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Executive Times |
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2008 Book Reviews |
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Final
Exam: A Surgeon's Reflections on Mortality by Pauline Chen |
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Rating: |
*** |
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(Recommended) |
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Click
on title or picture to buy from amazon.com |
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Worrying Liver
transplant surgeon Pauline Chen shares many stories from her experience as a
doctor in her book Final
Exam: A Surgeon’s Reflections on Mortality. Training doesn’t necessarily
prepare physicians for their own complicated feelings when their patients
die. With wisdom and understanding, Chen expresses her feelings and reactions
when her patients face death. Here’s an excerpt, from the beginning of
Chapter 3, pp. 55-: Every
morning around 7:20 in the hospital where I trained, the junior residents
would gather in the cafeteria for breakfast. Work rounds would be done, and
the senior residents and chiefs would have already gone off to the operating
rooms for the day, leaving us junior residents with lists of scut to complete
before evening rounds. In
the midst of overwhelming days, these fifteen minutes in the cafeteria were
a symbol of our united defiance. We would put all but the most urgent pages
on hold and stake out the same section of tables on the far end of the
cafeteria. Together, we would cavalierly devour what we called the “cardiac
special,” an intoxicating, heart-stopping, artery-clogging glob of eggs, cheese,
and sausage between a grilled kaiser roll—the caloric equivalent of a clay’s
worth of meals—and then poke fun at those attendings and senior residents in
whose thrall we normally cowered. We learned to squeeze a day’s worth of
socializing and gossip into fifteen minutes, and by the end of those brief
breakfasts, we would trudge back to the wards, our bellies and souls filled. Inevitably
these hurried conversations ended up centering on work—how much there was,
what we had to do, and how our lives were unbelievably difficult because of
it. We would take turns spinning our own tales of woe; it was, alter all, a
personal badge of honor not only to have lived through such horrors hut also
to have survived intact enough to join everyone else at the breakfast table.
There were stories about “crashing” patients, those whose clinical courses
took a sudden turn for the worse, traumas that involved half a dozen victims,
and, of course, chief residents or attending surgeons who reprimanded
unreasonably. All of us would talk, each with a horror story worse than the
others, the subtext always being that the person who told the worst tale was
the hardest-working, and therefore best, intern. One
morning late in my internship, the intern taking care of Mr. Roberts began
talking. We were all quiet because we knew that no one could outdo him. John
Roberts had been in the hospital longer than we had been interns, and every
one of us dreaded the month when we would have to take care of him. Mr.
Roberts had a particularly intractable case of Crohn’s disease, an
inflammatory disease of the bowel that can result in pain, diarrhea,
bleeding, and blockage of the intestines. Mr. Roberts had had several
blockages and operations previously, but on this hospital admission, his blocked
bowel was so inflamed that even the gentlest surgeon’s fingers wreaked chaos
in their path. He
never healed. One loop of his bowel stuck up against the wall of his abdomen
and developed a fistula, a tunnel between that bowel and the outside that leaked
abdominal contents through the nearest opening, his incision wound. Copious
amounts of fluid with ribbons of green bile and flecks of sloughed tissue
splashed daily onto Mr. Roberts, breaking up any tenuous skin cells that
tried to cover both the wound and the fistula. In an effort to decrease the
amount of fluid coming out from his bowel, the medical staff forbade Mr.
Roberts from eating and nourished him instead with bags of intravenous
nutrition. The nurses set up suction tubing to clear the liters of secretion,
but his dressings still saturated quickly, turning the skin around the wound
into a waterlogged mess. Mr. Roberts thus passed the days alone in his
hospital room hooked up, sucked on, and bathing in his own intestinal
contents. By
the time my turn came to care for him, Mr. Roberts had been hospitalized for
six months. I dreaded going into that room. Every morning when I went in to
examine him, lie looked neither at me nor at what I was doing. The shades
were always drawn, and the smell of skin soaked in small bowel contents, a
strangely sweet, less intense version of rotting pears, permeated the room.
His answers to my awkward attempts at conversation were usually terse. And I
always felt like part of the cause of his misery. Even if I had not been at
the operation and even if there had been no other alternative than surgery,
entering that room made me feel more a part of the brethren of medicine than
any other thing I did that year. He
was thin, that much was easy to tell from the gaunt figure that lay on the
bed. He had a pleasant face—oval but chiseled by male hormones. And he was
tall; his legs were always bent up, and even then his feet hit the end of his
bed. The nurses had miraculously rigged up a way to move all his
accoutrements, but I saw him outside the room only once, escorted by a nurse
who pushed along the pole and cart that carried the bags of intravenous
nutrition and the tangle of suction tubing. I was shocked hut recovered
quickly enough to stop and say hello. Mr. Roberts looked at me for a moment,
as if he was trying to focus his eyes on my face and could not
quite remember who I was. He smiled and then, looking at my white coat, said,
“Hi, Doctor.” So
when the intern who was in charge of Mr. Roberts that month began to talk, none
of us dared utter a word. Instead we sat mute, eating our breakfasts and
relieved for once not to be the best intern. Mr.
Roberts was not getting better, and the surgeon in charge was contemplating
surgery. It was a drastic step; Mr. Roberts would have to gamble on the slim
hope that surgery would help, even though the odds were that it would only
complicate things further. Or he could choose to live out the rest of his
life in his current state. Even at our tender ages, the choice seemed
excruciatingly difficult for a man who was not yet fifty. As the intern
continued to speak, his beeper went off. He looked at it. “It’s Roberts’s
floor. I bet it’s his nurse.” We watched our fellow intern as he took one
last bite from his roll and started walking out of the cafeteria, coffee cup
in hand. John
Roberts died a week later without the surgery. His death was the topic of
discussion the next morning at breakfast, and a few of the second-year
residents weighed in with their opinions. “You know every class of interns
has a patient like Roberts, someone who is in the hospital for the entire
year,” said one of them. “We had a guy like that, too.” The two other
second-year residents nodded, smiling and remembering their “John Roberts.”
By virtue of the several thousands of hours of clinical experience they had
acquired in the year before us, they seemed infinitely wiser than we interns
were. Another
second-year resident began to talk. “The key,” he said, “is not being the
poor sucker that’s on the service when the guy dies. You do everything to
keep that guy alive until you rotate off-service.” The interns all looked at him. We leaned in,
waiting fur the punch line. The resident took a bite of his breakfast sandwich
and began waving it around, like a professor at his chalkboard. “You do
everything to keep the guy alive because you don’t want to he the poor
bastard who has to go through a year of medical charts to dictate the death
note.” We
all sat back. All of us had humbled through discharge dictations on patients
we hardly knew; it required wading through the charts late at night after all
the ward work had been done and piecing together events from scrawled,
usually illegible notations. For John Roberts’s dictation, I envisioned our
fellow intern sitting in front of a colossal tower of charts for an entire
sacred weekend off. The following year when I heard that the next
intern class’s “John Roberts” had died, I remembered my Mr. Roberts and the
awkward morning visits, the smell of his bowel contents on skin, and the
gnawing discomfort I felt every time I left his room to eat the breakfast he
never could. Two years later, when another similar patient died, my best
friend in residency, Celia, and I spent a few minutes over dinner
remembering Mr. Roberts and discussing his medical case before we went off to
see our next patient. Thanks
to Chen’s fine writing, Final Exam
comes alive for all readers. She worries about her patients, and whether she
has done all she can for them. By sharing her introspection and reflections,
readers can appreciate what many doctors grapple with daily, and how, as
patients, we are part of being together with those doctors in a struggle that
for all of us eventually ends in death. Steve
Hopkins, February 21, 2008 |
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The recommendation rating for
this book appeared in the March 2008 issue of Executive Times URL for this review: http://www.hopkinsandcompany.com/Books/Final Exam.htm For Reprint Permission, Contact: Hopkins & Company, LLC • E-mail: books@hopkinsandcompany.com |
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