Amputations

I never thought much about amputations. They are common surgeries, most often related to uncontrolled diabetes, and seemed routine and unremarkable to me.

I've had the experience of witnessing several amputations while in my surgical service, all diabetes-related. Each time it surprises me with the sense of loss that comes with the amputation of a toe, a foot, a leg. I had never really considered the emotional impact of losing a limb. To be honest, I sort of thought that amputation resulted from a lack of self-control; the inability of the patient to monitor their glucose levels and make changes. Not to say that anyone deserves this sort of pain, but it seemed like a correlation between sugar and limb loss equaled a well-documented and preventable consequence. And then I had a black foot staring at me from a sterile blue-shrouded operating table.

I looked at it, and it looked at me, and I thought about all the things it had done for that person over the course of their life, how it was part of the patient. Bodies last longer than people, and it's natural to think that the body remains intact throughout ones' life. The operation to remove it reflects the difficulty, the tense dichotomy of this separation. It is a very physical removal- powered bone saws, strong manual bone cutters, and large scissors coarsely separate the limb from the proximal tissues. Nothing is pretty, edges are not delicately sewn. The necrotic tissue is essentially ripped from the living person.

And then you are left with a toe sitting on the OR table; a foot without an owner. You look at it and think "that was just attached a moment ago. Now it's just sitting there." You think about the extension of the person that it was- a baby's tiny toe, taking a first step, running, stubbed, swimming, carefully painted- and the gaping hole that is left from the amputation reflects the loss of something that helped shape a life. It always seems wrong to me to bandage up the stump without the limb, like the surgeon forgot something.

Even as these surgeries seem in contradiction with life, they are performed so people may live. A missing foot is a small price to pay for the excision of gangrene. There is a picture of me (on my second birthday) and my grandfather, who looks absolutely enamored with his granddaughter. He died a few months after this picture was taken. After hearing about my emotional reaction to the excision of a limb, my dad sent this picture to me. He gently reminded me that this precious moment with his granddaughter would not have been possible if he hadn't had the operations to remove a diabetic gangrenous foot and leg.

This is the glory and curse of the surgeon: you either cure or kill. The operating room is the fastest place in the hospital to make a difference in the long term prognosis of a patient. It's not for me- I like ongoing relationships with (awake) patients- but I can appreciate the meaningful work of the surgeon.

Grandpa Irv and a (very) Little Doc, May 15, 1986

Slice n' Dice

I am lame.

On the first surgery of my first day in the OR, I got faint and had to sit down. I am so embarrassed even to write that here. And it was on a simple tumor excision- no big deal! This wooziness from a girl that was a phlebotomist in college, thinks emergencies are interesting, had a relationship with a cadaver (named Phyllis!), and enjoys nothing more than the gory display of childbirth. Granted, I had just recovered from a pneumonia, and have a propensity towards hypoglycemia if I don't eat every two hours, but I don't think that was it. I think it triggers something in me when I see a sign of life in the patient on the table. When they become a person, and not a body, it freaks me out.

Normally I am okay with surgery. I stand there, assist, do what I need to do, and have lunch afterwards. In fact, I'm usually hungry in the operating room. As far as I can tell, the only times I have gotten woozy is when I connect the parts to a whole. I was fine with c-sections, except one time when the patient began complaining of pain. The thought that she could feel the pain of my knife instantly made me anxious and dizzy. A hysterectomy is a removal of a part, akin to replacing the air filter in a car. That's the level of attachment that I have towards the body. But one time, I was assisting on an open hysterectomy and saw the iliac artery, pulsing just beneath my tools, and right away I was nauseated. Of course I know that the person on the table is alive, and this is normal anatomy. However, I think that a sign of life- pain, a pulsating artery, the woman today who was talking to me about western movies- these force the connection for me between patient and body, person and pain.

Surgery is a different mindset than medicine. As my attending said today: "In medicine, you help people live with their disease. In surgery, you either cure or kill." The more I thought about it, the more I thought he was right. There is something to be said for being a mechanic, for leaving everything you got on the table, and walking away. It's not for me though. Those signs of life that make me dizzy- I think that happens because I love patients, because I connect and empathize with them. I don't think I'd ever feel fulfilled having a practice where the patients were primarily unconscious. Plus, its hard on you physically- to stand that long, under those bright lights, with your bladder exploding and stomach grumbling. I'm kind of dreading the next month. And I'm hoping that I can breathe my way through those moments where I catch a glimpse of human pain, and maybe even learn something about being a good surgeon.

California Dreamin'

I had a young patient in the hospital last week that I went to round on, and met her mother. She was a young Hispanic woman, anxious and obviously trying to do the best she could for her daughter. She said that she had recently moved here, and I asked where from? She said Arizona. Making conversation while I examined her baby, I said my school was out by Phoenix, and what brought her to Visalia? She said "I can get much more assistance programs for my kids here- it doesn't make sense for me to live anywhere else. My whole family moved here because in California, we can get so much free stuff."

Her honesty took me aback. I've said before that I can't judge anything as right or wrong, black or white. To an honest and educated person, things are always shades of gray. I cannot- and will not- comment on what my thoughts were at that moment, because what I truly think is that things are much more complex than they may seem. And my opinion is not really relevant anyway. This was just a conversation that surprised me, and demanded some thought. And I wanted to record it here because I thought it might provoke some thought in others.

Soldiers: The Silent Underserved

I loved my elective rotation in a family practice in Orange County. The office was decorated nicely, the exam rooms had winged armchairs instead of standard-issue medical office chairs, the office staff was a close-knit group, and the temp was a cool 67 degrees. It was exactly the kind of practice I'd like to have in the future. I saw many patients there, ranging from newborn to elderly, and enjoyed the various presentations of illness unique to a diverse family practice. One patient in particular was memorable, a young man serving in the Army.

The first thing I noticed about this guy was that he called me "Ma'am." It almost made me giggle- he was about my same age, maybe a few years younger, and I wasn't even the real doctor. He was clean-cut, polite, and respectful, wearing a t-shirt that I recognized as military fabric, similar to the ones my husband wears that are leftover from his years in the Air Force. I asked him what brought him in, and he held up his pointer finger, which was an ominous black color with red marks streaking up his forearm. He said a black widow had bitten it five days prior, and he had tried to lance the bite to relieve some of the pus, but it was getting worse. I asked him what he used to try to drain the area, and he replied "a steak knife, ma'am." Ouch.

I called in the doctor I was working for (clearly this was over my head), and she told me she had never seen a black widow bite before. Unfortunately (or fortunately?) I had already seen many, because in the community I serve, grape-pickers come in after a full-day's work with several bites on their fingers and back from the spiders falling down their shirts from the tall grape arbors. I had seen this because I work with underserved pickers. I never expected this active-duty military member to be more medically underserved than the illegal farmworkers.

The best idea was to refer him urgently over to the orthopedic clinic, given the likely systemic manifestations of the bite and the underperfused finger, but he couldn't go over there due to insurance limits. (When telling this story to my husband, he stopped me here and said, "TriCare" and rolled his eyes). Apparently the military insurance, TriCare, denies unapproved specialist/emergency visits, unless there is an "impending loss of limb, sight, or life." This was getting close enough to loss of limb that the doctor was uncomfortable, but couldn't get the visit approved. He had only come to the office today under direct order from his sergeant.

We gave him antibiotics, and she let me drain the pus using a scalpel (not a steak knife). He was a tough guy, but I knew it was hurting him. He left with strict instructions to come back in the morning to have it looked at again (Yes, Ma'am).

I was appalled. Here was this young man, putting his life on the line, and he was in danger of sepsis and loss of a finger because of insurance regulations? He should have absolutely the best insurance available, able to show his military ID card at any medical facility and receive care, no questions asked. Antivenom should have been given on day one, not palliative care on day six. This doesn't seem to be a topic civilians know much about, but I believe that if a feature article was run about it in a prominent newspaper, taxpayers would demand better medical care of our military personnel. I think this system compromises the medical well-being of the thousands of people that are responsible for protecting our country's safety. My own husband cites it as the main reason that he chose to leave the Air Force and reenter society as a civilian.

I don't know what happened to this guy. I wasn't in the office the following day (another doctor was on call), but I still wonder about him, and hope that everything healed well with no loss of function. Especially since the affected finger was his trigger finger- important for an Army man. I hope everything is okay, but I'm doubtful. If it did heal, it's because of his staff sergeant's orders and his own immune system, not because of care provided by the military. And that's a shame.

Babyfinder.com

I adopted all my animals. Either they were from the pound, browsed for on petfinder.com, or someone didn't want them anymore. In any event, they joined the family. While I know babies are a lot different than dogs or cats, this was my only personal exposure to adoption.

A few weeks ago, while attending to the NICU babies, I noticed one that didn't seems sick and wasn't getting visitors. She was labeled a "boarder baby" on my rounds report. I asked the attending what that meant. He said "it means that she was born and her mom gave her up for adoption. She's just staying here until we can find a home for her." He turned away, and then turned back suddenly. "Hey, do you want her? She's really cute. She has a little heart murmur, but that will probably close within the first year."

I was surprised. I thought that finding a baby to adopt was a huge, prolonged process, and maybe it is. But they were looking for a home for this little one right away. What struck me as funny was the way the baby was presented. All of the animals I adopted had a similar advertisement. The only thing missing for the baby was the "free to a good home" sign, a cardboard box replacing the isolette, and maybe a listing on a website like babyfinder.com.

I told the doctor I wasn't really looking for a baby right now, but I hoped she finds a good home. The doctor looked disappointed and said he understood. And then he turned to one of the nurses and said, "Hey. Do you know if Susie's still looking to adopt? We've got a cute one here." She must have been adopted, heart murmur and all, because when I came back a few days later, she was gone.

Then I started working in pediatric gastroenterology, and saw the most medically fragile kids I've ever seen. I loved it- the challenge of keeping these kids thriving, comfortable, and developing as normally as possible. I loved the challenge of talking with the parents about every aspect of their complicated kid's medical health, and enjoyed the rapport that was built between the patient, parent, and physician of this pediatric subspecialty. I marveled at these young parents' ability to care for their kid and be so knowledgeable about the multiple medical problems they had. They knew much more about their child's care than I did as the medical student. Premature crack babies with a short gut due to resection of necrotizing enterocolitis, feeding tubes, Down syndrome, epidermolysis bullosae (where the kid was wrapped in head-to-toe sterile gauze because of the deep blistering), kids in strollers with oxygen and parenteral nutrition on board, little girls with Crohn's disease, rare metabolic defects, and everything else- these kids needed care. I would sit there and observe, wondering, how do these moms do it? They are happy, invested and knowledgeable about their complicated child's care. Every minute of their lives is consumed with this kid, and they accept it as a part of a full life.

What ultimately came to amaze me was that the most complex kids invariably came with an adoptive parent. The crack kid? The nice lady in front of me wasn't the one who had smoked crack while pregnant. She was the one that accepted the kid after the prenatal damage was done. The kid with cystic fibrosis? She sat breathing noisily on her adopted mom's lap as her adopted grandma fussed over her. It was absolutely amazing- the unquestioned commitment that these parents had to their kids, kids that sometimes had preventable problems due to another adult's irresponsibility.

I think when most people look for a pet, they want to adopt a young, healthy animal. But these moms had committed to kids with disabilities, with lifelong special needs. How much of a commitment is a dog, really? Fifteen years? Compared to a lifetime commitment for a child. It was one of the best lessons that I got out of the rotation. And I hope that the little boarder baby, wherever she is, was adopted by a mom such as this.