A medical student, a patient, a surgery. A long night.
I checked my watch—5:33 PM. Class ran thirty minutes over, and I was already late for call. I rushed up to the residents’ quarters where I found the surgical intern I would be working with for the night. He didn’t seem to notice that I was late, or perhaps more accurately, he didn’t care. “Go get changed into scrubs,” he told me, “and go ahead and scrub in. We’ll probably have a case soon.”
I had been at the hospital since 6 AM that morning and hadn’t eaten since a very early breakfast. I had hoped class would end on time and that I would be able to grab some food before reporting for call, but, as it often is in medicine, things rarely go as planned.
In the locker room, I changed into scrubs and folded my slacks, shirt, and tie neatly before violently smashing them into the petite locker assigned to medical students. I tucked my shirt into the oversized scrub pants to help keep them from falling down, an undesirable faux pas, especially in the operating room. I slipped shoe covers over my tennis shoes, placed a hair net over my hair, and tied a surgical mask around my head in a fashion that would easily allow me to shift the mask on and off quickly if needed. I headed to scrub.
I checked my watch again—5:48 PM. I was making good time, and the resident hadn’t texted me yet, nor had the student pager gone off. I knew I would have time to eat if the hospital cafeteria wasn’t as busy as it was for lunch, and, luckily, it was practically empty. I ordered a cheeseburger and fries, because I had been working hard on my surgery rotation and deserved it—or so I thought to myself. Maybe it was because of how hungry I was, but it was the best burger I had eaten in a while.
In a stroke of luck, I still hadn’t been texted or paged about an incoming trauma or emergency surgery. I went up to the student call room and started reviewing my surgical textbook. I made it a few pages in before hearing my phone ding as a text came in that read, “To OR now.” His text was almost laughably typical of surgical residents: blunt and efficient. Back down to the surgical suite I went.
I had been on my surgery rotation for a week and was in and out of this area of the hospital constantly. But I hadn’t been there at night until now, and this was the most silent I had seen it. I checked what was still called “The Board,” but, in reality, was a large, flat screen computer hanging on the wall with the surgeries listed. Tonight, there was only one: “7:30 PM. Exploratory Laparotomy. Possible bowel …” My watch read 7:10 PM, so I had time to look up the procedure on my phone before the resident showed up. Bowel what, though? Obstruction? Perforation? Herniation? I wouldn’t know until the surgery, so I did my best to study what I could.
7:35 PM. The nurse anesthetist and the surgical nurse came wheeling the patient down the hall in her hospital bed. My teachers had been emphasizing the physical exam since day one of medical school, and this year I had finally began to feel comfortable with it. Through my other rotations in pediatrics, internal medicine, and psychiatry, I learned that a simple visual observation was a vital part of the exam. From twenty feet down the hall, I already knew she was sick. I saw an intubation tube protruding from her mouth, and being wheeled beside her bed were several bags of intravenous fluids and medicines as well as a bag to collect her urine from her Foley catheter.
I opened the operating room doors for them as they wheeled her into the room, and I helped them position her bed by the operating table. I went to the head of her bed and introduced myself as the medical student who would be in the room during her surgery. She calmly closed her eyes and nodded in understanding. I wrote my name on the board, grabbed two size seven surgical gloves and a gown, and unwrapped them for the surgical tech. I went through the opposite door that I had entered and grabbed some warm blankets from the warmer. When I reentered the room, the staff was removing her original blankets. Her bed sheets and the moisture absorber beneath her were spotted with blood. I noticed the color of her urine in the bag was dark as night. She was labored in her breathing, her neck muscles contracting violently, and the skin over her clavicles sinking in with each breath, despite the tube in her throat meant to help her breathe. I knew before that she was unwell, but her sickness was misery when seen up close.
Two notions hit me. The first was the question of who she was besides a patient. The way she nodded at me only a minute earlier made me think she must have been a kind person, but what else was she? She looked to be in her sixties. Was she a mother? A grandmother? Was she married? Was she a widow? Did she have family waiting for her after surgery? If she did, were they there out of obligation or out of true concern? The second was the curiosity of a future physician. Was her urine dark because of elevated bilirubin? I would expect her eyes and skin to be jaundiced if that were they case, and they were not. What landed her in the hospital? Was this surgery an inevitable result of a chronic process? Or was it acute and unexpected? I wished I had had time to look her up beforehand.
Her bloodstained sheets and blankets were no longer on her bed, and I snapped out of my wondering to place the new, warm blankets over her. I helped move her IV pole closer to the operating table, and I unhooked her catheter bag from her hospital bed and attached it instead to the table, to which it was time to move her to. I positioned myself at the foot of the bed, grabbed her ankles and, along with a nurse at her torso and one at her head, helped to lift her off the bed and onto the table.
The anesthesiologist—now in the room—then told her that she would begin to start feeling sleepy, and, again, she nodded calmly in response. He then administered the anesthetic through her intubation tube to her lungs and, subsequently, her bloodstream and nervous system. Her eyes closed and her breathing became more peaceful within seconds; she was asleep. The surgical technician finished spreading out the surgical equipment, and I helped the other nurses strap the patient onto the bed. Finally, the attending surgeon and resident entered the room.
The surgeon asked me my name with his back turned to me as he perused the operating room and inspected the patient. After I answered the attending, the resident told me to go get scrubbed. I used the Avaguard—the surgical antiseptic equivalent to hand sanitizer. The surgical technician was waiting for me in the room with the sterile gown extended before me, the inside of the sleeves facing me. I slipped my arms in and held my elbows bent and fingers and hands pointing up towards the ceiling. The technician shimmied the sleeve down to about the level of my thumb’s base. He then grabbed a glove and stretched its opening facing upward so I could plunge my hand straight down into it. Embarrassingly, only two of my digits entered the appropriate fingers of the glove, the rest stretching the glove in all directions, but I wouldn’t be able to fix it until I had the sterile glove on my opposite hand. The left hand went more smoothly—only one finger was misaligned. I fixed my gloves quickly before adding on a second pair through the same process. I patted down my gloves to fit snuggly, and, as I interlocked my fingers, I could feel some leftover antiseptic pooling in the webbed space at the base of my fingers.
I stepped up to the table on the patient’s left. The surgeon came in with elbows bent and hands at eye level, droplets of water sliding down his forearm and falling from his elbow. He went through the same gown and glove process with considerably more grace than I had. He turned to me and made eye contact for the first time, “I’ll have you move to the other side of the table.” I obliged and found myself on the opposite side of the patient, facing the surgeon. The resident—finished with his gown and glove—came to my side of the table. “Scoot over,” he told me. Again, I followed orders, annoyed with myself that I was foolish enough to get in the way twice before even the first cut.
They draped her with sterile covers, leaving only her abdomen visible with its Betadine-induced yellow hue. Straight down her belly the resident cut, making a c-shaped detour around her umbilicus before proceeding vertically down again to just above her pelvis. Before I knew it, we were gazing at her peritoneum, omentum, mesentery, and bowel—the anatomy of the abdomen I briefly reviewed prior to the surgery, but this time in real life. In they went, searching for the pathology that had landed her here in the operating room. The liver and gallbladder were “clean,” as the two surgeons put it, and the stomach and duodenum were healthy with no signs of a perforated ulcer.
They would have to delve deeper by “running the bowel.” They grasped the snakelike small intestines with their hands, pulling it up and out from the depths of her abdominal cavity and into the light. They remarked that the mesentery was thick and hard to cut through, even with some of their more sophisticated equipment. The resident’s hand shook as he pressed ever harder trying to cut it; the attending adding, “It’s fibrosed. Likely from her radiation treatment.” Another clue into the patient on the table. Though, somewhere in the prepping process she had morphed into an open abdominal cavity with exposed viscera. She hardly seemed like the same woman who nodded at me prior to surgery. She hardly seemed like a person at all.
As they continued down her bowel, it became apparent—even to my novice eyes—that her small bowel was anything but healthy. It was brown-black and necrotic appearing; a stark difference from her healthy bowel. This necrosis continued throughout the rest of her small bowel and colon in a spotty pattern. Even after going through her entire gastrointestinal tract and seeing her rotting bowel, the surgeons still weren’t satisfied. They had not found what they were looking for, so they started over again. On the second attempt, they found a small black spot on the ileum. To me it looked like a tiny ink spot, but, to them, it was the answer to the exploratory laparotomy: the perforation.
After some discourse between the two surgeons, they decided to take out the perforated portion of her bowel, which was also the most severely necrotic. It was agreed that the best option was to leave her open, see how she progressed, and—if she improved—return in two days to place an ileostomy. They didn’t seem confident she would make it to another surgery. It was decided to leave her incision site open, and, by the end of the procedure, she had a diamond shaped sponge occupying the opening in her belly, which was connected to a tube. The resident explained, “It’s basically our wound vac.”
After the surgery, I let my mask hang just below my chin, and I helped wheel her to the ICU. A team of nurses came in the room to help, and they talked about her like they knew her well. I overheard that she had been in the ICU for a week—another hint at her course.
When I was no longer needed, I stepped out of the room and pulled my watch from my back pocket where I had tucked it just prior to scrubbing—10:44 PM. I hadn’t realized it until just now, but I was exhausted. I made my way back to the student call room, got in the bed, and turned out the light. The pager went off just before I could fall asleep. “Trauma. ED Bed 2. Three minutes out.” I rushed down to the Emergency Department where I met my resident who was already interviewing the patient. She had fallen off a ladder and broken a vertebra but had no other concerning findings. We finished the exam, discussed the patient with the attending, admitted her to another service, and wrote the note.
The rest of the night and early morning went this way—closing my eyes for a few minutes, waking up to a page, and rushing to the Emergency Department to find a patient with a mild trauma, needing no immediate intervention. There were plenty of patients, but no surgeries and certainly no sleep.
At 5:00 AM I went back to check on the patient I saw in surgery. A man was sitting in a chair in the corner of her room. He looked as tired as I felt, and I imagined he probably got about as much sleep as I had. I introduced myself to him and discovered he was her son. Another answer to my earlier question: she had a family, and they—or at least her son—loved her enough to spend a sleepless night, probably many, by her hospital bed. I asked him how she did after the procedure. He said her pain had been well controlled, but the doctors told him she was getting worse. I went over to her bed, and I found the woman I had met eight hours earlier. She was sleeping calmly and looked peaceful. Again, she struck me as a kind person; I don’t know why. “I won’t examine her. I don’t want to disturb her.” He thanked me. I left the room.
6:35 AM. Morning rounds were almost over, but we had one more patient to see. It would be a family meeting with the woman from surgery. The ICU nurse and two white-coat-clad clinicians—one the surgeon from the night before—sat at a round table with four people in civilian clothes, one of which was the son I met earlier. I discovered during the meeting that the other three people were her daughter, another son, and her brother. Comfort care, intubation tube removal, and time until death were all discussed. When it was time for the surgeon’s input, he relayed to the family members that we had discovered extensive damage from her radiation and that there was little we could do from a surgical standpoint. “I’m glad we gave her a chance by trying,” was the surgeon’s condolence, and the family agreed. The other son looked at his family members and said, “That cancer treatment gave Mom fourteen years. She got to see her grandchildren grow up because of it. She is happy.” His family looked up to meet his eyes solemnly and their collective look said silently that they agreed. The meeting ended shortly after that, but I don’t remember how it ended. I couldn’t stop thinking about what her son had said. “She is happy.”
I never got a chance to look into her full history, and I never had enough time to sit down with any of her family members and ask them about her in detail. But, piece-by-piece, I was able to form a picture of her along the way—an image of who she was as both patient and person. The ending to her hospital course was that she was cared for by a group of doctors and nurses who tried their hardest to save her, and this medical student was humbled and honored to have been included in her care. However, after hearing her son’s remarks, I realized that the real end to her story belonged to her and her family members.
The trauma team and I left the meeting room, and I went home to catch some much-needed sleep after twenty-four hours spent in the hospital. Her family returned to her bedside where she would later die with an open hole in her belly, the last sign of a failed effort to save her life.
I unlocked my apartment door, opened it, and let my backpack drop to the middle of the floor with a thud. I went straight to my room and collapsed on the bed. I picked up my phone to set an alarm, and the time read 7:33 AM. Staring at the ceiling, I wondered what was happening with my patient. Maybe they just extubated her, I thought to myself. Maybe she died in the half-hour since the meeting. My heavy eyes collapsed shut, and sleep forced itself upon me.