Beauty

I've never really considered myself a super vain person- I don't take a long time in the bathroom in the morning, I don't pore over fashion magazines, I don't buy expensive clothes or wear a lot of makeup. Beauty is inside, I believe.
Yet today while spending some time in surgery I was confronted with a few very strong emotions that I had a hard time rationalizing to myself.
I entered the operating room with Dr. D and another medical student and the patient was already lying on the table asleep.
"She had a lump in her breast," Dr. D explained. "We're just taking it out for biopsy."
As I drew close to the patient I noticed how smooth her skin looked, how relaxed the lines of her face. I picked up her chart and the other medical student leaned over my shoulder and pointed at a number. She was only 18 years old.
I watched anxiously as the surgeon made the incision around the girl's nipple.
"Is it going to leave a scar?"
"Actually, she will hardly be able to notice it. It's amazing how normal it looks after it heals."
The biopsy went smoothly, except for the other medical student getting squirted in the eye with blood, and when they bandaged the patient up I tried not to imagine what she would be thinking when she looked in the mirror for the first time. Hopefully it wouldn't scar too much.
The next patient was an older woman who had had a mastectomy (breast removal) for a cancerous lump, and was in to have the other breast removed and reconstructive surgery. A team of 7 surgeons and nurses (plus myself and the other student) were around the table. I was intrigued to see the details of the operation. A blue radioactive dye was injected into the breast tissue, and after a few minutes, the surgeon passed a gamma ray detector over the breast and confirmed that the dye had moved into regional lymph nodes in the armpit. The surgeon cut through the skin of the breast, lifted it up and cut away all the tissue underneath and removed it en masse. Then a wide swath was cut across the lower abdomen (only leaving the belly button intact and dangling like a forgotten limb). The pocket where the breast had been was hollowed out and all the skin and fat lifted from the abdomen like opening a giant envelope. Then, still attached to it's arteries and veins, the graft from the lower abdomen was stuffed up into the breast pocket and stitched into place. The lower abdomen was pulled down in the fashion of a tummy tuck, with the belly button re-inserted and stitched into place. The involved lymph nodes were cut out and on the instrument tray the surgeon waved the detector over them and it beeped loudly. Then she waved it over the armpit and breast and it was silent. They'd got all the radioactive cancer out. Amazing.
But while the patient had the shape of normal breasts, they were covered in incisions.
"how will the scars look?" I asked.
"Not too bad. At least we were able to get all the breast tissue and involved lymph nodes out."
"What about her nipples?" I asked dubiously.
"Almost all my patients elect to have reconstructed nipples." the surgeon explained. "We tattoo them on and use a polymer implant for shape. They look not bad."
I'd seen patients who had had breast reconstruction or implants before. On the outside it looked all right, but underneath their chests were covered in ugly scars. I hugged myself and determined to look for lumps when I got home. I didn't want to end up on this table.
I felt desperately sorry for the poor woman. Perhaps she felt sorry for herself too. Or perhaps she was glad to be alive and rid of the cancer. I'm afraid of breast cancer. It's not like skin cancer on your shoulder that you can cut off, or colon cancer that you can get a part removed. Somehow it is very different and I think it strikes a chord very deep in the heart of many women. Even though we know it shouldn't be, a lot of our sense of personal worth comes from our physical beauty. For a woman to have a mastectomy and to lose her hair from chemotherapy is devastating in a way that pain and nausea isn't. It can crush her dignity and her sense of feminine beauty.
My brother's mother-in-law died last week from cancer. I saw her last in February standing outside in the snow, her eyes were bright blue like a summer sky and she was so very alive. It's hard to imagine that she is gone now. I think it takes a tremendous amount of courage to not only face one's own death, but also the gradual disappearance of one's beauty and dignity and feeling of worth. I know that Pat will be remembered not only as someone who was beautiful on the outside, but someone who on the inside possessed that inalienable beauty and strength that does not diminish.
As hard as we try, we can't keep what's on the outside looking good forever. We don't live forever. But the scripture says that as the outer person grows weaker, the inner person grows stronger and stronger and more beautiful as it conforms to the image of Christ. And that's beauty that does not fade with scars laced across the body; it only grows stronger and brighter in the twilight of a life that is slipping away.

Bad, bad nurse.

I'm writing this blog with the following three assumptions: a) no one who has anything to do with my nursing license reads it, b) no one who reads it would report me to the nursing licensing body, and c) if worst came to worst I'd still think I did the right thing.
My big confession is that I have transgressed my professional code of ethics as a nurse, not once, but many times. I thought about it tonight as I worked an evening shift and found myself consciously doing things that likely wouldn't pass the ethics radar. Ironically, I consider them to be the moral and loving action, even if they weren't 'ethical'.
In nursing school we were taught never to call our patients by pet names. It was unprofessional and disrespectful- they should always be addressed as Mr. or Ms. or by their first name. Good luck. What do you do if you have 30 patients and can't remember any of their names? You call them 'honey' and 'love' and 'dear' and 'sweetheart' and 'gorgeous', of course. Whatever works. Today I went into a smoking lounge looking for my patient Jack and when I handed him his pills he asked, “Are you sure you're looking for Jack?”
“Well, I don't know about Jack,” I said, “But on the chart it said to look for someone with a really big nose, so I figured it must be you.”
He laughed so hard he nearly spilled his drink. He really did have a huge nose.
And then there was a time I was helping an old confused man to bed, he was frail and dying and losing his mind and as I turned to leave his room he asked in a bewildered voice, “But aren't you going to kiss me goodnight?” I leaned over and kissed him gently on the forehead before I went out.
I know, shocking. But I'm darn sure that if I was hauled up for inappropriate conduct I would still feel the same way. That old man had no one. All of us humans, whether we like it or not, need physical touch to feel human. We need to be loved and cared for. We need to be appreciated and treated gently. And I don't know how long that old man had gone without receiving an affectionate touch from anyone. That moment stuck in my mind and now I always make a point of touching my patients. Appropriately, of course. A hand on their shoulder, a handshake, actually looking into their eyes and caring. I remember giving a young woman a hug once and she began to cry. She was 23 years old and she told me that her parents had never ever hugged her and she thanked me for touching her. Another girl once told me that she felt like a leper because no one touched her. Am I ugly and diseased, she asked? No, honey. The world is just selfish and paranoid.
And then this evening I asked one of my patients if there was anything I could pray for him for. I know, I know, proselytizing and forcing my religion on my patients is completely unethical and I could get the book thrown at me.
Yes, he said. I am constantly anxious and I feel like I have no peace in my heart.
I sat on the edge of his bed and prayed with him and he had tears in his eyes and when I left he thanked me over and over again.
Later in the evening instead of taking a break I sat and played a game of crib with two old patients who had nothing to do. One of them kept sneezing and drooling and every time it was his turn to shuffle the cards I envisioned the germs all over the deck of cards and I had to think brighter thoughts.
I know that sometimes I've been negative about nursing. In a sense I believe that God allowed me to be disillusioned with nursing so that I would go on and continue down the path he has for me as a doctor. But at the same time I am seeing more and more that whatever we do, whether it is nursing or medicine or teaching or homemaking or any other job, it's never just a job. It is a ministry. It is a calling. You can do what you love (like medicine, for me!) or you can learn to love what you do. I'm glad I'm not going to be a nurse forever, but in the meantime, I have learned to love what I do. I love special moments with my patients. I love being able to love them.

God loves you!

The other day I was looking through some old blog entries and I was surprised at how upbeat and optimistic they sounded, about the time when I first started medical school almost a year ago. There was no reason for them not to be.... but I noticed the tone beginning to change over the course of the year.
It's not like medical school is that difficult, I explained to someone yesterday. Actually I found calculus and chemistry a lot more challenging. It's all the other stuff that I didn't know I would be learning, that has kicked the stuffing out of me a bit and made my blog entries a little more real and a little more raw. Not all the stories responsible made it into my blog, I'm afraid. The things I didn't write about will probably stay that way, although I don't mind talking about them. But they are the things, unlike long hours in microbiology class, that actually make me into a better doctor. They are the things that have taught me what it means to be humble and to forgive and to demonstrate self-control and to not judge someone because I know I'd do the same things given the chance.
They are the things that have made me depend on God like I never have before. I think I would be completely disenchanted with medical school and with life in general and with my love life (or lack thereof!) if I wasn't so stupidly optimistic. Sigh. Some mornings I wake up with tears still sliding into my pillow, and other mornings I wake up and everything seems new and fresh.
I read an awesome quote the other day that resonated so deep in my soul and gave me hope.
“God loves you, and has a difficult plan for your life.”
A friend explained to me once that the Christian life is like a football game.... If you're running the right direction, expect to be tackled. Yes, you can learn to run faster. Or you can work out and build yourself up so that the next guy who hits you is the one that gets knocked down. Or, if you're 5'3” like me and don't have a lot of hope that you'll be able to knock someone else over, when you get knocked down, you can laugh....and then get back up.(Okay, I know that's not exactly the way football is played...)
God loves you, that's the truth. And he has a difficult plan for your life. Difficult, and wonderful.

A necessary pain

If you've had a chance to see it, you begin to realize how degrading surgery is for a person. I'm not trying to paint a bad picture of medicine here, or criticize doctors and nurses in any way, but after spending time watching people get various things cut out or off, I'm pretty sure that I'm going to eat my veggies, keep jogging and try to stay off that table as long as possible.
I visited one patient with Dr. T today before he went into the operating room for a hernia repair. An inguinal hernia (bulging out of intestinal or other contents between two layers of fascia (tissue) in the lower abdominal region) can be safely performed with local anesthetic and some sedation. It isn't a pleasant procedure, but there is no need to go through the risk of general anesthetic and intubation for a 15-minute uncomplicated surgery. However, this patient had asked to be knocked out completely for the procedure as he was quite nervous and had his reasons, I suppose.
Dr. T asked him to cough while he felt to see if the hernia would protrude. I always feel especially bad for my male patients in that sort of situation, but I try to remain professional, and remind myself that I am a doctor and I am here to help them and they really haven't got anything I haven't seen before. Well, usually. This unfortunate fellow happened to have cultivated an exceptional amount of hair from his beard down to his ankles.
Dr. T is a hands-on teacher and he gets me to palpate and assess funny lumps and bulges along with him, and poor Mr. G stared at the floor and I had the feeling he was willing me into nonexistence. After the pre-operative assessment, the next time I saw him, he was lying on the table in the operating room covered in a blanket while the anesthetist started the anesthetic. He began to drift slowly off to sleep and as soon as he was gone, the anesthetist tilted his head back and stuffed a plastic tube in and attached it to the pump and taped it in place. He put tape over the man's eyes to keep them from opening and one of the nurses removed his carefully arranged blankets. We prodded and pushed him into a convenient position for the surgery and then Dr. T took out a razor and began to shave him for the incision. As I cleaned up the fallen hair with a sticky glove I thought, I wonder if he knew he was getting an asymmetrical shave of the nether regions today. The circulating nurse began to swab him down with antiseptic and then he was draped with sterile drapes.
When everything was ready Dr. T made the first cut. I'm always amazed at how roughly it seems the tissue is handled. Sometimes the surgeon's whole hand (or both) will be inside, prodding and pulling, and then there are the retractors that seem to dig into the flesh and pull it open wider than it looks it can go. The electric cautery burns through the flesh and blood vessels are tied and snipped and the herniated sac was removed and plastic mesh put in place to prevent recurrence and he was stitched up again, after jamming a needle full of local anesthetic into the raw tissue. A quick swab and a bandage over top and the drapes are pulled off and the poor naked man is lying there and then covered up and eventually the tube is taken out and he wakes up and wonders why he looks the same as he did before but everything seems to ache.
Let me tell you, if you ever watched hemorrhoid or hernia surgery you'd drink prune juice three times a day.
Is all that pain and trauma necessary? The irony is that it will heal him. In order to heal him, good Dr. T has to injure him first.
The spiritual parallels are not lost on me. A couple of days ago I was feeling particularly low and I happened upon a verse in Lamentations. The writer is lamenting about all the hard things that have happened to him. In the past I always missed the most important word of the chapter: He. He, meaning God.
“He has driven me away and made me walk in darkness rather than light....He has surrounded me with bitterness and darkness....He has barred my way with blocks of stone....He pierced my heart with arrows from his quiver.”
Sounds like a cruel God, doesn't he? Why would God be responsible for causing pain? Is it payment for sin? But no, that is not the case. Farther in the chapter the author concludes, “His compassions never fail... they are new every morning; great is your faithfulness....It is good to wait quietly for the salvation of the Lord...let (him) sit alone in silence, for the Lord has laid it on him.” (Lamentations 3)
I pondered over the strange dichotomy in those verses. If the Lord is so compassionate and faithful, why does he purposefully cause pain and suffering? Why does he purposely shut out our prayers? Why does he purposely hurt me?
I know that sometimes the answer is that I have sinned and these are the natural consequences. And I know that in the bigger picture, I also partake of the consequences of the sin of all humanity. Yet I am coming to believe that God purposely causes suffering (at least in my life!) not because of my specific sin but because he loves me and is wanting to train me.
In surgery, when the patient is not incapacitated enough, and suddenly starts to move during surgery, the results can be disastrous. A quick slip of the knife and there goes a major artery. So the anesthetist straps them down, doses them up with sedatives, keeps them still. It is only in that perfect stillness that the doctor's perfect work can be done.
I think God is asking that of me too. To sit quietly, to wait patiently, to accept that pain is coming directly out of his loving, gentle hand. It is painful, it is degrading and humiliating sometimes, it is terrible, I can't see the end, but I know by faith that the Lord is good and he is faithful and he is loving.

“I say to myself, the Lord is my portion. Therefore I will wait for him.”

And unlike surgery assisted by an eager medical student, there is no danger of God screwing up.

The path to freedom

My sister tells me that my next blog entry should be about dimethyl ether. She's had a longstanding feud with a wart on her arm and begged me to help her freeze it off with some crazy looking contraption made by Dr. Scholl. The thick instruction book that came with the kit had 16 pages in English and French and on the second page, half-way down, it cautioned “do not use if you cannot see clearly to read the information in the information booklet.” We wondered how one would know not to use the wart remover if you couldn't read the line about not being able to read it. The booklet was even more helpful than that; on page six it cautioned that while using, one might smell some dimethyl ether. I suppose one would know right away what dimethyl ether smelled like based on its distinctly dimethyl ether-ish odor. At any rate, page 4 warned against inhaling any of the fumes, so I guess if you smelled what might be dimethyl ether, you would know that you'd inhaled what you weren't supposed to inhale.
All joking aside, I'm surprised how much bewildering medical information is circulating around and how many bewildered people read it. (And in case you think I'm being a know-it-all, I'm including myself in that category). For example, I had a prolonged discussion with my brother today about the necessity of childhood vaccinations. The problem is, with conflicting information available at everyone's fingertips, its hard to make a wise decision.
Today I was working with an obstetrician. We spend the morning doing ultrasounds on very excited and nervous mothers and I learned how to spot the four chambers of the heart and the aortic arch and to know if the brain is forming properly based on a few squiggly lines on the screen, and whether or not the baby is a boy or girl.
In the afternoon I sat with Dr. F while he saw a few patients in his office. One lady came in, an attractive young woman with a stack of charts about 8 inches deep and an angry look on her face like she wanted to kick in a door. I had received a brief history beforehand: she had delivered a premature baby that had lived a month in neonatal intensive care but battled for her life before finally dying. Babies born at 25 weeks have a 50% chance of survival but this poor thing never even got off to a good start. The mother was stuck in her grieving process: she had decided the medical team were at fault and she had highlighted pages of nursing notes to ask questions of the doctor and demand answers before potentially taking the health care team to court.
Dr. F is gentle and kind; he had explained to me that he himself had lost a child, so his introduction was compassionate and he began to try to elucidate the whole story out of the mother.
She had been in an abusive relationship and at some point social services stepped in and removed her three other children from her care. She unexpectedly found herself pregnant; she had been smoking, drinking occasionally, the labor seemed to be going fine, and she went into early labor. After a few more questions it turned out the drinking wasn't just occasional.... and the smoking was quite heavy....I sensed that she wasn't telling the whole story. She began to cry, tears streaming down her face. She had split up with the guy. She had the kids back but she couldn't work and she hadn't been able to let go of her little girl. When did you notice the baby's condition declining, Dr. F asked?
A week before the baby died she had been started on a new drug called Pavulon, which is used for neonates that require ventilation. Basically, when the baby's lungs are not developed enough to fulfill their body's oxygen needs, the ventilator takes over and forces enough air into the lungs. The instinctive response in even a premature baby is to fight to breathe on their own. However, without the ability to get enough oxygen on their own it becomes necessary to stop their own efforts in order to let the ventilator do the job. Pavulon paralyzes all the muscles of the body, starting with the eyelids and moving to the diaphragm.
This mother described watching her baby lie there and being unable to even blink, as her life slipped away. She felt it was so wrong what had been done.
The path you are going down is not helpful, Dr. F explained gently. In Canada we have a legal system, not a justice system, and even if a lawyer agreed to take on your case, it would never bring your baby back and compensate you for your suffering. There is no indication of gross negligence on the part of the health care workers; she simply was not ready to be born.
I could see what the problem was; it become clear when Dr. F asked her about her current alcohol use. She was struggling with guilt, and feeling like she might have caused the early birth and ultimate death of her daughter. There was no question that her actions may have compounded events, but she was unable to forgive herself and so was unable to move on in life.
I watched her go and desperately wanted to throw my arms around her and give her a hug. But I am a medical student and at that moment it was not my right to step in. When she had gone Dr. F turned to me and asked, “what would you have said to her differently?”
I explained to him that while antidepressants and a support group are part of the answer, health also encompasses a spiritual aspect. This woman could never forgive the medical team because she had never experienced forgiveness herself.
God's forgiveness is so freeing. It frees us to forgive those around us. Yes, there is a balance. Often I err on the side of making excuses for people and I allow myself to be used and hurt. But I don't want to miss the opportunity to be free by not forgiving. It is a daily thing. I need to forgive my Dad for stealing my snacks while watching tv. I need to forgive my sister for interrupting my blogging with stupid instruction booklets and dimethyl ether fumes. I need to forgive the people who have put me down, who have rejected me, who have hurt me, who have broken my heart. And the only reason I can do that is because I have experienced God's forgiveness.

“Bear with each other and forgive whatever grievances you may have against one another. Forgive as the Lord forgave you.” - Colossians 3:13