Posts tagged narrative
Breast Cancer Survivors Find the Michelangelo of Nipple Tattoos
In the waiting room of Little Vinnie’s Tattoos, bikers and punks sit side by side with church-going grandmas and soccer moms. Customers fly in from as far as Saudi Arabia, Spain, and Brazil, to an unassuming strip mall just outside of Baltimore complete with tanning salon, liquor store, and adult DVDs. Anxiously, they enter Vinnie Myers’ shop, the final destination for many breast cancer survivors attempting to recover what mastectomies have stolen away.
For all of medicine’s advances, the best option for areola reconstruction is tattooing, and in the field of cosmetic tattooing, Vinnie’s trompe-l’oeil “areola portraits,” as he calls them, are widely regarded as the best that money can buy.
A Rookie Cut
Over the past year, I have noticed a young man attending the barbershop I frequent. A tall and well-dressed adolescent who bared some resemblance to my barber, he initially started off with the scut work: sweeping the floor, greeting the customers, and watching. Always watching intently as my barber trimmed my hair.
Slowly, over time, he had begun to learn the tools of the trade - the different scissors and the brushes; the straight razor and the strop - and began to practice on the dummy heads.
Today, I went to the barbershop to find him cutting what must be his first set of heads full of hair. All the while, he was receiving pointers and tips from my barber, his father.
His eyes were focused, his body was tense, as he trimmed the weight from the man’s temple. Snip. Snip. As the locks fell to the floor, he re-examined his work. Was it too little? Was it too much?
“Remember to angle your brush up. It’ll give you more room to work with,” his father would say, and he would oblige and try again, with more angling of his left wrist. In the end, the older man seemed satisfied with the young man’s work. A sizeable tip came the trainee’s way, to which he hurriedly returned to the man.
“The cut is free. I’m still practicing.”
“You’re always going to be practicing. Besides, you’ve earned it. Keep the change.” The customer gathered himself and took his cane as he thanked the barber in training yet again. The young man was pleased.
“Next?” Of all the people waiting in the barbershop, no one took a second glance.
“Does your son know what he’s doing? I mean it’s a rookie cut,” came one snappy customer. No one moved. They wanted the expert, the experienced barber, the man who knew every bump under every patch of hair on their heads. They wanted his father. The brilliance of the man’s eyes that a moment ago seemed so alive, dulled. He put down the gown and reached for the broom.
“Sure, I’ll go,” I said, taking up his offer. He gave me a smile and motioned me to the chair. “Have a seat.”
I understood his plight. We were all in the same boat together. As learners, we depend on the good will of the people we see for us to gain experience, to be better, to become professionals. The process must start somewhere. It was time I returned this favour to another student.
“Caesar trim. Sides short. Front long,” his father called out.
“Hey.”
“Hello.”
“Thanks for giving me the opportunity.”
“No problem. We all have to start somewhere.”
Death surrounds us.
Recently, I have had many emotionally exhaustive shifts at the hospital. Some of my patients looked well; others did not. Regardless, many of them have died under my team’s care.
We are all destined to that outcome one way or another. In that sense, perhaps it was meant to be - the diseases had progressed too far or the patient could not carry the burden any longer. But my mind lingers on the life that escaped with their last breath, on the last dying days where my life had become intertwined with theirs.
My mind races and wanders to what could have been. Had we done enough? Did I do something wrong? If I had seen them a few hours earlier, could I have found a sign of the impending end? Could I have then given the patient and their family a few more precious moments together?
Despite my meticulous combing of the chart, I could never find the answers to these questions. We had done everything we could.
In the hospital, death surrounds us, ever hovering in the air, lurking behind every chest pain, kidney failure, and fever. Though we make advances everyday, Death always gets the last word.
“I’m sorry we could not do more,” I once said to a rapidly deteriorating patient.
“It’s alright. I know you guys tried. I’m grateful for everything. We gave it a hell of a run, didn’t we?” He mustered his fading energy to form a smile.
“Yeah, you sure did.” We shook hands for one last time.
“I’m ready.”
Becoming a Mentor
“Hello,” came a quiet voice. I glanced up from my paperwork to find a young lady leaning in across the counter. Her wavy brown hair framed a shy smile. A white coat hardened her otherwise soft and subdued attire while the red tubing and metal instrument around her neck helped identify her.
“Hello. How are you?”
“I am good. How are you?”
“Not too bad. Can I help you with something?
“Yes. I am a second year medical student. I was sent up here for our clinical skills session to assess a patient and I was hoping, if you have time, to help me with a few points on my presentation.”
I stopped for a moment, unsure of myself. Could I help this student? Perhaps I am not the right one to ask. But what is the harm in trying?
The Zebra
“Tom, come take a look at this,” the attending beckons excitedly. I get up from the charting station and walk over to his computer.
A CT scan fills his screen with a very large, obvious abnormality. “This is one of the biggest I have seen in my career,” he says. The patient had developed not only a large mass but a rare one, causing all sorts of systemic anomalies. Given the extent, it would be inoperable.
As we proceed to the patient’s room, the doctor explains the clinical presentation of mass effect on the body. His eyes are wide and flicker with a fiery excitement. He can barely control the rate of his words as he gushes about the various pieces of the unique clinical puzzle in front of him.
“Are you excited?” he asks after he finishes. I reply that it is “interesting,” much to his displeasure. “How could you not be excited? You might not see this ever again in your life.”
But all I could think about was how this mass, this zebra on a CT scan would soon bring our patient to their untimely death.
Within, I watched the attending as he spoke to the patient and their family about the situation. He explained things with such professionalism, clarity and assurance that I could see no better way it could have gone.
Yet it continued to disturb me, his excitement in it all.
Joseph Addison, a poet said: “Everything that is new or uncommon raises a pleasure in the imagination, because it fills the soul with an agreeable surprise, gratifies its curiosity, and gives it an idea of which it was not before possessed.”
For my attending, who may have seen thousands upon thousands of patients with very similar presentations, this zebra case must have stirred up a renewed sense of adventure, a break from an otherwise regular routine of patients.
Perhaps, it is that hot flush of novelty, that infectious high of our peers that perpetuate our own behaviour.
Too often our fascinations show outwardly as our primary intent. In the process, we forget that the patient has a name, has a right to be treated with dignity, has an illness that still needs to be treated. In the process, we forget that the condition does not define the patient any more than he defines the condition.
It is a strange situation we find ourselves in, to be excited and captivated by our morbid curiosity; on some level, we must in order to learn and improve as clinicians; at the end of the day however, it must come at the expense of someone else’s health. For that, I must always consider the fine line that separates respectful and disrespectful learning.
“Pretty neat findings, eh?” He nudges me. I take a look back at the patient’s room. I watch as the family huddle in an emotional embrace as they come to terms with our news.
“Yeah. It is really interesting,” I mutter bleakly.
The Surgery Oral Examination Summarized
After weeks of studying, it had come down to this day: the surgery oral examination. Historically, it has remained one of the most challenging exams in third year. It covers a wide variety of subspecialties to great depth; of course, who can forget the intimidation factor of a face to face interrogation?
I went into the first station, sheer terror gripping tight my heart with icy fingers, knowing full well what merciless horrors senior students had suffered in this hour in years past. I hoped I was up to the job.
I was not prepared for what I was about to endure.
From the moment I was seated and the timer started, the questions lay siege. An unrelenting torrent that had me choking and drowning in my own words. The surgeons meticulously picked apart my answers and showed me how wrong some of my answers were.
It was a sorry sight indeed; the other stations were no better.
I felt embarrassed, shamed and defeated. I had not only come face to face with the expectations of the surgeon and fell well short, but I had come face to face with my own. Worse than the biting comments of a surgeon was knowing that I had let myself down.
Having said that, the entire exam took me to that space that is often talked about but not always explored: the space of the unknown. The surgeons today forced me inwards and ripped from the depths of my mind the large voids in my knowledge. And though the experience getting there was not a pleasant one, I must move past this and press onward with the hope that I can retrace my steps to this sacred place in my knowledge scape and rebuild.
End of Dictation
Today, I was given the opportunity to dictate on two patients for whom I had done initial consults ahead of the doctor.
“Have you ever dictated before?” I shook my head. It was one of the skills I was to develop over the course of this year. Not wanting to lose this chance, I offered to give the dictations a shot.
“She’s all yours. We all have to start somewhere,” he agreed as he motioned me to the dictation room.
The phone sat on the desk. Stoic. Unflinching. Ready. I sat into the chair, fumbling through my notes and the patient charts as I tried to gather my thoughts.
So I got sick…
18 hour days? Check.
Sleepless hospital call? Check.
Stress? Check.
Clerkship 1; Tom 0.
It was a recipe for falling ill. I had been spending extra time on the maternity ward for days to get more experience. It is one of the few rotations where your learning opportunities are not dictated by a schedule. Babies simply do not come out between seven to seven. As a student, still learning the ropes, I simply have to make myself available. At all times. Every day.
I finished hospital call on Friday morning with a terrible headache. I still had ward rounds to do with my preceptor. My focus waned as we saw our patients from the day before. “Great work,” he said. “I will call you if anything comes up today.” I had forgotten I had signed up to join my preceptor for his call as well. Not wanting to look unenthusiastic, I nodded. I wondered in that moment if I had made the right call. Could a quick nap make my headache go away?
I would not have to wait long for an answer.
By noon, I felt even sicker, a knot in my stomach, nausea settling in and a pounding in my chest. It was a sure sign: I was in no shape to see patients. I called apologetically to the doctor.
“That is quite alright,” came his reply. “Take care of yourself because no one else will. Hope you feel better soon.”
He was right. No one is responsible for my health but myself. I had let the situation spiral out of control. The balance had tipped out of my favour. I had dropped the ball. But now came the slow recovery, back to a healthy state, back to a working state, back to feeling a hundred percent.
I hope to get there by Monday.
A Near Forgotten Feeling
Last night was special.
The call room was left unoccupied. Our pagers were turned off. Our homes sat silently in the dark. No books were read. No notes were taken.
Instead, we had a pleasant evening together at a pub. We ate and drank, told stories and laughed merrily. As we sat there, changed out of our now-typical collared and pressed business attire into shirts and jeans, my mind wandered back to an old life.
Our conversations, far removed from medical jargon and clinical cases, had me fooled that I would wake up the next day without rounds, consults, or procedures. It had me fooled that I would wake up the next day without a long list of things to do, to read, and to know. It had me fooled that I may wake up the next day stress-free.
Last night was special.
It brought us back to a social life that the isolation of relentless studying had shuttered out. It brought us back to a simpler life that weekend calls and late nights have complicated. It brought me back to a near forgotten feeling of normalcy.
Safety First
As I got ready to clock out for the night, I was paged by the surgeon to assess an emergent case in the surgical ward. A plan was set: we would rendez-vous upstairs to speak with the patient and review the chart.
The polaroid snapshot of the injury slowly faded into view as the patient told his story: a high impact trauma to the upper leg…non-weight-bearing…decreased mechanical function…swelling…pain…
Emergency physicians had already ordered x-rays an hour before; the scans and the radiologist’s report would be available on the computer by this time. However, when a picture is worth a thousand words, a radiologist’s report really does not do it justice.
In one word, it was “bad.”
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