Carnations and rectums

Today as I drove home from the hospital I thought, why didn’t I choose a career that made me feel smart? I could’ve become a preschool teacher. Or run a florist shop (hello, there’s only so much to know about carnations!) Instead I chose a career that consistently makes me feel stupid.
For example, my first major task of the day. Dr. T and I were examining a patient who had had surgery a week ago and had healed quite nicely. The incisions in his stomach were closed with staples. Dr. T handed me a staple remover and said, “Go ahead.”
Taking staples out isn’t rocket science; I learned it in nursing school 6 years ago. But actually, I thought as I opened the package, that was the last time I had a surgical patient and actually took staples out. They sure looked like funny staple removers, I thought, but I decided to be brave and go ahead.
“Ow!” The patient winced as I accidentally poked him right in his tender incision.
“Hold it the other way around.” Dr. T explained graciously.
I turned it around and took out the staples, one by one.
My second major task of the day came when I was watching a colonoscopy and Dr. T motioned for me to put a glove on and stick my finger in the patient’s rectum. Oh sure, I thought, why not? Doing a rectal exam is actually on my list of things to do before I die.
I stuck my finger in.
“All the way in.” Dr. T counseled me in a quiet voice.
So I went all the way in.
“Do you feel the tumor around the circumference?”
I’d never actually stuck my finger in anyone’s rectum before just to see what it felt like, but it did seem like what I would imagine a circumferential tumor to feel like.
“Yes.”
After I had extricated myself Dr. T advanced the scope and showed me the live pictures of what was indeed a well-developed case of rectal cancer.
Later in the day I scrubbed in for one of the surgeries and there is a complicated way to get into your sterile gown and I messed it up and lost the ties for my gown and the OR nurse had to use a metal clamp to hold it together at the back. During the next case I was standing near the anesthetist and he asked if I wanted to intubate the patient and I had to say yes, I had no choice. I started out holding the tongue blade in the wrong hand and he had to remind me how to tilt the patient’s head back and I got the tube in but then I wasn’t completely sure that I had it in the right place, so I had to ask him to check. It was indeed in the right place, and when we were done he said it was a difficult intubation, but I thought, if this was an emergency and I was the only one around, I probably couldn’t have done it. The anesthetist just sat there and ate bran flakes out of a Styrofoam cup and turned knobs on the monitors.
During the next case, a hemorrhoidectomy (hemorrhoid removal), I stood near Dr. T and held the patient’s anus apart with retractors while he cut out the hemorrhoid. Holding an anoprocto retractor in one position for the duration of an operation is hard enough, but being able to release it after your hand has frozen to the handle is even harder. At least the patient was asleep for most of the operation.
The surgical assistant was very nice and during one of the cases while I helped him suture, he quizzed me.
“What is the name of this fascia overlying the inguinal ligament right here?” he pointed down into the incision.
From somewhere deep in the recesses of my mind I remembered.
“Scarpa’s fascia.”
“And how do you spell it?” He asked.
“S-C-A-R-P-I-A” I said.
“Sort of.” He answered.
In the car on the way home I sounded it out in my head and tried to figure out why an Italian word was spelled the English way.
We can’t all have everything. I always said that if I had to choose between being dumb, ugly or mean, I would choose to be mean, because that was the most changeable trait. But after standing around stupidly all day I’m beginning to feel that the choice was already made for me. I was introduced as “Heather Davies, the medical student.” I should’ve just saved Dr. T the trouble and introduced myself.
“Hi, I’m Heather, and if you feel a very hesitant finger up your bum, it’s just because I’m nervous. And if you end up with a lot of air in your stomach it’s because I stuck the tracheal tube down your esophagus. And if you wake up and find my hand by your backside, its because the anal retractor is still stuck there too. And if your incision reopens because I jabbed you with a staple remover, don’t worry, I can staple you back together again.”
But all that aside, my dear readers, don’t worry. I still have many years of school ahead of me. Time enough to learn enough. After all, there’s only so much to know about rectums.

The ins and outs of surgery

Sometimes the designation of ins and outs can be arbitrary. We tend to think of a toilet or a garburator, for example, as being unidirectional. What goes in doesn't come out- at least not where we can see it. So it is with certain body parts. Yet, as I learned today, the line can definitely be blurred.
I just started a practicum with a gastrointestinal surgeon and found my first day in surgery with him today to literally be at the backside of medicine.
We started the day with seeing a few ward patients and then scrubbing in for the first surgical case- a lower bowel resection. The unfortunate gentleman had had his fill of diverticulosis (no pun intended, but diverticulosis involves inflammation of little pouches in the intestines that fill with fecal matter) and had elected to have part of his colon cut out.
Once he was thoroughly anesthetized he was positioned in a modified lithotomy position- which most mothers know all about- and most men can't even imagine- and most of his extraneous body hair removed by a scary looking resident with an even scarier pair of clippers. Of course removing hair during surgery makes sense, but I can just imagine the poor guy waking up and thinking, you shaved me where?
The second case was a colonoscopy- done under a sedative, not general anesthetic, so the poor lady was awake for the uncomfortable procedure. (A colonscopy involves inserting a camera up into the intestines and taking a video for diagnostic purposes.) I had just tried to convince my Dad the night before of the necessity of people over 50 getting regular colonoscopies, but after watching one today I decided to keep some of the finer details to myself and hope that he doesn't disinherit me after he has his first one.
The third case was a poor man with one of the biggest sets of hemorrhoids that I've ever seen- plus an anorectal fistula that had to be cut out. (Briefly, a fistula is an abnormal opening between two places, and in this case was a sinus that tracked from inside his rectum and opened up outside where it was not supposed to, and had frequently been infected.) Unfortunately he hadn't received proper bowel prep before the surgery- which nicely means that his bowels hadn't been evacuated first, so they evacuated during the surgery all over the doctor and the resident and the floor. Thankfully I was standing back far enough to escape judgment. The hemorrhoids were massive and there was copious amounts of blood and the smell of burning flesh when the cautery tool cut, and the infected fistula....
I've been suffering from a bad cold/cough but was feeling better today and decided to go to work anyway, but my nose was tickling and I could feel snot begin to drip down inside my surgical mask. There is nothing to be done about snot in surgery- but the feeling of snot dribbling down my face and not being able to wipe it was almost too much to handle. I just kept staring at that bloody, crappy mess of a surgery and tried to think beautiful thoughts.
The fourth case was another internal hemorrhoid repair, then the next two were both inguinal hernia repairs. During a break I went into the staff room and one of the anesthetists was sitting there with an open bag of plain bran flakes, eating them by the handful. I started to laugh cause I'd been thinking about bran cereal too.
“Hey, I work in gastrointestinal surgery.” He said pointedly. “I'm going to eat my fiber if it kills me. I never want to end up like one of those guys.”
The next case was an excision of a pilonidal cyst. Basically it involves an abscess formed by an ingrown hair of the anal cleft. I will leave you to imagine why the young man having the surgery was so embarrassed to see me appear in the operating room. Sometimes youth and beauty are distinct disadvantages to fostering patient trust and reassurance.
The last case of the day was long and drawn out- the woman had a ruptured appendix that needed to be removed. I was standing at the head of the bed talking to the anesthetist as he prepared to anesthetize the patient, and he was asking me questions and making fun of me. He had begun to run the general anesthetic via IV and asked me to come and hold the oxygen mask on the patient's face. Slowly she began to drift to sleep as she received nitric oxide and the anesthetic and when she went limp the anesthetist showed me how to keep her breathing by 'bagging' her (squeezing a balloon attached to the mask.) He had got out his utensils for intubation and explained to me that as long as I could bag her manually there was no hurry to intubate, one could take their time.
He held up the tongue blade and demonstrated to me how it clicked open.
“The most important thing to remember,” he said, “Is to go in gently. You can kill someone if you go in roughly. Or you can permanently damage their vocal cords, or perforate their esophagus. So gently is the way to go.”
And then he handed me the tongue blade.
I should add at this point that not only have I never intubated anyone in my life, but I have also never actually closely watched someone do it. And it is not an easy skill. Many medical students practice on cadavers first. I had no idea what to do with the tongue blade, nor with the airway tubing or all the other pieces.
“The thing you need to know,” the anesthetist said, “Is to go gently.”
The thing I need to know, I thought, is just how to do this in the first place. And he lifted the mask off her face and suddenly I had my golden 30 seconds to get that tube in. Well, I got the tongue blade in and tilted her head back and the anesthetist asked if I could see the vocal cords and I thought, is that what vocal cords look like? And I slid the tube down her throat and lodged it in her esophagus and then pulled it out again and the anesthetist helped me find the trachea and then I advanced the tube down into her lungs and removed the tongue blade and connected her to oxygen and her chest began to rise and fall.
“Be careful about pressing the blade against her lips.” He said to me. “Because if you cut them, there's a lawsuit. Now next time you do it, it will be a lot easier.”
I felt suddenly like I'd broken into a cold sweat of relief. Although it could have been the snot dribbling down my face, but at that point I didn't care. The ins and outs of surgery are not what I imagined them to be- sometimes grosser, sometimes scarier, usually exciting. And most importantly; they're educational- which explains why at this point I'm heading up the kitchen to drink some prune juice and have a bowl of bran flakes.

Faces and grace

Well, I'm back in Vancouver now and back to the cold and back to paperwork and the hospital and decisions and most wonderfully, my mom's cooking. Sometimes I forget how great it is to have someone make dinner for you.
Last night I was working at the hospital (nursing, not as a medical student- it's harder and harder to keep the roles separate), and because I knew that most of my patients had nothing better to do than lie in bed all day and stare at the wall, I decided to take my time looking after them. Of course there are important things that need to be done on time and there is lots of work and it's usually pretty crazy, but honestly, taking an extra minute to listen to someone's story instead of having that minute for my break is no great sacrifice.
I walked into Mr. K's room and the smell hit me like a wave. There were pictures in his chart of a sullen man with bandages covering half his face, and the description said 'inoperable cancerous facial tumor', but I wasn't prepared for the real thing. He had been refusing to have any medications or dressings put on the wound and I had gone to try to convince him of the necessity of both.
Half his face was eaten away by a fulminating mass of rotting flesh. His right eye had almost collapsed and his mouth drooped down on the right side and he could barely speak around it. The wound was oozing purulent yellow drainage and the smell was intense. Someone had placed a plastic sheet over his pillow and it was streaked in blood and pus. He looked like a figure out of a horror movie- the ones you say 'oh, they did a good job with that makeup!'. I was reminded of the phantom in phantom of the opera- only I was at the side of his bed, not on the other side of a tv screen.
“How are you, honey?” I put a hand on his leg and sat down on the edge of the bed. He looked at me with his hostile blue eye.
“What do you want?”
They had referred him to palliative care, partially because no one knew what to do with the wound encompassing half his face that was slowly eating his life away. He was skin and bones. Can you just cover it up? Maybe he wanted it open, to wallow in his suffering, to see the people around him flinch at the gruesome sight, to see if they could look past it and still see a man in need of love.
“I've brought you some pills.” I said to him. “And I wanted to ask you if it would be all right with you if i put a dressing on your face?”
“Leave it alone.” He glared at me. He reached for the pills and I held a cup to his lips for him to swallow.
I kept my hand on his leg and kept smiling at him, looking him in the eye.
“do you want me to open the curtains?” I asked him. “It's lovely outside today.”
“The light hurts my eye.” He said, struggling to form the words through his drooping mouth.
He glared at me. “I bet you wish you didn't have to work here.” He said.
“I love working here.” I told him gently. “I grew up with five brothers and I like the fact that it's almost all men here. Besides, most of the guys here are really sweet. Just about every day I get told I'm pretty.”
A hint of a smile tugged at the corner of his mouth and then disappeared again.
“It also reminds me of my grandfather.” I told him. “He passed away here. He served in the military and he would always tell me stories of his work as an aircraft mechanic. Towards the end of his life he'd tell me the same stories over and over again, but I didn't mind hearing them because they were good stories.”
“Was he a frame mechanic or an engine mechanic?” Mr. K asked grudgingly.
“I think he was a frame mechanic.” I said. “what about you? You sound familiar with it?”
He began to talk, slowly and haltingly, and as I nodded and asked questions he talked more. He told me how when he'd been brought to the hospital his daughter had taken all his things and thrown them out, burned them, including the one memento from the war that was most precious to him. It was a photograph of him in the trenches in France, that a young red cross man had taken of him after he'd been blown half-apart by shrapnel and his baby finger was hanging off by a piece of skin. He showed me where they'd reattached his finger and I felt the knobbly bone under his smooth skin.
He told the feeling of lying there waiting for a German sniper to run out of ammunition before it was safe to leave the trench and go after a fallen comrade. He told me of lying in a field hospital and then being transported by train to the main hospital and begging one of the nurses to loosen his bandages so that the jarring train wouldn't hurt so much. She had refused to take his bandages off and in the end he convinced the young red cross man to cut them off for him.
Now he was lying here as an old man, dying, refusing to be wrapped up in the bandages that for him represented a loss of control. He had already lost everything that meant anything to him. His anger and hostility were part of the dignity he was trying desperately to maintain.
When I got up to go he looked at me with that piercing blue eye. The smell of his wound was overpowering and I fought the urge to gag, and even more importantly, I fought to keep my visceral reaction off my face.
“If you need to come back to tell me anything,” he said haltingly, “I don't mind if you just tap me on the leg to wake me up. It doesn't have to be really important, but if you want to, you're welcome to.”
“Thank you.” I said to him, smiling. “Sleep tight, honey.”
There was a smile lit in his blue eye. “You're a lovely girl.” He said. “Thank you for talking to me.”
And I walked out and he was staring at the closed curtains and I looked at the clock and had missed my break but I didn't even care.

Letting go, letting God

Most people know me as a fairly resourceful and independent sort of person. I love adventure and I don’t think twice about jumping in with both feet into a new and exciting experience. In fact I see myself that way most of the time, so you can imagine how surprised I felt this week with what happened.
My first semester in Antigua I didn’t have a car and my adventures were confined to the very small university campus; the odd weekend trip out with all the other students and walks to the bat cave. The next two semesters I shared a car with my housemate and I sat in the passenger seat while we drove all over the island for all our adventures, and I let him do all the navigating. When we went out he paid for everything; when the car needed filling up or backing down the steep driveway, he did it. He did the barbequing and lit the pilot light on the stove and took out the garbage and dealt with the landlord and locked the house up when we went out and hooked up the internet and bought the groceries and in general just looked after me.
But then he left this week and I was here alone with Miriam for a few more days and suddenly it hit me. I had no idea how to light a barbeque. I struggled to make a pile out of briquettes and doused them with lighter fluid and blew on them for ages and finally gave up and fried the chicken.
I had no idea how much groceries cost. I bought way too little the first trip and way too much the second trip and now I have so much extra food I don’t know what to do with it.
I forgot to lock the house up and it rained while we were out and the beds got wet. I couldn’t get the car down the driveway and had to leave it on the street. I accidentally unplugged the internet and couldn’t get it to go back on. I forgot to take the garbage out and it’s still rotting in the carport. I decided to go to the beach and realized I didn’t know how to get there and Antiguan streets don’t have names; you just turn at the second donkey with a blue rope standing in front of a rock and then make a left at the tree that looks like a person and then a right at the yellow house with the fat lady on the porch.
I felt strangely lost and it was disconcerting to think that I’ve been here three semesters and I still feel like I’ve just arrived.
But there is nothing to be done, is there? I love having someone look after me. But when there is no one there I have to ask God for extra strength and somehow summon the creativity and the courage to be brave by myself. It’s not easy. I’ve finally come to the place in my life where I realize that I need looking after and I’m willing to let go of control to someone else; and suddenly I am thrust back into the cold reality of having to fend for myself again.
But it’s even deeper than that. How much do I trust God? I thought I had learned to trust God when I was all by myself on my adventures- and let’s face it, when you’re all by yourself in an African jungle or a French supermarket or an Antiguan bat cave, there’s nothing else to do but to throw yourself on God’s mercy and pray that he works things out. But then I had to learn to trust God by trusting another person. It’s one thing to trust God when you know that he’s always right and doesn’t make mistakes. But what about when the person you’re trusting in is just that, a person? Is my Dad capable of leading me the right way? Can I trust my professor to give me the grade I need to graduate from medical school? Can I relinquish control of all those little details to my housemate and not be afraid of what might happen? Can I sit in the passenger seat and not stomp on the imaginary brake every time we go around a corner?
The short answer is, yes. The big answer is, if God has ordained that situation or that relationship or that chain of command, then he is absolutely able to see that the outcome is exactly the way he wants it. I can demonstrate my trust in God by the trust I put in another person. And this is not foolish, blind trust: it is a conscious choice made with wisdom and courage, a choice to let go of control.
Having to do all these little things for myself again has been driving this lesson home. The big picture is that God is everything I need. The fine details of the picture are that God sometimes chooses to provide for us by allowing another person to fulfill our needs. But if we lose sight of the big picture we handicap ourselves and become unable to stand firm when we have to.
I’m pleased to tell you that I have been rising to the challenge- today Miriam and I drove to a hidden beach that is accessible only by a road that doesn’t look like a road- and I followed the vague directions of ‘follow the road to the end, turn left, go until the road ends and then turn down the road that doesn’t look like a road and just keep going until you can’t go any further’. And I fixed the internet connection and spoke with the landlord and backed the car down the driveway myself and figured out how to light the stove. And I made a wise decision not to swim in a rip current or jump off a cliff into the ocean, and I met an acquaintance and invited him to join us for dinner, and I talked intelligently at the American recession and the Canadian health care system.
I still may have no clue what to do with the barbeque, but I’m beginning to prefer the taste of fried chicken anyway.

An ending and a beginning

On Monday I finished my last exam and after saying goodbye to many of my classmates who were leaving, I sat in the car and stared at the road as we drove home. There was nothing to say; I was completely emotionally and physically and mentally exhausted. Suddenly all the momentum that I had been carried on; all the adrenaline and nerves and coffee and coke and motivation and prayer, all of it came crashing down and I was exhausted. I’m positive that if I’d heard at that moment that I actually had one more test to write, I probably couldn’t have done it. I felt completely empty.
In fact I was almost done in on Saturday night. We had a graduation ceremony for the students finishing their basic sciences and I danced my heart out for a couple of hours but then by 10:30 I stumbled to the car and fell asleep on the way home, barely managing to drag myself in to bed. It was too much.
But for some reason there is always a resurrection. Just when you think you can’t possibly go on, somehow God gives a little more strength.
On Monday after our last test we packed up our beach stuff and went to Pineapple beach for the afternoon; myself, Miriam, Burton, Jill, Vem and Dr. Gilbert.
The beach was hot and bare. We sunk our feet into the white sand and retreated under a sun umbrella and slathered on sunscreen. The water was clear as glass, even where it lapped at the shore, and we struggled into our snorkel equipment and paddled out towards a reef.
I’ve just been introduced to snorkeling this time in Antigua, at the pressure of my parents who told me if I tried it once I’d be hooked for life. They were right.
The coral reefs are like an underwater garden. It is as if a whole new world to explore has been opened up. There are long purple corals that extend like fingers reaching to the sun. Round brain corals, dark orange spiny sea urchins, waving green grass, giant pink conch shells, and fish! Millions and millions of fish. Schools of little silver ones, black ones with turquoise spots, large flat silver ones, tiny neon blue and yellow ones, long orange ones with bulging eyes and spiny tails, black and yellow clown fish......... Burton and Miriam and I swam through the reefs, the waves sloshing us against each other and the coral, and under our goofy looking masks we were all exhilarated. It felt as if we were the first people to step on the moon, or the first pioneer to stand at the rim of the Grand Canyon.

We took turns taking off our breathing apparatus and diving down off the edge of the reef, looking out into the mysterious unknown that as far as the eye could see was full of fish and plants and wonders. I felt like I was swimming through a national geographic magazine. There really are no words to describe it. We swam through schools of little fish that nipped at us and every now and again would see some amazing creature (like a turquoise and blue striped fish or a giant one that looked like he wanted to eat me) and we'd point it out wildly to whoever was closest to us.

We snorkeled for ages and then swam back through the long grass and the coral to shore, and lay on the beach, exhausted. I watched the fronds of a palm tree above me waving in the breeze and tasted salt in my mouth and the thick white sand all over my feet. Above me there was a tree with pale pink flowers that kept dropping from the branches. I watched them float down as if they were appearing out of the sky and drift gently down all around me.

"He leads me beside quiet waters; he makes me lie down in green pastures. He restores my soul."

Bright and morning star

These last days have been pretty rough. A few nights ago I stood on the beach in the dark, listening to the crashing waves, and talking to God. I remembered how he is called the lily of the valley and the rose of Sharon, the bright morning star.
The thing about the morning star, I thought as I looked at it glimmering against the blackness of the sky, is that it doesn’t show up in the sky until the very darkest part of the night. The same with the lily of the valley: it is a tiny fragrant flower that grows all by itself in a valley. The rose of Sharon is an exotic rose that grows like a splash of colour in a barren desert.
And so it is with the Lord. In the dark places of life he is like the morning star that appears in the pitch blackness, so small you hardly see it, and it says, morning is coming. There is hope.
Last night after classes I was exhausted, but I figure that if I’m going to be exhausted I might as well be really exhausted, so I joined a group of students who play soccer every Monday, Wednesday, Friday after classes. We play until it gets too dark to see the ball and then we lie of the field and talk and then stumble home to study.
The ball got stuck 25 feet down a culvert and I decided to go in after it. I had my entire body in before John, one of the other students, grabbed my ankles and dragged me out, yelling at me. John is Greek and his voice can be heard from about a mile away.
“We can get another ball,” he shouted, “But we can’t get another Heather!”
We found a football and started playing football instead. Being the smallest of all the other players, I definitely got more than my share of tackles. We ran and crashed into each other and fell and laughed and felt the stress of the month oozing out a bit. By the end of the game I staggered to the car, sweaty and exhausted. Burton and I stopped to pick up one of our professors and we drove home to cook dinner.
On the way we suddenly saw something in the road. We drove over it just as I realized that it was a giant crab.
“Stop!” I shouted.
We lurched to a halt and I leapt out and taking our laundry basket and emptying it on the back seat, I ran after the crab. I caught him in the basket and jumped back into the car. He was the largest crab I’ve ever seen; his pincer was at least 10 inches long. We carried him carefully into the house and took a couple of pictures, then I killed him with a butcher knife and stuck him into a pot to boil. I quickly whipped up some pizza and then jumped into the pool to cool off while it was cooking. My professor and I sat in the cool water looking up at the stars, sipping rum and coke. He had just heard some devastating news three days before and I asked him about it and there were tears in his eyes. We talked for a while, talked about God’s plans for our lives.
The pizza and the crab were done and we sat around the dinner table, me and Dr. G and Burton and Burton’s sister Jill. Burton and Jill weren’t crab fans so Dr. G and I sat there blissfully happy up to our elbows in hot crab and garlic butter and pizza and pickles and rum and coke.
Then we had chocolate and vanilla ice cream with melted nutella dribbled over it and fresh papaya from our neighbor’s garden.
I stayed up late doing laundry and dishes and then studying for hours and then collapsed into bed, listening to the howling wind and the distant crashing waves outside.
The football game and the fresh crab were like the morning star. The joy that comes in the garden of pain. The banquet table prepared in the presence of my enemies.
I don’t deserve it but I’m so grateful for God expressing his love for me in these little ways.

"I know that my Redeemer lives, and that in the end he will stand upon the earth. And after my skin has been destroyed, yet in my flesh I will see God; I myself will see him with my own eyes—I, and not another. How my heart yearns within me!" – Job 25

Lamentations 3

Yet this I call to mind
and therefore I have hope:

22 Because of the LORD's great love we are not consumed,
for his compassions never fail.

23 They are new every morning;
great is your faithfulness.

24 I say to myself, "The LORD is my portion;
therefore I will wait for him."

25 The LORD is good to those whose hope is in him,
to the one who seeks him;

26 it is good to wait quietly
for the salvation of the LORD.