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A Third Year Opus — Chapter One: Incidental Findings

The white coats and patient gowns that confer the implicit power dynamic of the physician-patient relationship are not to be found here in the operating room. This place has neither the tolerance nor the patience for this subtle symbolism. Here, on the other side of the Rubicon, the rules are stark, the stakes laid bare. The patient lies naked on the table, arms extended on boards, Christ-like, as the surgeon holds the knife handle and plays God.

This chamber will host two operations today. The patients are elderly, one emaciated, one rotund. They arrive on stretchers piloted by faceless drivers. The patients’ gowns come off, their minds swim in anesthesia. A parallel system of de-humanization and re-humanization is now set into motion. The surgeon removes a wedding band and suspends it from the drawstrings of his or her shapeless blue scrubs. Hair tucks under a cap, eyes and mouth hide behind loupes and mask. The patients disappear under large surgical drapes, their faces curtained apart from their bodies. The humanity of both surgeon and patient is distilled to its most elemental form. All that matters now is a blue-robed figure, an abdomen and a knife.

Abdomens are deceptively large. Even the cachectic patient opened under the fluorescence of operating room lamps contains the same seemingly endless length of bowel, the same pale gastric pouch and the same surgical absence of the gallbladder as a patient far larger.

There are two important differences between the thin and heavy surgical patients in this operating suite.

First, unsurprisingly, is the amount of fatty tissue between surgeon and target. The thin patient is exactly that — thin. A few incisions through skin and fascia, and the abdominal organs are readily visible. The body readily surrenders itself to the surgeon.

The large patient puts up a fight. Fatty layers, several inches thick, obscure the viscera within. And even once a path has been cleared, they resist the well-intentioned retraction of the medical student. Enter the Bookwalter retractor, conceived a half-century ago after its namesake inventor once fell asleep while manually retracting. A single post, a notched ring and a few ratchets and sheathes of fat are effortlessly pushed aside. The body now reluctantly surrenders itself to the surgeon.

Second is the nature of the pathology. Amidst the seeming chaotic anatomy of the abdomen, the liver of the heavy patient rests in a position of prominence. It dominates the right side of the cavity, reaching deep into the patient’s back. Its surface is elegant, its contours smooth and rounded, like a stone from a riverbank. A deep fissure divides lobes; the left one gently tapers as it extends medially. The color is deep and rich — burnt chestnut, burgundy wine. The organ is evocative of vitality and youth — it seems out of place in this eighty-year-old body.

The liver is marred by one anomalous finding. A chalky, circumscribed yellow lesion of the left lobe, the surgeon’s target, the hepatocellular carcinoma that had been discovered accidentally — or rather, incidentally — on an otherwise unremarkable radiologic surveillance of a pulmonary nodule.

The thin patient’s liver is, by contrast, hardly recognizable. Despite being two decades younger, this liver is shriveled and speckled, ragged and rough. Its scarred cirrhotic surface is evocative of the images of smallpox-stricken faces in medical history textbooks. Years of alcoholism have long since robbed it of its function and its beauty. Deeper in the abdomen, the pancreas is similarly diseased, peppered with salty calcification.

The thin patient’s pancreas and bowel are each partially excised; the loose ends of the tract and associated ducts reunited by stitchwork. The heavy patient’s tumor and its hosting hepatic lobe are cleanly resected. Drains are placed and the incisions stapled shut. The operating room lamps dim.

Pre-rounds are an unpleasant experience for surgical patients. Roger Marshall, the heavy man, never seemed terribly bothered by it. On the contrary, he seemed generally in awe of the hospital and its early-morning rituals. He was particularly pleased that his liver cancer had been detected early during the workup of a lung nodule — “Thank God for smoking, I guess, right?” he chortled in thick Brooklynese. That he could enter an operating suite with cancer and leave without it was deeply satisfying for him, especially in light of a successful battle with renal cancer over a decade earlier. Roger — two, cancer — zip. “A few more days of physical therapy, and home free.”

Roger’s optimism and good humor were infectious, and he quickly became my favorite patient on the service. I frequently came up with excuses to drop in on him between cases, mostly to shoot the breeze.

Late one night, Roger complained to his nurses about itching and sneezing and received a dose of Benadryl. On pre-rounds a few hours later, I followed the loud echoes of snoring that led to his room. Roger was flat on his back in bed, slack-jawed, thin wisps of white hair reaching for the ceiling. It was a comical sight. Now we finally knew what it took to exhaust his tireless spirit — not cancer, not surgery — but allergy pills.

Good morning, Mr. Marshall.” He stirred after a louder third repetition, and answered my questions with a series of grunts, snorts and gurgles approximating Swedish. “I’ll come back later,” I said, checking his incisions. Clean, dry, intact.

I didn’t think much of it. It seemed odd that such a seemingly benign medication could sedate a person so profoundly, especially one of Roger’s impressive weight. But what did I know? It was only a few weeks into third year. I hadn’t learned that whether one hundred pounds or one hundred kilos, 80 years old is still 80 years old.

Roger aspirated that day. In the coming days, his respiratory status became increasingly precarious — a combination of atelectasis, an evolving pneumonia and a long smoking history. The chain of decompensation then turned its sights on his heart, resulting in alternating tachy-brady arrhythmias, which landed him in the intensive care unit for higher-level monitoring. The ICU stay was short-lived and he arrived back on the medical-surgical ward, shaken and smiling weakly.

Then he crumpled.

Back to the ICU. Intubation. Tracheostomy. PEG tube. The next time I saw him, he was sedated. His son sat at the bedside. Roger was barely visible amidst a sea of tubes, wires and leads that reached into and out of him. “I don’t think he would have wanted all of this stuff,” said the son, gesturing at the mess. “I don’t know. But I wasn’t going to just let him die.” To this day, I don’t know if he was justifying the interventions to me or to Roger.

Or to himself.

We watched him sleep. His hair still reached upwards.

A few weeks later, I had moved on to a different service, and Roger had moved on to a rehabilitation facility where he would continue his recovery. I decided to visit.

In retrospect, I don’t know what I was expecting our encounter to be like. Maybe I was hunting for catharsis or an explanation. It was my first experience with the bruising and often brutal course of a hospitalized patient. He had suffered considerably, endured invasive procedures and experienced dramatic deconditioning, all secondary to a tumor that was asymptomatic, one that had been discovered incidentally.

Was it all worth it?

Hepatocellular carcinomas possess variable growth rates, and large tumors are frequently inoperable and carry poor prognoses. Without intervention, the tumor might have grown further and killed him. Better to have had surgery, complications notwithstanding. These were the facts, but they were utterly unconvincing.

It was the Fourth of July. Roger was gaunt. He appeared half of his previous self, though his chart claimed he was only a few pounds lighter. I mustered whatever cheer and humor I had, “Mr. Marshall! Who told you that you could bust out of the hospital?” He smiled weakly, pointed at his tracheostomy site apologetically — apologetically — and rasped a greeting. His family had visited earlier; his grandchildren’s coloring books and blunted crayons were still scattered on the table. Get well soon Pop-Pop adorned a homemade card with etchings of stick figures.

I hadn’t thought about the trach. Communicating would be tricky. Luckily, he had a notepad and pen on his lap; unluckily, he had also indecipherable penmanship. We went on like this for ten minutes or so, my spoken words alternating with his written scribbles, a stilted, forced conversation about fireworks. I’m ashamed to say that I was itching to leave.

We wished each other a happy Fourth. I told him I’d do my best to come back and see him again. “Hopefully next weekend.” I don’t think he believed me. Maybe my unease, my guilt, had been plastered across my face throughout our visit.

I never saw him again.

Editor’s note: All patient names have been altered to protect patient privacy. 

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.

Ajay Koti Ajay Koti (17 Posts)

Columnist and in-Training Staff Member

Morsani College of Medicine at the University of South Florida

Ajay is a pediatric resident and a Class of 2017 graduate of the SELECT MD program at the University of South Florida. He is passionate about delivering primary care to underserved populations—specifically, low-income and homeless patients in urban centers. Ajay will be specializing in pediatrics, with a particular interest in child maltreatment.

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.