19 October 2010

The Joy of Inflicting Pain

In a discussion of DSM IV axes of psychiatry, Dr. A, the department chair, asked us what we thought the most common psychiatric diagnoses amongst physicians were. We came pretty close to guessing. His top 3? Obsessive-compulsive disorder. Masochism. Narcissism.

The first is probably self-explanatory. The second…in brief… is related to the extremely delayed gratification process we willingly go into. I’m not sure any other career (tell me) is like this, in the time between deciding what you want to do, the years and pre-reqs until you can actually start school, school, training, and practicing on your own. And the hours, oh, the hours…
Between my starting pre-med classes and finishing residency, at least 14 years will have elapsed.
(it is possible to do a bit more quickly. But not by a lot, actually. Shortest duration would be approximately… 9).

The third. This may seem interesting in juxtaposition with masochism, but I think it goes along with a martyr complex. Do we talk about the hours we work? How hard it is? How much debt from school? The pay in residency, which works out to close to minimum wage, calculated per hour? (assuming 4 weeks vacation, 80 hours per week (and it’s really closer to 100), not taking out taxes, hourly is about $11: 4 years of college, 4 years of graduate education, and an MD).
(I just said it). Do we complain about pre-med classes, in particular organic chemistry, and the weeding-out process that does make things brutal, demoralizing, and…just…mean at times? (Professor for my second semester orgo lab course – “congratulations! You’ve made it this far, we don’t have to weed you out anymore. We’ll stop deflating grades.”). To get into medical school, we take an 8 hours- straight – test. It’s not that it’s hard. It’s about endurance. So much of this is about endurance, sacrifice (because of the god/martyr complex. Because you’re going to be, to do something “good” in the world).
Do martyrs complain?

But this goes along with narcissism. It’s a very elite club. We believe we’re “special.” And, as Dr. A said, we’ve grown up being told we’re special. You’ve got to be high achieving for awhile to get into med school, later. Not smarter. More competitive? Harder working? Maybe. Goal-oriented? Yes. And getting in – well. Families like to brag about that. There’s an awe, a halo, a cachet about the profession. We’re “special.” Orientation week, we were already in the alumni association (true). We had a white coat ceremony – a whole ceremony, with parents/etc, to have our advisors put the *&^%#$$ (my current feelings about them) white coats on us as we walked solemnly across a stage. And then we repeated, solemnly, the Oath of Lasagna (formerly…Hippocratic. This is the updated one. And yes, it’s really the oath of Lasagna).
You get a new name when you finish medical school. My preceptors, many of them, will walk into a room and say “My name is Dr….” (Somehow, I prefer “I’m Dr….”. Yes, you are that. But saying it’s your name? As if you were born with this, this indelible…? Maybe the verb “to be” seems more permanent than “name.” Maybe it’s just me). PhDs don’t get called doctor as often. My patients often call me doctor, even though I do tell them I’m not one. Nurses will call me doctor, and I tell them too. (Some get annoyed, sometimes, asking me a question, calling something to me, “Doctor!” when I’m sitting down, back to them, reading a chart. I don’t turn around. Talking to me? Must be someone else. “Doctor’ isn’t my name anymore than Ntangen was. It’s not their fault. They don’t always know my name. And calling out “medical student” might sound odd. But I’m not in the habit of responding, anymore than I would respond to someone else’s appellation).

Our entire lives, we have been told we’re special. We’re “special.” And then we enter a profession in which we are allowed to defy societal norms of behavior, every day. I walk into a room and tell someone to take off their clothes. Do they? Yes. Do they let me touch them? Yes. Granted, it is with a therapeutic purpose, and that’s why they came to see me in the first place. Particularly in exams where they can’t see my hands, I tell them “You’re going to feel my hands now.” Or “I’m going to start by examining your neck.” Or your eyes. I ask questions that, if I asked to any other strangers, I would get yelled at, hit, or thrown out of the establishment (potentially). At the very least, people would probably walk away. While examining…say, a person’s abdomen, if I see a scar (particularly if the patient told me she had never had surgery – this happens more often than you might imagine. People forget. A lot), I ask “what’s this?” “What happened?”
And they don’t get to ask me questions back – though sometimes – very benign ones. And they don’t get to touch me.

We think we’re special. I was thinking about medicine in relation to massage, the other day. Supposedly, doctors have “healing hands.” (some surgeons insure their hands. I’m pretty sure this is true). Overall, in the grand scheme of things, yes – things doctors might find with their hands could lead to serious findings, could lead to healing. But our “healing hands” often cause pain. During the exam, discomfort, at the very least. If I find something that hurts, I’m going to press on it at least twice. I need to check. And then, again – “does it hurt more when I press down, or when I let go?” After a visit to the orthopedic surgeon, my hands ache – a lot – for at least a day, if not more. Does this hurt. “Tell me, if at any time, this hurts.” And I write it down.

We have the power to inflict pain. “Things that are good for you.” Injections. Drawing blood. Procedures. I like procedures. I like having practical skills. So, do I enjoy lancing the abscess, doing the incision and drainage (I&D)? Yes, I do. Did I enjoy doing my first paracentesis the other day? (after ultrasound, I used lidocaine to numb the skin of the patient’s abdomen and then stuck in a large bore needle to draw off fluid from his ascites, 2/2 liver cirrhosis. At least 5 L of fluid. Getting the fluid out helps him breathe better, be able to walk without stopping to catch his breath every few feet, being able to sleep at night without waking up, gasping. He knows this. I know this. But when I put the needle in… victory! For me. Pain – for him.

One of the patients I I&D’ed asked me if it was the worst abscess I had ever seen. Well, it wasn’t, not remotely, and I told her I’d seen worse. Did she want to hear that, or did she want to hear that she was “special”, too? I hastily reassured her about her pain – I know it’s very painful. Can’t intimate that this is, should be easy for her. I learned suturing on foam, then pigs’ feet, then patients in surgery. Now, I do it on patients who are awake. We tell them, the lidocaine, the numbing medicine injections, hurts more than the procedure itself. Is it true? I don’t know.

Surgeons, actually, don’t inflict pain. It’s much easier to forget that the space you’re cutting into, that layer that takes a little pressure from the scalpel to slice neatly through and start spreading open layers, separating beautifully….
Is human.
It’s draped. The surgical field is draped in blue, there’s a hole, and that’s where you cut. The hole might actually be sticky plastic wrap, which helps keep the skin in place and keeps the area a little neater. Slice through the plastic. Into the skin. You can’t see the patient’s head – anesthesia gets that, on the other side of the curtain. It’s not sterile on that side. But to anesthesia it looks like a head with tubes sticking out of it, maybe, eyes taped shut. Things beeping. Lots of machines with things beeping. And vacuums and containers and things flowing out of tubes, and the smell of the cautery…
maybe not everyone wants all their senses engaged with this one.

I will always be grateful for the first surgery I observed. This was in Mvangan (Cameroon). I won’t say “scrubbed in on”, though in American parlance, I did. I walked in, wearing sandals. December 30th, 2005, must have been. It was the same day I left village for the first time after moving there, going up to Ebolowa to celebrate New Year’s with other volunteers and some of our Cameroonian friends.
Doc knew I was interested in surgery, so he’d invited me in – I was hesitant, the first time. He was scrubbed, and he was the only one in scrubs – no, maybe Eco was too (first assist). The room was hot, humid, in the perennially 85-950 rainforest with 90% humidity. Approximately. No screen on the window. No power – but this was daylight. We did have sterile drapes. No general anesthesia, without electrodes or intubation or any other way to monitor. It was ketamine and..something else…that I wish I remembered. Description for another day.
The patient, 30 or 40 something year old man, had been in a moto accident. His bowels, perforated. Had to be fixed. They had trouble putting him under – everyone was saying he must use drugs, he must, he must – they couldn’t do it. He wasn’t lucid, but he wasn’t completely out, either.
And so for the entire operation he was moaning. Moaning as he was cut into. Moaning as he was eviscerated, bowels piled on his abdomen as Doc searched for the defect. And then he started kicking. Knee into Doc’s stomach. I reached over and grabbed his leg, held it down, whicle the surgery was finished. No one in that room could ignore that this patient was alive, that what they were doing, this violation of bodily integrity and autonomy in the purpose of – to put it succinctly, playing god – was to someone with a beating heart. Whose lungs were function on their own – proof, the moaning. Proof, the kicking. ABCs? Check, check, check. He was alive.
And he lived.

When you’re operating – open, laparotomy – on someone who is moaning, you know you’re inflicting pain, you know the pain will be even greater when they wake up, and you have to concentrate even more (I imagine) on the task at hand. With a patient fully sedated, you can focus. Hands. Anatomy. Moving things carefully.

I do remember that day. First worried about what my own viscera would do when faced with…viscera, outside of another person’s body. But then, you do what you need to do. I wasn’t quietly in a corner, holding a towel over my hands if I hadn’t scrubbed. Trying not to fall over , standing for so many hours, as I kept shifting my weight. I was there, I was active, I was doing something basic to help. Keep the patient from kicking the doctor whose hands and knives are inside him. Can’t get sick when you’re concentrating. And not a single thing about me was sterile. My hands to his foot. That, too, is necessary.


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