Friday, February 15, 2008


It has been an incredibly long time since I last wrote. Not mere notations, preoperative histories, postoperative orders, consultations, but really written. Words that get translated into emotions, the breath of life into a string of words that make a sentence. My very own personal black and white emoticon. I feel stiffled. Being in my last year, all I ever seem to do is study. It wraps its black, heavy hands around me and envelopes me in frustration and discourage. I live the textbooks and motivated by the fear of failure, I drum it into my being. Tattoos of drug doses, anesthetic considerations and minute rubishy minutiae into my skin.

Even with this, I realize my lessons in Africa, and still believe that freedom is another word for nothing left to lose. I also realize that I am bound by my fear, it eats me slowly like a growing cancer and there is little I can do to prevent it from metastasizing. You see, now I have everything to lose. I have decided that I am committed to going back to the 3rd world. To help, to teach and of course for myself to learn. I have gained far more in terms of perspective, knowledge of myself and my husband and our relationship than I have ever given. Please let me tell you a story.

I had been back over 2 weeks. Africa had changed me, people said they saw it, a confidence, an aura, a deeper knowledge of sort. I was on call, and I looked at the list.

"Oh, no an organ harvest. What are we taking?"

Why did I hate organ retrievals so much? The anesthetic is easy, no? The patient is already brain dead, what else could possibly be worse? (now with all my studying, I can rhyme off a list of goals and considerations, but that was then...).

I will enlighten you. Yes, it is true, the patient is brain dead and yes, from my perspective, there is minimal intervention, all the lines are started and the patient is intubated. But, it isn't really the anesthetic that is so difficult. Its the emotional experience, the investment of your personal self into the patient.

When a patient is brought into the room, there is an emotional tie between you and he or she. It is so intensely personal, for the duration of the surgery, you are the primary caregiver, you dictate each breath, each heart beat, every movement or inaction. It is a huge responsibility and inevitably there is the investment of self, of thought, of empathy. In my first year of residency I was working with a staff man who angered me immensely by a single sentence. We were slated to do an organ retrieval and the patient was in ICU. With a single nonchalence sentence he made me lose all respect for him and fired me with a certainty that I would never, ever lose this ability to feel and care for my patient as a person. What he said to me was "come on, lets go get our bag of goodies".

But that is a different story. To continue, I went to the ICU to pick up my current patient. She was young, a victim of homicide. The car she was in crashed into a wall after her pimp had gotten high and driven off with her. She was of native descent, her hair, partly shaven off was dark and past her shoulders. It was matted with blood and dirt and wrapped with dressings. The other doctors had done all they could to save her. I watched her blood pressure, her central venous pressure and monitored her end tidal carbon dioxide. Each breath I took, she took. I tried not to look at her. I tried not to see her. I didn't even know her first name, just her surname and the ICU bed. By distancing my self, placing blinders, I protected my emotional self. This is what doctors learn to do, to not cry when their patient dies or is dying, to leave the emotional baggage at work and to walk home to be covered by the purifying showers of oblivion, their family, their friends. Thus, this too is what I did.

Organ harvesting is all about timing and temperature. There are usually two teams involved. One team will initially start to harvest the liver, pancreas, kidneys because that takes time to dissect and in the last few moments of supported artificial life, the cardiac surgeon waltzes in and in a fluorish of self importance and disdain yell out "lungs down" and "lungs up" when attacking the sternum with a saw. Then you see the thoracic cavity, the large arteries and veins and the beautiful interconnected system of the heart and lungs. Nothing is as beautiful, not even the lazy leopard, as the working heart and lungs.

The cardiac surgeon usually is dark, with intense eyes and quick, decisive movements. Ergonomics and efficiency at its best. The heart is usually taken first, it is the organ that is most at risk of ischemic injury. Then they infuse the lungs with cold Winnipeg's Solution. A solution of different salts, sugars at a particular pH to optimize preservation of the organs. It is at the point when the heart's arteries is perfused with a solution in readiness for removal, that the moment that I despise the most occurs. I watch my monitor, and see the wavelength lengthen, widening, to attempts of heart beats that we call agonal beats. The heart slowly stops and most people turn off the monitors. I usually say a prayer for the patient at this point..."eternal rest grant unto her O' Lord, let perpetual light shine upon her, may she rest in peace..." Sometimes I stroke the hair and attempt to straighten the lines. This is my private time for goodbye, silent heart, lungs no longer needing breath, this is when I let them go, even though they were not there to begin with.

Watching the slowing heart mesmerizes me. Even with the monitors off, the patient no longer needing my care, I usually stay and watch the retrieval of the lungs. This time the Winnipeg's solution was very cold and I watched with fascination, the lungs lose the blood and the alveoli fill with cold solution. It made the lungs turn white, with streaks of light grey. The East Indian surgeon gently dissects the lungs from the thorax and for a shining truthful moment he lift the white lungs into the air. I watched it and time stood still. The lungs floated, white and shiny and with both dome like shapes in the air, they looked like Angel wings. Surprised I took a breath in and in awe said to my current staff.."don't they look like Angel's wings?".

"Shhhhh", he whacks my arm, "don't say that"

It was then, a realization, a clarity, another moment that compounds my belief that there are no such things as coincidences in life. While the patients heart was silent, mine pounded and I thought of the hope that the organs would bring to the recipient. A new life, a growing ability to foresee a future, for now there was a future, optimism, a chance at a second life. It was hope embodied as a pair of lungs which looked to me like Angel's wings.

Later, much later, when the fading image of the white lungs dissipated, I spoke to the nurses, told them about the whiteness of the lungs, how I had never seen it before, that it made me think of wings. The nurse shuddered. She looked at me strangely, a sidelong glance. "What is it?"

"Don't you know? Don't you truly know? that patient we just did the harvest on, her first name is Angel"

There truly are no coincidences in life.