Obliterants: Fall 2011

U n i ve r s i t y o f M i am i M i l l er Sc h o ol o f M e d i c i n e

Obliterants Introduction by Gauri Agarwal. M.D.

Issue 2

2011

I recently strolled through the Boca Raton Art Museum with my children, looking at animals and trees that had been carved out of wine corks, pencils, and rubber shoes by Federico Uribe. We spoke at length about what had compelled him to create such pieces. In essence, he had taken objects from the detritus of our daily lives and created vivid, vibrant, celebratory sculptures that begged to be looked at. As I sat recently with third year medical students at the hospital during a Humanities session, I was again very curious about what had compelled them to choose or create a particular piece. In this issue of Obliterants, we have tried to find those layers that lie beneath a life of medical training. You will read about the wisdom to be attained from a beloved child, a near-death event, a poignant patient, and other startling experiences. There appears to be a common theme of finding peace, comfort, and humor in this path of healing others. We hope you enjoy this issue, and that you find peace and joy in the coming new year.

What They Don't Tell You In Scrub Training by Hannah Matthew Credits

With no anticipation of being a surgeon, I generally avoided the operating room until third year. I assumed that I would attend scrub training, waltz into the OR, and to quote a friend, "do work, son."

Editors in Chief: Paul Rothenberg Brian Garnet Editors: Brigitte Frett

In fact, there are a myriad of skills that you are never informed you need. And they make a difference. So, I decided to share a couple here:

Myra Aquino Mary Lan Advisor: Gauri Agarwal, M.D.

1) The Skill of Not Being Short.

Inside this issue: I and Thou

by Aaron Weiss

2

Sixteen

by Todd Hoffenberg

3

Priorities

by Nashay ClemetsonSaunders

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Mother Medicine

by Ekaterina Kostioukhina

5

Painkiller

by Mike Keyes

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The Birth of Michaela

by Brian Garnet

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Submissions Send to: obliterants@gmail.com

The OR (like a sad metaphor for life), is made for average sized people. Not gnomes, like myself.

In retrospect, I probably should have considered more carefully that section of "disabilities that may affect your ability to practice medicine" part of AMCAS. A sterile scrub should be no problem, until I realize that in order to scrub appropriately I have my body one inch away from the sink. One has to maintain this position, while avoiding actually hitting the sink...for 3-5 minutes minimum. My own technique has b e e n t o d e v e l o p a l ea n forward tiptoe hunch situation. If this was a yoga move, it would probably be called "Fish About to Leap into Sink." On the upside, it is a good calf workout.

Of course, say I make it to the OR sterile. Then one realized that the table is set up for surgeon's ease and comfort, not your own. So two stools later, you are reenacting

the aforementioned yoga move, but replace Sink with Body.

Which brings me to wonder, why aren't we doing surgery sitting down yet? Those ENT people have it right. With a lot of the laparoscopic techniques now, I am sure a couple comfy chairs a ro und a lo we re d t ab le would work out great. Throw in some mood music, a fireplace-it would be perfect. In fact, they a re probab ly doi ng this somewhere in Dubai, probably between in a hospital made of gold, poised on top of the indoor ski slope.

2) The Skill of Getting Out of the Way This is probably not a surprising skill. What was surprising was how difficult it is to carry out.

Between the wires, carts and constant rotation of people in and out-it becomes pretty difficult to find a safe corner to stand. Usually, if you aren‘t actively involved in the procedure, you are playing a game of musical chairs. Except the music is off and the other players are inanimate objects.

Staying out of the way also applies once the surgery has started. Somehow, one has to simultaneously hold 2 retractors, scissors and a 4 by 4. Or direct a camera, while crouching at the corner of the table, and twisting out the resident‘s way. And then, as soon as you find a comfortably

numb position, you somehow have lost view of the surgical field.

3) Mastering Languages

Different

Apparently, I missed the part when people learned to communicate through masks.

That or I have been bumping Kanye too loud and have actually shot my hearing. Either way, half the time someone says something to me, it sounds like Darth Vader having an asthma attack.

This is amplified by the fact that no one really uses real words anyway. ―There‖ and ―up‖ somehow indicate that I am supposed to do some fancy rotate-y, lift-y thing with a camera. Awesome. ―Adson, Richardson‖-they sound pretty similar when 3 people are talking at once and I only hear half the word.

Luckily, the scrub techs, not I, are in charge of handing people the right instruments.

In the end, of course all these ―skills‖ are worth it. They allow you to be part of teams that literally take apart and rebuild human bodies. To describe that experience, wo rds seem inadequate, so-*insert heavy mask breathing and muttering here*.

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I and Thou by Aaron Weiss Ironically, medicine, and medical school in particular, can often cloud one's judgment, especially concerning priorities. After one year of medical school, my attitude towards life had drastically changed. Instead of enjoying myself in the company of family and friends, I would instead study incessantly, trying to get that one extra point on an exam or one-up one of my classmates. Even at the time, I recognized my ridiculous transformation but did nothing to stop it. Wading in the Sorsogon Bay, I had a moment to reflect and gain an appreciation for the little things I had so quickly rebuffed. I vowed to regain an appreciation for the important things in life; I thought that this realization was glaringly obvious but difficult to amend, given my competitive surroundings. I thought this was a most appropriate story to share with medical students, possibly experiencing something similar.

―For every minute I have left, I will thank God for the day and the moment I have.‖ – Jim Valvano I had never thanked God, or had even spoken with God for that matter. I was preoccupied, consumed with the miniscule details and monotony of life.

What was I eating for dinner? What is a monoclonal cell line? Why can‘t the Canes get a win? Seriously, they need a win! I am able to recognize the folly of my actions, even while committing them, and I admonish myself. Yet, I continue to care. Not about the important – life, love, and family – but about the irrelevant. Fast food, textbooks, and box scores dominate my conscious. I hope they spare my unconscious. Truthfully, I wouldn‘t know.

Walking down the beaten path, literally, I feel the sun upon my face. And yes, at the moment in the Philippines, I have got one distinguished tan, or is it the antecedent of melanoma? The greener grass is an intriguing paradigm. I have realized that the lighter one‘s skin, the darker the person yearns. And vice versa! One‘s skin can become a comfortable place, especially when combating the elements. Sun, water, tuberculosis, and roosters? Yes, roosters. We left the cock fight and proceeded down the beaten path. Overlooking the Sorsogon Bay, I mulled the existential ideals of Martin Buber, combining the entities of I and Thou into a single philosophy. ―Play is the exultation of the possible,‖ he writes.

Really?

I had taken this to heart. The work of Buber, a book given to me by a 21 year-old shaman, who appeared far wiser than I. So, I traded him The House of God, the antithesis of his vocation, yet similar in many ways. He told me that he loved it and hated it equally. So I dove into Buber‘s language, searching for meaningfulness in life and in the relationships between I and Thou. Speaking of diving, it was time for a boat ride.

The Philippines is a beautiful place – pronounced Pil-i-penes – the ―H‖ is silent. Surrounded on all sides by jungle canopies of palm trees and crystal clear blue water, I took a moment to reflect. Similar to my Pilipino friends, I was living in the moment, temporarily ignorant of my responsibilities or future.

It was a great moment, and one I will never forget.

Because the next moment, I was tossed into the ocean.

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I‘ve always hated life jackets! They are onerous and unbecoming. It quickly became apparent to me that Pilipinos also hate life jackets. We waded in the water, hovering around our sinking ship, searching the horizon for help. There was none. Surprisingly, there was no panic either. Together we waited, sans one determined character, who decided to venture back to shore for help. We discussed survival plans and strategies for attracting attention – yet we were still able to laugh and comment on the state of the setting sun. And it was an incredibly beautiful sunset, coating the mountains with a polish that was equally captivating and irritating to the eyes. In hindsight, commenting on the sun seems comparable to asking Mrs. Lincoln her opinion of the theatrics on stage.

My grandfather always told me: ―The man who expects nothing, appreciates everything.‖ I had expectations but they became more modest with the passing moments. I gained an appreciation for the little things in life that shouldn‘t be taken for granted. Health, safety, a good laugh, and joyous moments. Because life is just a series of moments tied together by the person experiencing them. And while appreciation is subjective to the beholder, there is undeniable potential. I told you I was taking Buber to heart.

We were eventually rescued, and I was relieved, though determined to retain my appreciation for the important. I vowed to appreciate the moments and take myself less seriously. Understand that life is a beach – learn to play in the sand, or exult in the sand, if you will. I could use some sand.

Approaching the rocky shore, we passed the determined individual, who left the group hours earlier. He denied assistance and achieved his destiny, a feat I have always admired.

It established a dichotomy in which both parties were successful. And provided an interesting adjunct to my concepts of I and Thou.

I ate a delicious dinner. The most delicious dinner of my life, to this point. Then I called my father.

It was Father‘s Day in Tennessee, so I had to call him and tell him about my afternoon. My dad has always been easy to please. I would typically get him a tie or a box of licorice on this sort of occasion, which he appreciated. I‘m looking for a girlfriend who‘s easy to please. I‘m still looking for a girlfriend. I didn‘t have any material gift for my dad this year, but I was still alive to call. I let him know I appreciated everything he‘s done for me. He told me that this was the best gift he had ever gotten.

I thanked God and agreed.

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Sixteen by Todd Hoffenberg How old are you?

That's the first thing I ask.

21.

I would have guessed sixteen.

Though this is the adult clinic, so I knew that was wrong.

She is there to obtain insurance and has no medical complaints.

But the right question starts a stream of tears.

And somehow makes it OK for her to share what happened 5 years earlier.

Sleep problematic.

Interest waning.

Guilt overshadowing self confidence.

Energy lacking.

Concentration deficient.

Appetite inadequate.

Psychomotor. I forget what to ask here.

Suicide. That would be a shame.

This poem is about Ms. P.D., a 21 year-old African American woman who presented with major depression and complications from a sexual assault when she was 16.

Afterward I am shown post-surgical pictures.

I search for the medical terminology.

Sometimes it makes such ordinary things seem so heinous.

Sometimes it makes such heinous things seem so ordinary.

I was hoping for the latter.

16.

The closest I could come up with was "impaled".

That offered no protection.

Sixteen.

The object they removed was several centimeters in diameter.

Not what any of us imagined.

Why then, was my emotional response so blunted?

Am I incapable of visceral reaction -- an empty shell.

Surely this is the king of atrocities -16.

Whereby every fiber of innocence is beaten and battered until it resides where only ghosts dwell.

What a terribly naive thought.

This was an act of perverse preservation, With certain prideful intention, Such as to ensure that innocence remained permanently stamped -A mark which I so astutely observed to read: "Sixteen"

After this experience, I spent a few weeks ruminating before I committed it to paper. I couldn't sleep much the night after. The whole experience tore at me like a depression -- something you can suppress and convince yourself that it's not affecting you. It was easier to convince others, though I spoke openly about it on several occasions.

In the medical profession, what is our role in this kind of rehabilitation? We did more than we were charged to do, providing resources so that she may seek help through the channels our society has developed. But it is up to her to walk those paths. And what if all she needs is a confidant? Where do we draw the line of getting too involved and not getting involved enough.

Patient advocacy. We can spend a lifetime studying and not learning anything.

There sat a woman, a living breathing human being, full of wit and wisdom and of naivetĂŠ.

Someone whose path to salvation was obviated by our interaction.

And obfuscated by every second she spends alone.

Who is there to protect her from the sharks?

Who could be there to protect her from the sharks?

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Priorities

By Nashay Clemetson-Saunders Destiny is built out of your strongest priority today!

During our third year of medical school, we have scheduled humanities sessions, where they ask us to bring in a piece of art or writing and discuss it with our peers.

—Dr. Noel Woodroffe

Priority-something given or meriting attention before competing alternatives (Merriam-Webster)

Journal excerpts: September 12th: Today was the first day of my surgery rotation. I have been looking forward to this day ever since I started med school but all I can think about is hopping on a plane and going to Jamaica.

September 13th: As much as I remember that today is the 12th anniversary of my brother‘s passing, the most significant memory is of giving birth to Marcale 5 years ago. I woke up this morning with a heavy heart. Here I was, with nothing on my schedule, and there was Marcale, all the way in Jamaica, without me, on his birthday. I tried to console myself with thoughts of last year and the years to come. I told myself that one day, when he‘s older, he‘ll understand why I missed his birthday, even though I had promised to be there. But, when he called me, a little after 1pm, I couldn‘t fool myself anymore. A promise is a promise, and I promised him that I‘d be there. He said, ―Mom, I had a nice party at school. Now, Papa and I need to come pick you up from the airport.‖ So I drove straight to the airport. I knew I would get in trouble because I would miss my 2nd day of surgery, but I cannot disappoint him. When I finally got home (Kingston) that night, Marcale was sleeping in mommy‘s bed. I gently lifted him into my arms and whispered, ―Happy birthday boo-bear.

Do you know who this is?‖ With his eyes still closed and a big smile on his face, he said, ―Mommy-Nashay. You came for my birthday. You are the best mommy in the whole universe!‖ This decision to visit Marcale was much more for me than delivering birthday gifts and seeing my child: it was a matter of priority. It was a priority to grant him his wish and keep my promise. And this heralded the beginning of my future as a mom. As a physician, a future where I will constantly have to make decisions about what is a priority for me, my family, and my patients. I may have to miss important events in the future, but Marcale will always remember that mommy came all the way across the Caribbean Sea to see him on his birthday. On that day, I was destined to be the universe‘s best mom!

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I had a hard time finding a "piece" for the session. As I walked by my refrigerator a few days before it was due, a picture of my son in a frame that read "Mom, you're the best" caught my eye.

I thought back to these journal entries that I had written earlier in the year, and I wanted to share with my classmates, my unique experience of being a mother in medical school. At first I was concerned that my classmates would not want to hear me talk about "mommy" stuff, but on the morning of the assignment, I awoke thinking seriously about how my priorities had changed and how much of a role my son played in that process. I then decided to share my thoughts on mothering and doctoring because those were two very important and often conflicting areas of my life.

Marcale absorbing GI physiology

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Mother Medicine by Ekaterina Kostioukhina I created this painting on the first day of art class with my daughter at the Boca Raton Museum of Art. All the kids were working on their projects and there was a lot of extra paper left over so I decided to give it a try. I wanted to make something to express my love for medicine, something that would include "patient centered care" and would show the feelings of a patient with a disease and how medicine helps to relieve that pain. The painting shows a person who is guarded by a stethoscope that represents medicine. The stethoscope is shielding this person from many of the diseases that are represented by the bugs, molecules and other things floating around outside the almost womb like environment that the stethoscope creates for this patient. However, medicine is not perfect and the hand of this patient that is hanging unprotected shows signs of arthritic nodes which we still don't have a cure for.

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Painkiller by Mike Keyes I realize a part of me has already died I never lived the way I wanted, so now I say goodbye To what could have been, as I'm headin' towards these darker skies Tryin' to find my way by lookin' through my father‘s eyes Separated by earth, I‘ve been destined since birth To feel the sorrow of adults, and to question my worth "Why am I here?"

Surrounded by darkness, feelings encompassed in fear I try to reach out, but alas, nothin' is near...

Why have I been forsaken, picked to feelin‘ this pain Until my heart is achin', sick from dealin' wit shame?

I'm but a boy livin‘ in a shell of a man I‘d love to talk to God, but doubt that He'd understand That at times I wanna welcome an eternal sleep For my yearning soul'll find relief, when it finally earns its release But fearin' the unknown won't allow me to die So I try to find a purpose ‗stead of living a lie Still I'm just a shadow of what I used to be The hallowed product of my truest misery With my eyes I've been a witness to far too many lives Lost from missing signs of imminent suicide So I cry tears of sorrow every time I see this fate When the fires of ambition get extinguished this way How can my brothers wane & fade away from this light?

How can I find the way to take the pain away from their plight?

All I can say to my brothers is, "I will always be there Even thru the darkest times; you will make it I swear."

This is a poem written from the bottom of heart 2 the ones who've dealt with pain, like I've felt from the start

This poem was written in dedication to people who have contemplated and/or attempted suicide. I'm an emotional guy, so it was written when I was in a particularly brooding state of mind. A few individuals I have known in my life have committed suicide and thus any transient depression I go through immediately brings about thoughts of them. Going into the medical profession, we have a job to overcome our personal issues in order to help those who need us. I tried to express that sentiment in this poem. Remember: just as we must mask our own feelings at times, we must always be wary that the ones we care for are not doing the same.

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The Birth of Michaela by Brian Garnet After each of my first two years of medical school, I travelled to the Bicol region of the Philippines and worked in a clinic run by Dr. Mitchell Schuster who donates a month every year and immeasurable time and resources to providing health care in a rural area where most people live on less than $1 a day and have no health insurance. I wrote this story after my first trip there, and then added the ending after going back and meeting the 1 year old girl who‘s birth was the first birth I‘d ever witnessed.

The hospital lights seemed blinding at 3 AM after coming in from the street. Two female scrub nurses grunted while prepping the table, and I was trying to pull up anything I could on C-sections in the copy of Unbound Surgery in my iPhone. Dr. Medina came in and tells us we wouldn’t be scrubbing in, but we could watch the emergency C-section we just paid for. Mikey, our bridge to the Filipinos, tried to tell her that Aaron and I were M4’s, but she’s one of only 2 OB-GYNs in Sorsogon Provincial and we had just observed her remove a 20 pound mucinous cystadenoma earlier that week. This night, for around $200, we hoped that we could help save the life of Benigno’s wife and new baby. She was a 28 y/o G5P4, at 44 weeks gestation who had 3 previous C-sections, all classical. Dr. Medina looks about my age, but her eyes have a cold, locked-in stare giving a glimpse into the tragedy she’s already witnessed in her few years of practice. In spite of her extensive exposure to the difficult reality of medicine in a third world country (in a region where nobody has health insurance), she seemed laid back and ready to do the procedure without getting paid, but Benigno couldn’t get the money together for the anesthesia.

When we first pulled up to the side of the hospital next to L&D, Dr. Medina was backing out in her mid-90s Toyota Camry. Nicest car I’d seen in weeks. There was no point in her waiting around if there wasn’t any money for anesthesia. It’s one thing for a physician to provide free care, but another thing altogether to spend half a month’s salary in the pharmacy in addition to not getting paid. Mikey pounded on her window to stop her while Aaron and I went with Benigno to find the patient.

Benigno was the hardest working man back at the clinic and retired boxing champion of Sorsogon province. He has the face of a man who lived his life in a province of the Philippines. Chiseled features glistening with the moisture from the thick air; not an ounce of subcutaneous fat, and leatherlike skin weathered and darkened by the sun.

I met Benigno’s wife for the first time as she laid on a rusty old L&D bed.

The room had about 8 beds and she was the only one who wasn’t sharing it with a family or another pregnant woman. The unit seemd relatively empty for this hospital, but otherwise looks the same. A big square room, some windows high along the ceiling that may have been transparent 65 years ago, IV bags hanging from ancient, rusty former Vietnam war beds left behind by GI Joe. I held her hand, and checked her pulse as Mikey rushed Aaron off to find the anesthesiologist. Her pulse was a little tachycardic, but I wasn’t checking it for any medical reason; I just want to make her feel like the Americans were doing something. See, I had won the paper, rock, scissors battle of who got to go with the family to the hospital for the surgery, but her husband pleaded with the driver to allow 6 people to ride over the hills on his trike-- made to carry maybe 4 to the hospital-- so that both Aaron and I could be there. He said he needed us there because we’re American and our presence during the operation would ensure that his wife and baby would be okay. I knew my role, and I was just trying to be a calming influence. I told Benigno’s wife in poorly pronounced Tagalog that everything was going to be okay. She smiled at me while it set in that I had no idea if everything was going to be okay.

She squeezed my hand and groaned as a contraction caused a wave to rise through her lumbar spine, lifting her pelvis off the bed. Nobody had been willing to induce labor, sure that her uterus would rupture, but now it was here.

in what seemed like two seconds. In the next two minutes, the scrubs have Dr. Medina gowned and gloved, and the patient prepped with a quick douse and scrub of betadine. Another fifteen seconds, and Dr. Medina has dissected down to the uterus, showing us where the old scar tissue is about to rupture.

She says that if we were to watch for another two minutes it would tear open in front of our eyes. All I see is a lot of beefy red tissue. Amidst the quick hands of Dr. Medina and the equally quick reactions and retractions of her assistant, the second scrub nurse grabs the baby, cuts the cord, throws her onto a bare metal instrument cart and is gone. Before the cart is whipped out of the room, it feels like the world stops. The only thing I see for that instant is this beautiful baby girl. The only thing I hear is her cry. Aaron looks at me and mouths, “That was f***ing amazing!” under his mask. I can’t see his lips move but I know exactly what he’s saying.

Baby Michaela, named after Mikey, who guided all of us to be just where we needed to be that night, is out of the room so fast and I remember where I am. She won’t remember the drama surrounding her birth, her only birth, but I will always remember every detail of the night I watched a baby come into this world for the first time. The sound of suction is like a slap to the face and I notice the nurse changing the gallon size glass jug that’s already full of blood. It hits me again; I have no idea if everything is going to be okay. Dr. Medina is tying surgical knots faster than I ever imagined they could be tied.

My feet start to ache a little as I watch her tie what seems like the 100th knot in the scarred, unrecognizable, uterus. Once the bleeding is under control, Dr. Medina takes out her frustration on the uterine tubes. What are four more knots to ensure she never gets herself into this spot again? As they close the abdominal wall, Dr. Medina lets her team know she’s buying them some early morning fried chicken from Jollibee. A surgeon I know back in the US once told me that he doesn’t trust anyone who gets hungry during surgery.

It’s exactly one year later and I’m walking out of the dormitory throwing my stethoscope around my neck. It’s 10:00 and I’m late for clinic and my mind is racing. One of the women who works at the clinic stops me and says, “Brian, this is Benigno’s baby! It’s her first birthday today.”

Michaela’s eyes are so big and beautiful. For a moment, once again, the world stops as I sit and hold her on her first birthday.

The OR didn’t seem any brighter than the hallway. When Benigno’s wife sat up, she kept her arms straight out in the position of the armrests of the bed. For a second, I imagined her as Jesus on the cross while the anesthesiologist prepped her back with betadine and dropped her spinal anesthesia I SSU E 2

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