From THIS WON'T HURT A BIT (and other white lies):
MY EDUCATION IN MEDICINE AND MOTHERHOOD
By Michelle Au, MD
Grand Central Publishing, May 2011
Excerpt from Chapter 1: Apologia
What is happening now is this: I am wearing a pair of too-large latex gloves, with my right hand reaching up between an 85 year-old man’s legs, searching for his anus.
He is a large man, over 300 pounds and extremely demented, flanked on one side by my intern and on the other by his nurse, who are both struggling, holding his legs apart to aid me in the hunt. My goal is to stick my index finger into his rectum and retrieve a piece of stool, so that I might smear said stool on a card to check for occult bleeding in his gastrointestinal tract.
But I am not thinking about occult bleeding in the gastrointestinal tract, or this patient, or his multiple medical problems, or his anxious wife hovering outside, one ear to the door, listening to everything. What I am thinking about is how it is now 5:00pm and I still haven’t eaten lunch, and how right after the ritual smearing-of-card-with-poop, I will be making a beeline to the nurses station, where I think I saw a few stale bagels laid out, left over from Grand Rounds this morning. I am going to eat those bagels, I think with a grim determination as I insinuate my gloved hand into a fold.
“Help me!” the patient screams. “They’re stealing my money!”
“IT'S OK, MR. MOSKOWITZ, WE'RE JUST DOING A QUICK TEST, WE'LL BE FINISHED SOON,” the resident bellows, in that tone of false, gritted-teeth cheer completely familiar to anyone who has spent any time at all in a hospital. I am a third-year medical student, and this is my General Surgery rotation. Despite the rosy notions with which I started my medical training, that even as a medical student I would be Helping People and Making a Difference and perhaps showcasing my flawless diagnostic acumen honed after two years in front of textbooks, making neat but never showy saves while my overtired resident sat oblivious in the corner with a pile of charts—what I had come to learn over the last year was that in the world of academic medicine, students are viewed as being good for only three things. Writing long, overly detailed notes in the charts that no one, save other medical students, will ever read; changing CDs on the operating room stereo while the surgeons are scrubbed into a case; and doing the menial dirty work that no resident would ever do if he or she could find some way to avoid it.
“Help me! Help! Aaaah!” Mr. Moskowitz is still screaming. I wonder what this must sound like to his roommate, who is cowering silently on the other side of the pulled curtain.
“Did you get it yet?” My resident looks sweaty and harassed, holding up Mr. Moskowitz’s legs, trying to clear a path of flesh enough for me to get where I need to go. I can read his face and see that he is thinking about the other twenty-three patients on his list, and all the things he needs to do before he can sign them out to the overnight resident and go home. His pager goes off again, the second time since we’ve been in the room.
“Umm, almost.” Not wanting to be branded as the med student who couldn’t even find a patient’s asshole, I don’t have the heart to tell him that I’m not even close. Gingerly, with my left hand, I lift up Mr. Moskowitz’s scrotum, figuring that whatever crack lies in the middle underneath is most probably my best bet. I find what looks like a promising track, and with my gloved hand, start to work my way backwards within the fold.
“Did you Surgilube up?” My resident is starting to look the way I feel—like he wishes that he were dead.
“Surgilube? Uh…no, I forgot.” Silently, but with perhaps as much contempt as one can express without saying a word, the nurse rips open a pack of water-soluble lubricant and squirts a dollop onto a piece of dry gauze. I reach up, almost losing my glove in the process, and coat my right index finger with the gloppy clear goo. “Thanks.” The nurse just exhales forcefully through her nose.
“Now go for it,” my resident says to me. To the patient, about 20 decibels louder, he adds, “OK NOW, ALMOST DONE! JUST ANOTHER SECOND!” Perhaps as an indictment of my skill, Mr. Moskowitz gazes off into middle distance and farts.
“OK, I just need a little bit longer.” I follow the same fold of skin backwards, figuring that at some point I will hit a puckered hiatus, reach in, hit paydirt, and end this nightmare for all of us. I move posterior, more, and then some more, until my hand is down against the bed. Nothing but a dead end. How could there be nothing there? Is it possible he doesn’t have an anus?
“What can we do to help?” My resident asks, in a tone of voice that leaves no question: finish this thing or I am going to kill you.
“Maybe...maybe lift him up a little more?” Grunting and straining, the resident and nurse manage to roll Mr. Moskowitz’s butt up a few more inches. Reaching back further, sweaty and hungry and desperate for a chance to wash my hands, I finally feel what I’m looking for. Poking one lubed finger through, I find a piece of stool perilously close to the surface, and with a small hooking motion, scrape a small piece off and pull my hand out. Panting, I look at my gloved finger with the small piece of fecal matter balancing on the tip, and feel absurdly pleased.
My resident is already snapping off his gloves and heading out of the room. “Let me know if it’s positive,” he says as he’s walking out the door—to the patient’s wife, waiting outside, he shouts, “HE DID GREAT, WE SHOULD HAVE THOSE RESULTS IN JUST A FEW MINUTES, OK?” slowing down but not stopping. And then he’s gone.
I’m still standing there with my brown-tinged finger. “Wait, now what do I do?” The nurse silently hands me the card and the bottle of developer. I scrape some of the stool onto the little windows on the front of the card and drip on some of the clear developer fluid. If the test is positive for blood, the fluid around the stool should turn a grayish-blue after three minutes. If it’s negative for blood, there will be no color change. I take the card, stick it into a clean glove, and then put the whole package into my pocket, figuring I will check it again once three minutes has elapsed. “Mr. Moskowitz, the test is finished. I’m sorry if it was unpleasant,” I say as I pull down his hospital gown and replace the bedsheet over his chest.
“They stole everything from me, you know,” he says conversationally. Then, as if it’s somehow related, he adds, “You’re a good girl.” I guess all is forgiven.
I wash my hands and walk back to the nursing station, where I find that someone has already eaten the rest of the day-old bagels. I rescue a few stray poppy seeds and stick them in my mouth morosely, feeling like Oliver Twist almost relishing this pathetic tableau. Just then, I see my boyfriend Joe, a fellow medical student rotating through the Vascular Surgery service while I’m on Colorectal. “How’s it going?” he asks.
“Shitty. It just took me about half an hour to guaiac some guy because I couldn’t find his asshole.”
He makes a sympathetic noise. “Don’t feel bad. My resident just told Andy and I to Foley some lady,” (that is, to insert a Foley catheter into her urethra to drain the bladder) “and Andy accidentally tried to catheterize her clitoris.”
I made a pained face. “Hmm. But actually, that does make me feel better.” Joe makes a see you later gesture before walking away, and I pull out the guaiac card from the glove in my pocket to check on the results. The test window is a light grayish color. While it is clear that a deep grayish blue would be Bad and no color change would be Good, I really don’t know what to make of the light gray. As if on cue, my pager goes off. It’s my resident.
“So what did the guaiac show?” he asks when I call him back. The noise in the background sounds like he’s at another nursing station, and I hear voices in the background, as if he’s simultaneously having another conversation while on the phone with me. “Yeah. No, the other guy with the perf. Tomorrow.” And then a little louder, into the receiver, “Was it positive?”
“Uh, the guaiac? Um…see…” I’m not really sure what to tell him. “I think it could be positive, but it’s not, like, so positive. Like, instead of really dark blue, it’s only tinted light grey, but it’s not, you know, nothing. So I can’t really say that it’s negative either. It’s sort of…so-so.”
There is a silence. “I’ll come by and take a look.” And with an aggrieved sigh and some unintelligible mutter, he hangs up. I wonder if I am the stupidest medical student he’s ever worked with. I wonder if I am the stupidest medical student in the class. I wonder if it’s possible to get kicked out of medical school for being unable to interpret the results of a stool guaiac. And now the nurse is yelling at me because I accidentally left the guaiac card with its hard-won brown smears on the table next to the empty bagel tray, and people eat at this table, don’t you even know you shouldn’t be bringing patient samples back behind the desk, what in the hell is wrong with you?
Want to read more?
Or read another excerpt from the book, about the events of September 11th, 2001.