monday, March 2, 2009
Reflections on trip to the Medical Examiner’s Office (on Monday, October 20)
This is a journal entry that I wrote last October after my class went to visit the county medical examiner's office. I hesitated to post this one, because it's a little gruesome. But it's my honest reflection, so I wanted to leave it mostly intact. Read at your own risk...
.........................
For me, the week preceding my trip to the medical examiner’s office was probably more haunting than the experience itself. I blame a classmate for this. A week ago, as we were walking to her car after Anatomy she said to me “It’s kind of strange; you know, the people you see on Monday are still alive right now. And they probably have no idea what’s coming.” …Wow. How’s that for a perspective shift? As soon as the idea left her lips, I felt this strange feeling of panic/nausea roll deep in my stomach. Throughout the week I felt like time was an enemy, mercilessly rolling on and counting down to the death of the unnamed. I found myself brought to tears on multiple occasions. I was mourning the unknown victims. It was strange to cry for someone I didn’t know who was likely in fine health, but what else could I do? Could I pray that God would spare those who would lie dissected before me within the week? No, that was a strange, circular logic and not possible. I felt like I could only mourn - mourn and pray that God was preparing them for the journey.
Just a week prior to my trip to the medical examiner's office, my younger sister’s classmate committed suicide. At sixteen years of age this poor child decided that she had nothing left to live for. Comforting my sister and personally reflecting on this tragedy had already made last week emotionally taught for me. I was already angry at death. Like the opening of floodgates, my mind had descended into the memories of the unwelcomed, early deaths of loved ones in my own life. I didn’t want to go to the medical examiner’s office. I didn’t want to have to see more death. Too often death comes like a thief, stealing life from its victims and likewise from its victims’ families and friends. I do not like death. And I didn’t want to confront it in full force on Monday.
Despite my misgivings, I went to the medical examiner’s office anyway. I knew that I needed to deal with facing death because, as unwelcomed as it is, it is a reality in this hurting, failing world of ours.
The visit was indeed gruesome. Our patients included a 2 year old girl who had been accidentally left in a hot car for hours and a husband who had committed suicide by shooting himself through the head. There were two gun-inflicted homicide victims and two motor vehicle crash victims. There was also a woman who had allegedly overdosed on her pain medications. There were several others that I cannot even recall now. It was a busy day at the office. As per protocol, the patients were stripped and lain on cold, steel tables; they were cut down the middle, rib cages snapped, chest cavities opened, organs removed, dissected and weighed; they were scalped, skulls sawed, brains removed, pieces preserved. After the procedure, organs were places in random order back into the chest cavities, and the skins were closed. Each scalp was re-fastened with a single stitch, and the patient was re-bagged to be shipped to the appropriate funeral home. Everything was done very matter-of-factly, which helped in a small way to make the autopsy seem less cruel. Still, I found my mind wandering to the victims’ fates. The man who ended his life – was his choice really best for his family? It may have ended his suffering, but did it end his wife’s? For the woman killed in an automobile accident – did she leave any unfinished business behind? How was her family? They probably had no idea that they would be planning a funeral this week. And the little girl – how was her family? Were they plagued with ‘what if’s? Had they already made plans for her future? As if these thoughts weren’t disquieting enough, my mind drifted to the fact that I was standing in the only medical examiner’s office in Maricopa County. All victims of “unnatural” deaths passed through this room - including all personal acquaintances and friends of mine who had been prematurely robbed of life. That medical examiner’s office seemed to me to be a dismal place. Medically speaking, it was fascinating; we were exposed to all sorts of anatomy. But I ultimately could not distance myself from thoughts of the stories surrounding the patients we saw. I don’t think I would have wanted to.
This whole experience helped me to realize that as a doctor I’m not yet prepared to deal with death. I’m not scared of death, nor am I scared to die myself. Due to my personal spiritual convictions, I see death as a journey. I am apprehensive because I fear for those who aren’t ready to make that journey. And I fear for those who are left behind. Like many, I am familiar with the feelings of a survivor. It feels as if you’ve got an irreparable hole in your heart, and the emptiness is accompanied by plaguing questions like “why?” and “what if…?” Here my personal convictions suggest that such questions are not for me to worry about, but instead I should trust that all things work together to compose a symphony of life that is larger than the confines of my imagination. Truly, I believe that the God I worship detests death and despair more than I ever could. And I find comfort in believing that this God has defeated/will defeat death itself. There will be no need for a medical examiner’s office anymore.
.........................
For me, the week preceding my trip to the medical examiner’s office was probably more haunting than the experience itself. I blame a classmate for this. A week ago, as we were walking to her car after Anatomy she said to me “It’s kind of strange; you know, the people you see on Monday are still alive right now. And they probably have no idea what’s coming.” …Wow. How’s that for a perspective shift? As soon as the idea left her lips, I felt this strange feeling of panic/nausea roll deep in my stomach. Throughout the week I felt like time was an enemy, mercilessly rolling on and counting down to the death of the unnamed. I found myself brought to tears on multiple occasions. I was mourning the unknown victims. It was strange to cry for someone I didn’t know who was likely in fine health, but what else could I do? Could I pray that God would spare those who would lie dissected before me within the week? No, that was a strange, circular logic and not possible. I felt like I could only mourn - mourn and pray that God was preparing them for the journey.
Just a week prior to my trip to the medical examiner's office, my younger sister’s classmate committed suicide. At sixteen years of age this poor child decided that she had nothing left to live for. Comforting my sister and personally reflecting on this tragedy had already made last week emotionally taught for me. I was already angry at death. Like the opening of floodgates, my mind had descended into the memories of the unwelcomed, early deaths of loved ones in my own life. I didn’t want to go to the medical examiner’s office. I didn’t want to have to see more death. Too often death comes like a thief, stealing life from its victims and likewise from its victims’ families and friends. I do not like death. And I didn’t want to confront it in full force on Monday.
Despite my misgivings, I went to the medical examiner’s office anyway. I knew that I needed to deal with facing death because, as unwelcomed as it is, it is a reality in this hurting, failing world of ours.
The visit was indeed gruesome. Our patients included a 2 year old girl who had been accidentally left in a hot car for hours and a husband who had committed suicide by shooting himself through the head. There were two gun-inflicted homicide victims and two motor vehicle crash victims. There was also a woman who had allegedly overdosed on her pain medications. There were several others that I cannot even recall now. It was a busy day at the office. As per protocol, the patients were stripped and lain on cold, steel tables; they were cut down the middle, rib cages snapped, chest cavities opened, organs removed, dissected and weighed; they were scalped, skulls sawed, brains removed, pieces preserved. After the procedure, organs were places in random order back into the chest cavities, and the skins were closed. Each scalp was re-fastened with a single stitch, and the patient was re-bagged to be shipped to the appropriate funeral home. Everything was done very matter-of-factly, which helped in a small way to make the autopsy seem less cruel. Still, I found my mind wandering to the victims’ fates. The man who ended his life – was his choice really best for his family? It may have ended his suffering, but did it end his wife’s? For the woman killed in an automobile accident – did she leave any unfinished business behind? How was her family? They probably had no idea that they would be planning a funeral this week. And the little girl – how was her family? Were they plagued with ‘what if’s? Had they already made plans for her future? As if these thoughts weren’t disquieting enough, my mind drifted to the fact that I was standing in the only medical examiner’s office in Maricopa County. All victims of “unnatural” deaths passed through this room - including all personal acquaintances and friends of mine who had been prematurely robbed of life. That medical examiner’s office seemed to me to be a dismal place. Medically speaking, it was fascinating; we were exposed to all sorts of anatomy. But I ultimately could not distance myself from thoughts of the stories surrounding the patients we saw. I don’t think I would have wanted to.
This whole experience helped me to realize that as a doctor I’m not yet prepared to deal with death. I’m not scared of death, nor am I scared to die myself. Due to my personal spiritual convictions, I see death as a journey. I am apprehensive because I fear for those who aren’t ready to make that journey. And I fear for those who are left behind. Like many, I am familiar with the feelings of a survivor. It feels as if you’ve got an irreparable hole in your heart, and the emptiness is accompanied by plaguing questions like “why?” and “what if…?” Here my personal convictions suggest that such questions are not for me to worry about, but instead I should trust that all things work together to compose a symphony of life that is larger than the confines of my imagination. Truly, I believe that the God I worship detests death and despair more than I ever could. And I find comfort in believing that this God has defeated/will defeat death itself. There will be no need for a medical examiner’s office anymore.
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