The grit you feel

An image of a pearl came to mind as I got to know Meril. She was a born-and-raised midwest woman, and her friendliness was characteristic of the region. She was the wife to a farmer, a mother to three farmers, and a soon-to-be grandmother to perhaps a painter but probably a farmer. She had never left the state and had never taken what I would call a vacation. She was average height, average weight, and lived a life seemingly of routine. She did not impress me with sophistication, enchantment, or elegance, and it was precisely because Meril did not possess these qualities that she reminded me of a pearl. The baseline similarities between the patients on the floor and the standardization of health-care delivery made it easy to think of every patient as another pearl threaded onto a string full of them. Meril became pearl #17, neighboring pearl #16 next to her, and soon #18 following her.

Meril had been diagnosed with Crohn’s disease some decades ago, but her disease had been stable up until the last few years. Except for a couple hernia repairs, Meril had been a stranger to the hospital and had an unexciting surgical history, which was the service she now presented to with a perforated bowel.

I was a third-year medical student just beginning my general surgery rotation. I started with the idea that the rotation would coax my desire for a surgical specialty like a bellow to a flame. The theater of surgery was alluring. I enjoyed the anticipation of what felt like a performance about to begin, a mixture of growing impatience and delight, that I felt time and time again as I walked through the operating room (OR) doors. The lights and the dance between tool and operator on flesh and bone mesmerized me.

Meril’s performance was, in general, a success. Her perforation was micro in size, reminding me of how I was taught to patch a blown bike tire when I was living in West Africa as a Peace Corps volunteer. Water could be used to spot the hole in the tubing if it was too small to see. Sections of the bike tube could be pushed under water and with a slight squeeze, bubbles would appear when the hole was submerged, thereby showing where the patch was needed. Luckily, we didn’t need a bowl of water to locate the hole in Meril’s bowel, which was patched perfectly, but we were presented with a problem as we were closing. In accessing Meril’s bowel, we had cut out a considerable amount of scar tissue as well as the mesh from her most recent hernia repair. As a result, there was inadequate tissue to close her midline incision with enough laxity to avoid the possibility of evisceration. To remedy the situation, the attending performed a procedure called a component separation, which involved deeply dissecting Meril’s abdominal muscles free from neighboring tissue so that they could be manipulated more easily and brought together at the site of her incision. It is a procedure not commonly performed, and I can remember a subtle look of concern on the attending’s face when the incision was finally closed. He was not concerned for fear that his expertise was insufficient, but rather that the necessity for this technique would be a harbinger of an uncertain recovery. The attending took me aside after Meril was wheeled out.

“He who takes the knife to a Crohn’s patient should dig two graves,” he said. I nodded enthusiastically in agreement, but his words sounded repetitive after having seen with my grandfather what felt like every Western movie ever made. I hadn’t been around enough to see anyone else take the knife to a patient with Crohn’s, so I let his words fade away.

My residents told me the exact questions I should ask patients in the days following abdominal surgery. The list included questions such as “Have you had a bowel movement?” “Have you passed any gas?” and “Have you been out of bed?” I clung to this list of questions as the backbone of my prerounds, and some mornings they constituted the only conversation I had with the patient. This was the case when I saw Meril on her first-day post-op. My inability that morning to explore her life beyond what I saw in front of me was a product of false presumptions. In my tremendously limited experience in the OR, I had already let myself fall victim to the subconscious belief that if the surgery was successful so too would be the recovery. I did not give it a moment’s pause that her recovery, despite her disease and the attending’s forewarning, would be any more complicated than that of pearl #16 who had a laparoscopic cholecystectomy or pearl #18 who was having an appendectomy. I figured the routine questions would be all I would need to know. I thought she’d likely be up and out soon enough, our paths likely never crossing again. She reported improvement in her pain that morning and over the following days reaffirming my decision to stick to my list.

Then, maybe four or five days after her procedure, came the day when the trend of Meril’s progress was bucked. In fact, her status was quickly collapsing. All of a sudden she reported uncontrollable, searing pain at her side and what had previously been a pretty picture of stepwise construction toward rehabilitation was now crumbling like a building whose support beams could no longer resist its weight. The component separation had failed, but not where her muscles were forced to meet at her incision site. Instead, her abdominal muscles had ripped posteriorly off her bones, like meat torn from a drumstick. An encore performance was scheduled, but unlike the last one, there was never a feeling of success. Her muscles were reattached to her bones, but her incision stitches had to be cut to relieve the tension. To cover the spotlight into her abdominal cavity, we used a delicate and expensive porcine mesh. Meril’s patch covered nearly the entirety of her anterior abdominal wall and while it allowed Meril to maintain ownership of her organs, it came at a cost. The integrity of the mesh had to be guaranteed, meaning it needed to be regularly monitored and routinely moistened. For us to do this, we were forced to leave her incision open. So on Meril’s second post-op day 1, she laid in bed with an open hole in her belly. In fact, the hole was less in her belly than it was her belly.

Even when she was in searing pain, Meril maintained a hopeful front as she had following her first surgery. Her pain was at its worst when we had to change her dressing, which was a daily task. Quickly, I learned the edges of her skin that were the most sensitized, those which when touched lightly with a cotton swab would cause her to cut her breath short in pain. I learned how slowly to unpack her wound, which was always far more painful for her than repacking it again with damp sterile gauze. When the team walked in every afternoon for her change, she would prophylactically press her patient-controlled analgesia (PCA) button a few times and turn her head away before we uncovered her abdomen to reveal the beefy red margins of her skin and subcutaneous tissue and white porcine mesh. I only remember one time when her interest trumped her instincts and she did not look away but watched our hands under her skin. In that instance, she showed me how quickly blood could rush from a person’s face. As torturing as this was, Meril never let her pain get the best of her. She could wince, press her button, and at times tell us evenly that the pain was becoming unbearable, but she never lost her composure and would always thank us after we were done.

I’m guilty of too easily thinking of pain management from a singular perspective. I’ve often reflexively relied on the idea that adequate pain control could be as easy as Meril pushing her PCA button. There are times when I have failed to appraise different types of pain other than physical. A cut in the belly had seemed more damaging than loneliness, and perhaps it’s the relative ease with which the pain from a cut can be addressed that makes it always seem more of a priority.

I stopped believing that Meril’s recovery was guaranteed. The fear she had at the beginning of her admission that she may never leave was now an unspoken fear I shared. Making matters worse, the length of her hospital stay had made it more difficult for her husband and children to visit as often as they had at the beginning. It was routine to find her husband alert and by her side the days after her admission, but since her second surgery I usually found her alone in the mornings with no evidence that her husband had slept beside her. This is when I began to notice a change in Meril’s attitude. Her hope was being slowly smothered, as she was forced to confront reality, alone. My view of Meril as a surgical case, an outcome, and another pearl on the string was expanding. I was beginning to see my mother lying in bed day after day with a hole in her gut being drained not as much by the physical pain as by the psychological pain.

I no longer stood at Meril’s bedside rattling off my list of questions. Instead, I sat next to her in the recliner where her husband once slept and I cast aside my mental list. I asked her what she enjoyed doing beyond her familiar hospital room walls, only to find that surfacing memories of her normal life had a tendency to make her feel worse. It was difficult for me to engage with her. I hadn’t met patients who had become so sick so quickly, and whose future was so uncertain. What was particularly difficult was the acuity of her condition. Meril, two weeks ago, had been with her family in their farmhouse, cooking and baking and playing Euchre in the evening after dinner. She hadn’t been concerned about her future because things were stable, but now all of a sudden her life was a distant past and she was ashamed to think she had taken the good parts for granted. I never thought of myself as someone who could organically ask engaging questions to relative strangers, but I wanted to distract her and so I decided to tell her stories. It took a little while for her to warm to the idea, but quickly, there was one story that she particularly enjoyed and asked me to retell.

It was the story of a particular day when I was living in West Africa. The village I was living in was small and quiet and made up of farmers, mostly. Their animals, of the classic farm variety, were given total freedom within the village during the day. Goats, chickens, and donkeys wandered from one courtyard to the next, as if they were tasked with daily audits of neighboring property. The noises they would make could sometimes be extremely annoying, and on one morning, the noises started early. I saw a baby goat, born in the night, standing below my bedroom window next to its mother and bleating incessantly for no good reason. I distanced myself on the porch where I spent the rest of the morning reading, my senses soon numb to the noise. However, around midday, there was an abrupt change in the bleating of the baby goat and within seconds, a full-grown hog came running across my courtyard. Hanging from its jowls was the baby goat. As soon as the hog rounded the far corner on the other side of the courtyard, the mother goat came into view in frantic pursuit, and after her came four laughing boys desperate for entertainment.

I watched this train of chaos from my porch and where buildings obscured my view I followed along by listening to the sounds of terror and excitement. At some point, the pig must have grown tired and released its hold on the baby goat, who I envisioned running wildly back to the relative safety of its mother’s underbelly. But it’s mother rejected it. I know this because later, after the village had recovered from the commotion, I found the baby goat in my courtyard’s latrine. It had snuck in through a crack in the door and was hugging the only corner shrouded in shade. It’s legs were trembling. It was oblivious, likely delirious and shell shocked, and allowed me to collect it in my hands without a fight. I adopted him on the spot. I named him Charlie and imagined that one day he could become my guard goat, putting a stop to the daily animal intrusion on my courtyard, and I could help him seek revenge on the hog that destroyed his purity. Recognizing his weakness, I hustled into my house, reconstituted some powdered milk, and grabbed the dropper I used to sanitize my water. I rushed outside to feed my goat boy, but he wouldn’t take it. I went back inside, threw down the dropper, stared at the milk on my table, and mentally ran through the things I owned that could pass as a nipple. Luck struck quickly and I began searching for a condom. I thought to myself that the reservoir at its end would be a perfect replica of a goat’s nipple. I found one, punctured the end, poured milk into it, and sprang back outside. To my relief and feeling the satisfaction of a successful mother, Charlie took it vigorously and drank an entire condoms volume of calorically insufficient milk, but fluid and food nonetheless.

What I was doing was not going unnoticed. I was always watched, at times for nothing more than being a tall, white American man. So on a normal day, there was usually a small audience, but on that day, I was putting on a special performance and word spread rapidly. The villagers watched bewildered, as I jogged back and forth from my house to the latrine with a condom that at one moment was full and the next completely empty. The temptation to investigate was unbearable, and it wasn’t long before a man wiser than me approached the latrine and discovered what I was doing. He assigned some children to capture the real mother goat, and in a flash, they brought her to the courtyard and pinned her to the ground. The man clutched Charlie and shoved his mouth to his mother’s tit. He latched, the true mother bleated, and we watched for a few moments to see whether their bond had been mended. Eventually, the kids let up and everyone began to walk away, including the mother goat with her born-again baby chasing after her. I never saw the goats again.

A one-day-old goat galavanted throughout the village in the jowls of a pig, rejected by it’s real mother, and adopted by a tall, white American who fed it through a condom is a ludicrous story. Meril laughed until the pain in her belly cut her short, but it was a story that she resonated with, which is why I think she asked me to retell it so often. The more I told the story the more her laughs became quiet nods of solidarity. Her disease had unexpectedly and abruptly taken her away from her life. Her recovery had been anything but easy or routine. She was not holding her breath for a happy ending. I thought sometimes after listening to one of the stories she looked less anxious and more at ease. Her body wouldn’t be as tense, the demands of her pain seemed easier to quiet, and the muscles in her face, particularly those around her eyes, would relax.

“Do you think you’re the baby goat?” I asked her once after telling her the story for the third time. She bleated.

“If it comes to it, I’ll warn you before we have to feed you with a condom,” I told her.

“Just tell them I prefer cow’s milk,” she said.

I followed Meril over the entirety of my time on service. She was admitted on day 3 of my rotation and was not discharged before I switched to obstretics one month later. A couple of days before I had to switch rotations I asked her what her distractions were. Her answer was a nod to me and to the TV.

On my final day, I saw my patients as usual, saving Meril for last. She had known it was my last day and the day before she had told me that she was planning on throwing me a going-away party. I walked in and she yelled, “Surprise!” at me from an empty room that hadn’t changed from the day before.

“Don’t you like how I’ve decorated the place?” she asked.

“You must have been up all night,” I told her.

We chatted for a while and as the silence between comments grew longer and longer, I took out a book from my pocket.

“It’s Cat’s Cradle, by Kurt Vonnegut,” I told her. “You may have already read it, and you may not care to. It won’t hurt my feelings. But it’s one of my favorites, and it’s one of the best stories I’ve read in awhile.”

Two nurses, who had scampered in when Meril had yelled, looked at each other from opposite sides of the bed. One of them started to tear up. Meril looked at me with slight disappointment.

“I throw you this luxurious party, with all your friends,” she gestured to the nurses at her side, “And this is how you thank me?” She held up the book and a smile had slipped through her disguise.

We laughed and the weeping nurse started to look a little embarrassed to be weeping. I thanked Meril for the party, we said our goodbyes, and I walked out. I don’t know what happened to Meril. I don’t know if the construction of her clinical picture rose again finally reaching the point where she could walk out of the hospital against her biggest fear. Or, sadly, if that was the last bed she ever slept in and if that book was the last she ever read.

I think about Meril sometimes when I have a list of patients in my hand. I remember what I thought of Meril and all the patients she represented when I first met her, and then how that narrative changed. The funny thing about pearls is that when lined up on a string, they all look the same. They’re simple, perfectly rounded, and replicas of each other. But if you take the time to put one between your teeth, you remember that each one was made individually from thousands of pieces of sand and that no matter how much time passes, there will never be another pearl made exactly the same. The grit you feel with one in-between your teeth will always be unique.