Why go to Medical School: La Soufriere

I am five years old and running, my arms out by my sides like a banking airplane, around the lip of La Soufriere, St. Vincent’s volcano. We’re 3,800 ft above sea level and too close to the edge. I have to throw three stones before one goes far enough to hit the bottom of the crater. 10 seconds. That’s how long you’d fall and tumble it you made a wrong move. It’s easier than you’d think since I’m inside a cloud right now and can’t see in any direction.

I wanted to be first. The hike is in three stages with 40ft bamboo reeds bending overhead and hundred-foot drops on either side. We walk into and out of clouds, past rivers of bubble-rock from the previous lava flows, and up loose stones and ash as the summit comes in sight and the pitch increases. We’ve kept together for the most part, but with the end so close it’s each man to his ability. I’m in the middle of the pack and decide to start running. My legs are burning and I’m blowing off huge volumes of CO2. I know I’m among my people when Alexander asks, “Where’d you get the extra ATP?” I start using my hands; it’s that steep. I’ve passed 60 yards at 20 degrees and have the lead by a yard or two. No one else wants to pass me as much as I want to be in front, so it’s just a matter of pacing now. But screw it: I start to run again. My legs are shaking and burning and I would feel miserable if it didn’t feel great. I summit and it’s flat and I start sprinting to the lip.

As a kid I remember being awed by heights. Standing at an edge where a fall meant death, I would let me toes hang over just to know that I could. I was trying to prove to myself that I wasn’t afraid. Still am. I sat on the lip with my bag and swung my legs over to lean forward and look straight down. It’s never stopped being exhilirating.

Over the lip you can see a massive mound in the crater. It looks like someone tried to plug the volcano. 20 years ago, it wasn’t there, but the constant pressure of gas underneath has caused it to bubble out and displace the lake that used to be. Along the side, even 100 meters up, you can smell the sulfur and feel the heat from the center. I’m told that there’s a rope that leads down from the lip. I’m too tired today, but next week I’ll give it a try.

I am so glad that I go to school in the Caribbean.

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Why go to Medical School? We’re both crazy.

Walking out the doors of the Anatomy Lab a man is standing in front of me. His hands are busy around his waste, shuffling his penis back into his pants, smoothing the creases of his underwear and now pulling his pants up from his thighs. He’s looking at me like we’re both crazy.

“Yes?” was all I could offer, waiting for the punch-line.
“This wear de keep de bodies?” he asked.
“Say that again?”
“The dead bodies in there?” I’m racing through the reasons that he would ask this and why I would answer him. That’s when I see the name tag. This man is one of our volunteer patients at the Clinical Skills Lab. Since we don’t do genital exams this term I still can’t explain why he was undressed and half-across campus, but this is Grenada and I’ll have to let all of that slide. He’s probably harmless.
“Yes, this is where we keep the cadavers. Can I help you?” Turns out that he came over to find out how he could donate his body to the school once he died. His pants fall down again as I usher him into the Secretary’s office. I watch her eye’s bug and offer no explanation; I wouldn’t want to ruin it for her.
* * *
Going to school in the Caribbean is fantastic if you’ve got the right head on your shoulders. If you go to a restaurant and read the menu, you can’t kid yourself and think that what is on the menu is available. The menu is instead a list of things that were once available and may be available in the future. This is due either to a lack of ingredients, the staff is too busy to make your order, or the staff does not care to make your order. If you need a blown tire fixed, you can open up the Grenadian yellow pages (which might as well say, “no we don’t do that, call this guy” on every page) or you can go to the roundabout by Lance Aux Epines and look for a guy with a grey beard and a sock on his head named “Vincent.” Vincent, you are told, is a good guy.

Not everyone that comes to Saint George’s University can take all of this. Sure it seems like a series of little things, but that’s what death by a thousand cuts is all about. I can’t imagine what it would be like working in any medical setting (or other high pressure situation) with the girl that stomps her feet when her luggage doesn’t arrive on time or the guy that loses his mind whenever we have a Grenadian Traffic Jam.* It’s nice knowing that in my future professional life, seeing “SGU” on a resume will mean that they couldn’t have made it through while holding on to those attitudes.

The person that does come here, takes everything in stride, and thrives is just the type of person I want by my side if things fall apart.

*Grenadian Traffic Jam: In Grenada, people often stop their cars in the middle of a two lane road to open the trunk and begin selling lemonade. Drivers then weave by to stop, chat and buy a drink. You’re going to be late, wherever you were going. Honking doesn’t help.

Foreign warning

I don’t write about this but it is an important thing to remember whenever you are going to medical school. Whether it is more common in the US or abroad, I can’t know. Mexican Medical Student reminds me:

“Folks, regardless of medical school, there are those who shouldn’t try to become physicians–this path isn’t for everyone. A warning to those American students struggling to get into US programs considering a foreign medical school: a foreign school *is* a viable alternative, but since you aren’t dealing with the “cream of the crop,” (witness the profound statements above), expect to deal with a lot of behaviors from people that you’d think you would have left behind in high school. Add to that, the culture clash of the country in which you go to school, and it’s can make for a stressful mix–all of which, unfortunately, detracts from studying and applying yourself to your task at hand. Be prepared.”

Severed Vacation

I do not enjoy vacation. Studying medicine makes me feel so useful that I go into withdrawal outside of it. Reading Atlas Shrugged with all my spare time doesn’t help matters any. I try everything I can. I cut my vacation short by starting a week late, electing to stay in Grenada to dissect cadavers for research. I cut another week by going to Milwaukee for the Annual Congress of Clinical Anatomists. I lose a week to a Michigan trip with my family, and I leave that early to spend a week at the University of Alabama at Birmingham (UAB). Why? To dissect for research, of course.

Working at UAB is my first time in the South and it’s everything with fresh eyes. Southerners chew gum lazily. Without wind, you’re under a heavy hot blanket. When walking for coffee in scrubs, everyone says, “Good morning, Doctor.” It’s pleasant.

I am at the UAB with other members of my group to finish dissecting projects in the hours between the classes of their first year students. We have complete access to 35 bodies and we all feel like kids in the dead people store. Each of us has come a long way from those first heady days of Anatomy Lab. After all, we have chosen to be here without threat of a grade.

We’re cutting into people? I don’t want to; I’ll just watch. I’m glad they put bags over their heads. Should we name her? That’s disrespectful! No it’s not. I’m naming her ‘mittens’. Should we say a prayer first? Oh, god. Give me the goddamn scalpel, Amen. How’s that?

For all the posturing, it was a special thing to watch my hand cut into someone for the first time. It was my hand that did it, by the way. I had nothing to do with it. After so many bodies, it losses its specialness. When it’s time to work, you approach, address the body, and then dive in for cleaning and measurement. A few minutes later you zip up your work and it’s time for the next axilla.

Most of us have been the ones quick through the door when it came to cutting, the ones that called for the scalpels. But here at UAB, it is a little different. Their cadavers are fresher, fixed with less formalin, smelling less, more robust. It feels like walking into a house so clean that you kick of your shoes even though that’s never been your custom.

Most of the students that flew down can give a few days or a week. We would stay longer but our classes are starting in a couple days, a few thousand miles away in the Caribbean.  A few students say, “screw it”  and decide to miss a few days of the first week, this being such a great opportunity for work.  It’s only because I decided to stay that I get this morning call,

“Marios, what am I dissecting this morning?”
“Severed head.”
Choking, “What was that?”
“Ask Vince to show you the severed head. Skeletonize the Facial nerve and clean away all fat and fascia.” Hearing my held breath, “Tophy, you okay?”
“Fine Marios. Just fine.”
“Congratulations. It’ll be fun. You’ll do fine.”

I find Vince. He takes me into the cooler where they keep the fresh cadavers. These people died a few days ago or a few weeks ago and have donated their bodies to the university. At UAB, there is abundance. I wheel a small bin into the prosection room and remove the lid. Thomas is staring straight at me.

I reach down to pick him up and can’t at first. Not expecting the extra weight, I give my arms a moment to recruit more fibers before he moves.  I hold him in the air while another student helps me clamp the vise grips into either side of his head. Of his head. I adjust the lights, pull up a stool, and grab my scalpel.

I can’t do it.

I push his cheek and it moves. I try to draw the backhand of the blade against his scalp to mark my incision and I scratch some of his skin. Before, I thought that cutting a fixed cadaver was the great big leap, and I was wrong. I stare at Thomas some more.

If you’re going to be a surgeon, you have to do this. How many people get to work on a fresh cadaver? What opportunity are you wasting?! Do it, topher. DO IT!

I let the blade sink in and I begin to draw the curve of his hairline down to the front of his ear, then drop to the bend of his jaw and forward to the point of his chin. I pull the line upwards and around the mouth, into the sweep of his cheek where tears would have slid and then around his socket and up, until I meet again at the widow’s peak. He’s bleeding, not in force, but in an ooze that marks each position of a superficial vessel. It’s creeping me out.

***********

His face flap is in the bucket. It took an hour to do, pulling up a corner and separating it from all the anchors of fascia. The beauty of dissecting is that you’re only as fast as your mind. I was trying to save every vessel and nerve fiber early on, terrified of doing harm, until I remembered that the Facial nerve has no cutaneous branches. At that point it became snip, snip. Finding the target nerves leaving the parotid gland was magic. Pulling against the fat to see all of the brilliant colors of muscle, nerve, artery and vein is something that my fixed cadavers could never do for me. I’m no longer bothered by how real this all is; I’m too busy being hypnotized. The nerves branch and split, branch and split until they are thinner than hairs and I can’t believe that I haven’t destroyed them yet. They’re so strong and wet and alive.

Gross, messy, scary, morbid.

Say what you want about dissecting the face of a man that died days ago. Just don’t leave these out:

Amazing, glistening, beautiful, perfect.

Cracked lips

If someone were to ask me, “What’s the stupidest thing you’ve ever done?”, I’d answer with this: trying to be in control.

Working on the terminal onc ward is pretty stressful if you’re emotive. People came to our floor because they were going to die. A lot of them were there for a week to receive the next chemo cycle before heading back home. Some of them stayed for longer, months even. But no one ever got so healthy that they left for good. Thankfully, I’m not as emotive as most.

You start to get a feel (or think that you do) for how people are doing. Some are feeling so well that they start thinking their cancer may be going away. Others are holding steady with their treatments, walking up the down-escalator. Some are doing horribly but are stably horrible. Those are the ones that are just agonizing to serve. I remember starting on the floor and taking care of the same women for three months. Every two hours, adjust position in bed. Clean as necessary. It was always necessary.

I remember a frail patient of mine that was in her seventies. Her family knew that things were worsening and that this weekend would be her last. Everyone from out of town was coming in and spending the full day with her. As a tech, it was always a strange experience entering the room to take vitals or perform a blood sugar test. The family members would watch me so intently and then each advance their chins to me, awaiting the result. “Her blood sugar is 136.” When there is no control, there must be control. Keeping track of BP, HR, and sugar are all our best attempts at control of some kind.

The family left for the night. I had ten patients for my census and checked in on her as much as possible. She was heading downhill and her breathing was becoming more and more labored until she started using her accessory muscles to pull in the air. They call this “agonal breathing” which just about hits it on the nose. I stood by her side and waited for the nurse to respond to my page. I didn’t see her do it, but the woman reached out and grabbed my wrist. It was unexpected and cold and it gave me a start. I reflexively pulled away and then felt a heavy embarrassment and sadness for her. I think I reached out to hold her hand. The nurse came in and the two made eye contact. She had such fear and the nurse looked at her and said that it was okay. You’re dying. It wasn’t cruel or improper, but somehow perfect for that moment. She relaxed.

There was nothing I could do for her. She was dying in front of me and I would be there for her final new and final final experience. I saw that her lips were cracked. I got some lip balm, held it out, and between gasping breaths she pursed her lips so that I could apply it. That was my stupid attempt at control. I can’t remember if I held her shoulder, or hand, or just stood there doing none of those things. She was staring straight ahead, bracing. And then she stopped.

We called the family. They came up the elevators crying at 4 in the morning. They stayed with her until 6 and, before my shift ended at 7:30, I walked into the room. After taking off her gown, I tied her feet together. I tied her wrists together. And just as I had turned her side to side so many times before, I managed her into the big white plastic bag. I wrote her name on a tag and looped it into the zipper. Security came and wheeled her away.

Alive, I could do something for this woman. Dead, I could do something for this woman. But dying? They didn’t cover that in training and it seems like something impossible to get entirely right. Even so, when the best you can do is stand in the room and treat cracked lips, it seems especially futile. A new patient with a new cancer and a new family was in the room within the hour.

Two years later and I still feel the pang of failing her that day with my stupid attempt at control. Worse, I know that it was one of her last memories.

Connections

The way that I came to St. George’s University in Grenada is funny to me.

My father enjoys playing frisbee golf. Chances are, you’ve never heard of it. Each player walks around with a backpack filled with different types of frisbees: long and short drivers, mid-range, putters, rollers, frisbees that cut an “S” in the air, and so on. They throw these things around trees and through clearings toward a metal basket and they LOVE their sport.

My father is a friendly guy with a laugh that makes others want to laugh. He makes easy friends. The summer after graduating from college I was wallowing at a part-time job, hoping for anything medical that could help me gain an apartment of my own. I watched the Graduate and thought about going into plastics. Friendly guy that he is, my father met a nurse named Rob N. that figured the apple couldn’t have fallen to far from the tree. He arranged an interview at Big Hospital and I had my job as a tech.

I did all sorts of things at this job and learned that the worst of what I had to do didn’t bother me that much. This was supposed to be the litmus test of medicine, akin to seeing a girl without makeup, hungover, vomiting. Still love her? Then go marry her. In my mind, I was ready to go to medical school.

I applied to several schools, was interviewed, wait-listed and rejected. It was from the physicians that I had come to know on the hospital floors that I learned of SGU in the Caribbean. I did some research, was impressed with their board pass rates and residency placements, and decided to apply. A month later I was interviewing and received the first acceptance letter in a long time.

Down in hurricane-wrecked Grenada began the baptism of fire that is Biochem, Anatomy, Histology, Embryology and Clinical Skills in the space of 4 months. I loved it. Socially, academically, and melanin-wise I was thriving.

The next term I had the brilliant idea that I would tutor Anatomy and Biochem. I discovered that in the captive and competitive audience that is a medical class, women find brains as attractive as anything else, giving rise to the phenomenon known as “nerd hot.” To boot, my best friend was the most sought after guy on campus. I invited him to tutor with me.

During the meeting of the Anatomy tutors, a knew professor was introduced to us. Stolen from a nearby school, Dr. Loukas said that he was interested in anatomical research and would like to start a research group at SGU. He had our full attention. Meetings were arranged and a club was formed. We were the founding executives.

One year later, our research has continued with few pauses. We put together our projects and headed for Milwaukee for the Annual Congress of Clinical Anatomists to present. I gave my first terrifying speech. Their, we met another professor interested in anatomical research that Dr. Loukas had come to know quite well.

Two weeks later, at the end of what remains of our summer vacation, we are in Birmingham, Alabama dissecting 8-10 projects in 35 cadavers. We begin dissecting each day at 7am and work till 12:30 when the M1’s come in to learn about the brachial plexus. We’re off till 3pm but can’t go many places with the stink of formalin that we wear like capes. Instead we nap and read. I finish The Tipping Point and start to wonder at all the forks in the road that have brought me here.

I fly home. Tomorrow I fly off to the Caribbean to finish the last part of my second year. Tonight, funny enough, is the going away party for the guy that started it all. Rob N. It’s the only day I could have been home to see him and say thanks and the last time I’ll see him for a while.

Funny though, that it all happened at all.