Surgical Residency Graduation Speech

House without God


I thought it would be a good idea to reread The House of God. I had read the bitter satire of medical internship while I was in medical school, aghast by its lack of humanity, its cynicism, but realizing that it was written amidst the backdrop of Watergate and a country aggrieved by its leader, feeling cheated and licking its wounds. So too was the protagonist, who spent his days and nights charged with the care of GOMERS, the patients who won’t die no matter what you subject them to and The Yellow Man, the patient you want most to save and can’t. I reread the book during my surgical internship and ironically found myself envying the male camaraderie he found in his fellow interns and wished that my even more calls than he had were as “light” – it’s all relative.

I read page after page, with my own book going on in my head, recounting my own experiences, sorrows, joys. My back was propped up on the double window of my bedroom, overlooking farmer fields and a dusky skyline, my two cats that had been through med school, one curled under each of my arms, and Jack my black pound puppy, now grown and sleeping in his enormous pillow bed. The cats and I were used to having the bed to ourselves now. My husband John, had been gone almost a year, first in Louisiana, then deployed to Afghanistan for the past six months. He went to operatively stabilize the Army’s Special Forces and the Afghanis fighting Al Qaeda on the border of Pakistan, or at least to repay his monetary obligation for a medical school scholarship. Either way, he was gone, and my head swam with the years I had lain exhausted in the same bed, asking myself what this surgical training was all about for the past five years, sometimes laughing, usually crying, but always asking.

Exhaustion took hold, the book fell off my chest, and my mind went back years to my first months of internship. The first week was easy. I was so thrilled to be a part of a community I literally grew up in, the same hospital corridors I followed my father, a fast-walking surgical attending who used to race me down the stairwells as we’d crash into other people. I loved rounds. He dictated orders to me. I thought I wrote TPN. Stomas confused me, but after a while I figured some people just poop out their bellies. We went to the doctor’s lounge and stuffed cookies in our pockets. Twenty years later when I worked for him, I was thrilled when people referred to us as “the twins.” It never occurred to me that my training as a female would be any different than his. He never raised me to think I was any different, which is probably why I was confused for so many years.

I was almost finished with medical school and my husband with his internship when I got the call. I was doing a rural surgical clerkship when my husband reached me and said, “It’s your mother, she’s in a little bit of trouble.” For some reason, I thought he meant we may need to make bail for her -- she was rather feisty, but no. She had a Grade IV subarachnoid hemorrhage, and the cats and I drove five hours to find her getting a ventriculostomy to drain her head. As she deteriorated and needed intubation, we transferred her to Philadelphia, which happened to be down the street from where John and I lived in Olde City. My father moved in with us, in our one-bedroom apartment with the two cats and soon puppy Jack. After my mother’s aneurysm clipping, my father wrote his letter of resignation, retiring his practice of 44 years to be my mother’s nurse.

Months later we all moved back to Harrisburg, exhausted but relieved and on to a new adventure. What struck me so hard about internship was losing my life. No one can prepare you for 120-hour work weeks or staying up for days or the times you sleep at the hospital post-call because it’s too late, you’re too tired and it’s not safe to drive. Sometimes I got on the highway the wrong way. But I learned how to take care of patients, trial by fire, overwhelmed, one mistake at a time. As residents, we were like hungry stray dogs -- angry, tired, at each other’s throats, just trying to survive. We were institutionalized, trained to be hypervigilent of patient care in an abusive environment, but vigilant we were. My Chief Resident, with whom I would never initiate a conversation, told me not to let an attending or upper level see me eating or drinking coffee, that if I must have a bagel in the morning, stick it in my pocket and take it into a call room so no one would see me eat, “If they see you eating, they’ll assume you’re not working.”

I adjusted to institutionalized life. In early October, I got a page, “Dammit,” the automatic response. “Dr. Marshall, your mother’s in the emergency room.” I froze. The terror of the last year shot through me. I was prepared to lose my mother, again. As I walked to the ER, I choked on my own breath. There was my mother, standing, smiling, with a full head of hair, no scarf, holding out a piece of cake. “You missed Linda’s birthday; I wanted to make sure you got some cake.” I was ashamed. I hadn’t seen her to know that her hair had grown back. I’ll visit more often.

By Christmas, I was a complete zombie. On Christmas Eve, my husband paged me from his party. He was interceding in a fight over putting together a little girl’s bike, as our friends drank too much and argued over Christmas presents. John was drunk too, glad to be out of his own hospital, away from his own surgical residency, trying to forget that we had at best a long-distance marriage. I was hardly amused by the merriment, bitter and tired; I was packing up an 18 year old kid, shot in the neck, in spinal shock, climbing in the ambulance to help take him to the trauma center. Christmas Eve, you know, short-staffing. I heard he died one year later of pneumonia in a nursing home. Merry Christmas.

I drifted deeper into sleep as the sky grew dark, and I felt the “comfort” of second year, when I wasn’t the plebe and had the confidence to handle quite a bit on my own. At 2-3 central lines or dialysis catheters a day at my hospital, I had put in at least a hundred by second year. One thing you learn about lines is that it’s a feel thing, and it’s dangerous to back-seat drive. We hated it when an attending would come by, ostensibly to bill for the procedures that we did, but occasionally they gave direction. These were the same catheters that they didn’t know how much heparin went into the distal and proximal ports (“It’s written on the catheter,” we’d tell them.) So I unfortunately placed a 12Fr dialysis catheter into an old man, a supraclavicular subclavian artery cannulation, which I couldn’t have done if I had tried. Three hours later, I called the CT surgeon eating his spaghetti dinner with kids screaming in the background, the same one who had done my father’s CABG while I was a second-year medical student. “I’m telling you he’s got an expanding hematoma.” I fought with the ultrasound tech that was overworked, paid more than me, but didn’t want to come in. An hour later I was in the OR and watched as the code cart was pulled into the room and the anesthesiologist worked as hard as the surgeon. I thought I’d vomit in my mask. I called my father, crying, what have I done? The patient’s family embraced me. I was so upset, I think they felt sorry for me, and we actually formed a bond over the next several months as I took care of other family members. The oddest part was the stories that came out in the OR, the CT surgeon, my general surgery attending, the anesthesiologist, the senior resident on call with me, “Oh, one time I did worse than this…” It was like a group catharsis. The patient did fine. But we never forgot.

By the end of the year, I felt good about myself and my skills. I was pushed to my limits. I weathered months on Penn’s trauma service; I could do anything. One day in May, I spent six hours on a bladder cancer case. The attending left and of course the patient crumped. It was almost midnight; I was post call, not having slept the night before, in a strange hospital. Fortunately, I had gone to medical school with one of the residents there. I called him. “I can’t even spell my name right and this lady’s dying in front of me.” I wasn’t distraught because I didn’t know what to do, I wasn’t sure how I’d drive home that night and get up a few hours later to meet my sister in Maryland. I called my husband on my cell phone and made him talk me the 45 minutes home. I made it.

By June, I had an opportunity to transfer to another program, a “better” program, closer to home. The grass is always greener. Then you learn: there is no green grass. I left the hospital, the one I had grown up in, post call, of course, and drove to my parent’s house to, I don’t know, transition. Still dazed and sleepless, I picked up my cell phone to page Mike, my senior resident, feeling sentimental and wanting to express my gratitude for “bringing me up right.” The residents had taught me most everything I knew. The loud crash and choking smoke of my airbag woke me from my stupor as I totaled my car into the two in front of me. I got out and checked the other passengers, called my father to pick me up, dialed my husband who was scrubbed in the OR. His scrub nurse said he was busy and couldn’t take my call. I told her to tell him that I totaled my car and was at the side of the road. She said she’d give him the message. Just then Mike called back. “That’s the last time I thank you for anything,” I say.

So with no car, a stiff neck, and airbag burns, I started my new program as trauma chief two days later. Dr Clancy was signing on, switching from Dr Dawson, me and two brand new 2d years who had never done trauma. Out of the frying pan and into the fire. Thirty patients, half in the ICU, no sign out, how bad could it be? At 10:00, five hours into the day, my pager, that I didn’t know how to work went off, 2222. This was the code at my other hospital to announce that the residents were meeting for lunch. “That’s early,” I thought. “That’s a trauma!” Dr Clancy barked at me with utter scorn. “Oh, where’s the trauma bay?” He equally understood the following day, when I was unaware of the construction, and every single trauma floor patient had been moved to a different wing between the time I saw them and we took him on rounds to the empty ward. “They were here.” I don’t know why he didn’t think it was funny.

I spent the year wondering when I was going to operate but grateful for the opportunity to rotate through Memorial Sloan-Kettering and see how things were supposed to be done. By May of my third year, I was ready to do more than trauma, and had one day left before my breast conference in Atlanta. Home free. At 3PM the trauma buzzer went off – shit! A woman was pinned by a forklift and wheeled in as a trauma code. No Dr Dawson. I directed her code, bilateral chest tubes, lines, pericardiocentesis with blood return, positive DPL. Where was he? Dr Dawson flew in, chin raised, asked for report. She lost her pulses – again. We quit. People walked away. Dr. Dawson was out the trauma bay doors. “Wait,” I got pulses. Up to the OR we went: pericardial window, diaphragm repair, splenectomy, G-tube, J-tube, can’t remember what else. I saved her; I finally paid back karma because someone had saved my mother. I hugged the patient’s daughter as she cried. I understood the look in her eyes. I felt comforted, for a while. I heard she died six months later of pneumonia in a nursing home.

Just then my snooze alarm startled me. Not yet. Not yet. I groped for the button. The cats were purring. There was no way I was leaving the comfort of my bed. The sun was peaking up over the fields, and as always, I was the first one awake in my neighborhood. My fourth year of residency I mostly forgot. I guess it’s a defense mechanism. I became a patient myself and experienced the terror of facing a possible cancer diagnosis. My parents, John, and my best friend, Kristie stood by my side. The news was good and bad; I didn’t have cancer but I’d never have children. The rest of the year was a blur that I’ll try to forget forever, never wanting to believe that some people are truly inept.

When my snooze sounded for the second time, I didn’t want to get out of bed, didn’t want to go to work. John left for another time zone in July. I heard his frightening junior attending stories. He called my father for advice; I called my father to help take care of Jack. I tried to see John at an October meeting in New Orleans. I had my palm read and was assured nothing bad would happen that year. John deployed suddenly to a front unit in Afghanistan before Christmas, and my father died suddenly from cancer in January. I wondered if I could hold the palm reader liable. So Jack and the cats and I and Kristie picked up the pieces, again, we drank a lot of wine; I swam like a fish, walked in the woods. And then there was my service, my junior residents, my patients, my clinic, patients who asked to see me, and asked to take me to dinner, hugged me when they came for their appointments. I saw the new calm in their faces when I talked to them; I heard my father’s words but with my own twist. I learned to mother without being one. And that soothed me.

The alarm nagged for the last time. You’re right. Jack wanted out, the kitties were hungry, and it’s time to go to work.