Dangerously Close

The first few months of medical school are consumed with anatomy, biochemistry, and cell biology. Histology, maybe, and the physical exam. Most of those classes are a hazy, pleasant-ish memory to me now. For example, the elderly pathologist who lulled everyone to sleep by reading directly from his overhead slides in an unruffled voice until one day he exclaimed “What’s this? Well by golly it’s a Howell-Jolly Body!” At which point I woke up for 5 minutes.

But somehow no one ever forgets the anatomy lab. It’s recalled with perfect distilled clarity every now and again when I catch a whiff of formaldehyde or phenol. Like, just the other day as I was ablating a portion of my patient’s toenail bed.

I turned my head away from him for a moment. “Es que este olor… bueno, nada mas que no me gusta mucho.”

Before my oblivious patient I was suddenly 22 again, in a room of dead bodies, drenched in repulsive sickly sweet preservatives. Immersion. Handed a scalpel. Told to cut. Against every instinct in my naïve little heart. White as the sheet that used to cover this respected elder who gave her body to science, to us, now lying naked.

Suddenly with a clipboard staring bewildered in the mid-term at tags tied to tendons. Rotating after each “ding” to the next cadaver, longing for my own, whom at least I knew. Willing, teleporting myself outdoors into the blinding heat and late-summer stillness just outside the window. Lost in the last dying days of my childhood. The days when I knew enough and knowing wasn’t everything, anyway.

Wishing there was some sort of mid-term that might test my knowledge of kitchen implements, or garage tools, so I might feel like I knew something at all. Then confidently I could write “This, Dr. Professor Sir, is a measuring cup. 1/3 cup to be exact. Exhibit #35 by contrast is a sieve.”

Staring into the abyss of What I Need to Know. At the crossroads of earnest interest and imperative mastery, the fear of failure gives you the courage to don a white coat and with it delude yourself into believing you’re impervious to pain and death.

I made it through the class.

Several months later we started Neuroscience. After a few lectures we were sent back to the lab. Nothing, not the white coat, not the desensitization of anatomy class, could have prepared us to see our lady’s brain lying neatly on a cutting board. A single serrated bread knife was on hand.

We were told to cut. Sagittal sections, about a centimeter apart.

Nervous laughter.

“So, who wants to cut open the brain?” I offered. No one took me up on it. “I’m not doing it myself.” The holy grail of humanity, the sacred seat of the soul, the great mystery of consciousness. We’d been told the consistency was like tofu, the extra firm variety.

Years ago on an ornithology field trip in the middle of a 30-mile salt flat a group of girls had to pee. Wordlessly we spread into a circle about 15 yards across. We faced in, and all went together.

Somehow subverting our instincts is easier when we do it as one.

I made the first cut. Then I passed the brain to the left, and my partners, in sequence, took their turn.

That weekend I went camping in the desert. We took a guided tour of some caves. In the dark among strangers, it was all I could do not to blurt out “Say, on Thursday I cut up a human brain.”

Why? It felt like a confession I needed to make. Like it might absolve me of the crime. Also I wondered a little what they all might think if they knew.

All I was trying to be was a doctor. I felt like a monster.

I said nothing.

Now there are a million moments like this that set me apart. Horrors we see and do every day that give us an air of mystery and a privileged place in society.

My landlady works with veterans, as a psychologist. She’s busy at the moment with the returning Iraq and Afghanistan troops.

She sat opposite me on the couch. “They are all suffering so much. So many of them have anxiety, panic, PTSD. They’ve seen such terrible things, it’s like they can’t be normal again.”

“Is it all of them?” I asked. “Do you think some will turn out to be okay?”

“Well, I worry more about the ones who seem unaffected. Those are the ones who do worse. Humans can’t see that kind of devastation and be unaffected. If you’re numb to it something’s wrong. Those are the sociopaths, the killers.”

The ones who can mutilate a brain and then casually go on a cave tour. The ones who can pump on a teenage chest for 30 minutes and then give up and have a sandwich. The ones who can look into the eyes of a heart that’s breaking and feel nothing, and glance up at the clock.

My God, what sort of “healers” might we be at the end of all this? To stay alive in this profession we’re strategically deadened. Afraid for our own survival, we jump through all these hoops. Some drop out. They’re “weak.” We’re worn down to exhaustion working night after night, so we never complain. Worn down to the point we’re relieved to see that the struggling cirrhotic has died overnight and we have one less patient to round on in the morning.

Did I just say that out loud?

Outsource the empathy to the nurses, folks, because there’s nothing left here. Nothing but an empty, encyclopedic brain and beating, mindless heart.

Can it be true? Has it all been bled out of me?

See the patients faster, Doctor, that’s not fast enough. They might cry, they might beg, but you’ve got others waiting. Give them a piece of paper, they’ll be fine.

You’re just trying to take on too many things. Set a reasonable agenda. Tell them to save the other 8 items for next time.

That baby just died? Here’s another one on the way. This one needs to be removed surgically. And the answering service has someone on the line who’d like to know what flavor of pudding to mix with ciprofloxacin.

She has cancer. He’s suicidal. She’s had her foot removed. Talk to them, sure, but no more than 10 minutes apiece.  She’s been kicked. He’s addicted. She doesn’t understand her diagnosis. His cat just died.

I’m neck-deep in charts and urinalyses. What the cadaver horrors didn’t drain from me the endless ticking clock will. This is primary care. This is the trenches. I’m dangerously close to numb.

Fortunately, so is his toe. It took a bit of extra lidocaine but the digital block worked. He’s smiling. The ingrown toenail was a pain. He’d tried to remove it himself with pliers. Apparently I did a slightly better job.

I believe I’ve killed the nail bed with phenol. My soul may yet survive. Maybe.

*Note: the suffering and death seen by most physicians pales in comparison to the trauma experienced by many veterans. I don’t equate our lot with theirs, and I give them the credit they are due. This was written merely to make an interesting comparison. And, mostly, to hold out hope that humanity and empathy can be reborn, even when all seems to be lost.