Second Nature

It’s merely the second week of my rural rotation, and I feel like I have been here for a long time. In part because it’s such a small town, and there’s not much to see. Although, I really haven’t had much time to get out either. Yesterday the surgeon that I have been sharing a house with took me with her to see a c-section…..on a cow. You see, it’s calving season here, so the veterinarian is very busy. You’re probably wondering what a doctor who operates on humans is doing at a vet clinic assisting a cow c-section. It’s because so many people here in town have to multi-task, because it’s not busy enough to do just one job.

So the scrub nurse (that’s the nurse in surgery who hands all the instruments to the surgeon), also works as an assistant to the town’s veterinarian, who is also her sister. So I got to go watch a cow c-section. It was very very bloody, but otherwise, not much different than human surgery. Shave the hair, cut the skin, find the organ, cut it open, do what you need to do, then close it all up with sutures. OK, maybe it was different, as they had to attach the calf’s legs to a winch that would pull it up out of the cut open uterus. And, sadly, the calf was dead. This is a great tragedy for the farmer, not only because he lost a potential new calf, but also because with a uterus that is now all stitched up, and a history of a complicated birth, the cow will no longer be able to breed. I was too afraid to ask what they would therefore do with the cow. Some of the farmers here are so self-sufficient that they do their own epidurals (that’s a shot you give in the spine, to decrease the pain of labor), as well as c-sections. It’s a handy thing to know how to do, especially when the vet clinic could be over a n hour away. The cow yesterday did not have the luck of the farmer having those skills, and the long drive to the clinic was too much for the yet to be born calf.

That was the highlight of my weekend. Tomorrow I return to work at 6 am, for yet another bustling call/work at the outpatient clinic, the inpatient hospital, and the ER. I was on call just a few days ago, and as usual, it was very busy. We had a guy who walked into the ER complaining of chest pain. It turns out he was having an active heart attack. I watched as the doctor and nurse went through the methodical steps of how to manage a heart attack. Put on the EKG, once there is evidence of heart attack on the electrical tracings, put in at least 2 large bore (hole) IV accesses, then put patient on oxygen, administer nitroglycerin, aspirin, and morphine. Nitroglycerin is to open up the blood vessels, aspirin to discourage any further clot formation, and morphine for the pain. Because that patient had arrived within 4 hours of the onset of his pain, we were also able to administer some clot busting drugs (several thousand dollars for one dose).

Then we were on the phone with the cardiologists in Bend, the closest hospital that has a catheter lab, where they could take the patient and try to open up his clogged heart arteries. Unfortunately, there was a snow storm, and they could not fly the helicopter over to Burns to pick him up, and the roads were bad enough that to put him in an ambulance for a 3 hour drive was too risky. Luckily the clot busting drugs worked. Within several minutes his EKG returned to normal, and he stopped having any pain. We watched him overnight and the next morning they transported him by ambulance to the catheter lab in Bend. As my preceptor was talking through the whole procedure of how to handle a heart attack, I just watched in wonder, and laughed out loud when he said I could run the next one. Yah right!

Then I had my first experience with a dying patient. She was very old, 96 years, and dying of pneumonia, despite all our interventions, oxygen, fluids, and antibiotics. After a week in the hospital the family agreed it was time to switch to palliative care (comfort care, with no treatment aimed at curing). This meant stopping the antibiotics, stopping the IV fluids, and even stopping the oxygen. We continued to increase her morphine when she was crying out in pain, and just several hours after her last grandson had arrived and said his goodbyes, she passed away. I was not in the room when she died, but entered several minutes later to check to make sure that I could not hear any breath sounds, could not hear any heartbeat, and could not feel any pulses. I also had to open her eyelids and check to make sure her pupils were fixed and dilated as I shined my pen light into them. It was such an odd experience to see the blue of her eyes, still moist, but with none of the sparkle that signifies life. Her body now was just an empty vessel, and I could tell the difference.

It was not as traumatic as I thought it would be, although I did have tears in my eyes. Maybe it was because she was so old, and her family was ready to let her go. Maybe it was because it was such a peaceful death, unlike the suicide I saw last week. For whatever reason, I thought to myself that I could get used to seeing patients die, and used to my role as a physician in that regard. We’ll just have to see. We have another women in the hospital right now waiting to die, but she is much younger, and is riddled with cancer all over her body. We have to give her so much morphine for her pain that she is unable to be awake to spend her last days with her husband, who sits by her bed with heavy grief in his eyes. This one won’t be as easy for me I’m sure.

I guess what’s been slowly happening to me over these last several weeks, and over the last year, is that doctoring is becoming second nature. A patient asks me a question, and instead of feeling like a deer in headlights, and looking around for someone more experienced or knowledgeable than me to answer, I take a breath and just say what I know. And in this process I realize that no matter how arduous it all is, no matter than I am unable to take care of myself as much as I’d like, no matter that there is more struggles to come in my training, I feel so completely that this is absolutely the calling for me. I feel incredibly tired at the end of the day, but also so fulfilled and gratified. At this point, I cannot imagine myself doing anything else but doctoring. What I also know from these two short weeks in rural Oregon, is that operating on a cow will never become second nature.

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