my surgery essay in the med school journal

<http://www1.wfubmc.edu/Oasis/Issue+12+-+September+2008/Long.htm>

Fluid

Amy Long

It all comes down to fluids. Fluids, the ins and the outs, crystalloid, colloid, the maintenance in increments of 40, 20, 10, ice chips and Lactated Ringer’s solution. I have spent a good portion of the last month recording, making sense of, calculating and ordering fluids. I have been baptized by emesis, tears, sweat, gastric secretions, blood, sputum, diarrhea, lymphatic fluid and, of course, urine (particularly that of baby boys!). I have drawn fluids, injected fluids, drained fluids, held pressure to prevent leakage of fluids and suctioned off fluid.

It all comes down to fluids. “He took my belt and hit me. He told me I had to sit in the water for five minutes because I had messed up myself.” A four-year-old boy lying shrouded in a white sheet told us his story without emotion. “It hurt. I cried,” he concluded. “He cried inconsolably for hours,” said a woman no older than me hovering over the bed. “When did this happen?” someone asked. “Two days ago,” the mother answered. “I put bandages on it but he just kept crying.” I watched as my teammates gently pulled back the sheet and fought the desire to recoil from the horror of what had happened to this little boy. Huge blisters of partial-thickness burns covered his perineum, genitalia, buttocks and ankles. I had seen burns frequently on the pediatric surgery service but never non-accidental ones, never ones inflicted on a child by his father. For the first time in my career as a medical student, tears came to my eyes.

It all comes down to fluids. I dipped a white washcloth into a basin of saline and tentatively started washing the small foot. “Press harder,” my resident instructed. Liquid splattered on my gown as the blister broke, pink raw skin left behind. As we scrubbed on, I reflected. I had not been the most confident medical student in the past month. The OR, a mysterious inner sanctum of medicine, left me at times terrified of making mistakes, tongue-tied and exhausted and swollen from standing. I spent a lot of time apologizing for my ignorance. But in that moment of furious scrubbing, I forgot all of that. I found myself at the top of the table scrubbing, pasting Silvadene-coated gauze over the fragile skin and carefully coating the genitalia with antibiotics as if I knew what I was doing. My resident kept handing me the needed supplies and telling me, “It’s all you.” Maybe it was the horror of it. Maybe it was a way of keeping me from breaking down, or maybe it was because it was the 28th day of my surgery rotation; whatever the reason, I finally found some nerve to be assertive.

It all comes down to fluids. After surgery, upon discovering that the patient’s urine output had rapidly decreased, we ordered a bolus of fluid. I found a spare moment and rushed upstairs to visit him an hour later. I found him hunched in his bed, tears dripping down his face, with Mom and the nurse trying desperately to soothe him. I ran out and returned with a pitcher of ice and a Thomas the Tank Engine toy. He calmed down with morphine and ice. His mom thanked me with a teary-eyed grateful glance. I again found tears in my own eyes. I walked out and realized that what I learned from a month on peds surgery was to let go of my own expectations, misconceptions and fears. In order to truly be an excellent surgery student, you need more than technical skills. You need to be confident, compassionate, and above all, adaptable, ready to solve any problem, surgical or otherwise. Because… in the end, it all comes down to fluid.

Emerging Disability???? yep.

and we interrupt this endless thoughts on disablty and medicine to enter the world of disability and theology a plcae where even fewer thread…

One of the central tenants of disability life and culture is community. Although independence is a valuable resource, community is what makes our lives work. When you talk about access, education, employment rights and NO PITY what it all boils down is the right to participate in community. Out of lives of isolation, out of institutions into life.  We fight for independence and indepent living but not as a rejection of community but as a rejection of  false community. Disabled people learn early the value and the needs of relationships with other both physically and socially. Community is not a new trendy concept to us its a lifestyle.

The fact is I can’t push myself up a flight of stairs. I can’t do it. If there is no railing I am in trouble even on my feet, I am in danger of falling flat on my already flatter than normal face.  I know this and so I take the opportunity to reach out and grab a friends arm.  Friends who know me well and of course my family don’t wait for me to ask, they offer their arm and this is a silent, sincere, gesture that does not make me feel pitied but rather supported, loved and  safe.  My friends who are blind rely on their friends even more (although I am not good at serving them in this way because of my gait)  at times where a dog is not going to be able to come with them.  When ever two or more disabled go out together (hysterical stuff happens lol), you will see the meshing of strengths and weaknesses…we help each other where we can, since I am ambulatory I put the chairs in the back of the car and my friends with power chairs let me grab on when we roll a lot and my shoulders get tired (yes imagine a wheelchair train ).  Also we share the struggles with each other, my medical school struggles make fun stories to tell one and all but by telling them I am supporting others who want to do what I am doing, I am also contributing to the wider disaibity narrative of liberation. We support each other not out of pity or out of obligation or because we likey being cheesy but because we need each other.

When I read  or particpate in emerging christian discussions of the early church sharing their resources and talents so that no one was poor or hungry among them or around them.  When people talk to me about intentional community, in living copperatively, in sharing our resources, in living simply. This is what I think about not church, not my Christian friends (although I do love all you dearly), not even my family (who as families go is top notch), I think about disability life.  I know its not exactly the same but I feel that at an abstract level it is. We share what we have in our resources, experiences, in ability and we recieved shared resources in disability.  We don’t deny our weakness but use at as an opporutinty to share and understand.

to be continued at some later date when I don’t have to run off to a wedding in VA….

background for the non-emerging folks out there…

There is much press, discussion and conversation amongst Christians of my generation about how we think the American church missed the boat on well pretty much everything from the gospel to politics to lifestyles to megachurches. Nothing is sacred in this conversation and everything is fair game for scrutiny.  The conversation seeks not so much to rebell but to take our church back to a christ centered radical lifestyle of first century church..the church of the actual bible compared to church of American materialism… Some of these folks call themselves emerging, some of these people are part of house churches, some of these folks call themselves non-denominational, some call themselves post-modern ande some hesitate to lable themselves at all, etc I find myself at home theologically within this conversation.

What if the Hokey Pokey is NOT what’s its all about…

Walking….

Really is it that important???  Now I realize I am biased. I am quite accustomed to alternate transportation.  But really, do you have any idea how far people go to get their kids to walk?  I met a 3 yr old with CP (quad). He is cognitively fine, his fine motor and gross motor are a struggle (as expected). His current development goals..  It was alllllllllll about walking.  I watched his PT work with him. He struggled, was in some pain and even cried at several points. His Pt told me he had made very little progress in the last year. Its obvious medically this is a kid who will almost for sure will never walkwithout an assistive device and even then he will probaly quickly choose a wheelchair…why you ask???? Because he will want to keep up in middle school and high school, not get knocked down and not be utterly exhausted by third period. )

WHAT HAPPENED TO DRESSING HIMSELF???? USING A PENCIL???? FEEDING HIMSELF??? This kid has major fine motor issues and they are taking the backseat to walking which is most likley fultile for him anyways. There is occupational thearpy in his weekly scedule but it takes a back seat to PT and all things to do with walking.

And I see this all the time, everyone is so focused on meeting the magical gross motor milestone of walking that the parents, phyisican, teacher, thearpist, etc get tunnel vision and instead of thinking what does my child need in 20 years to be functional and independent? We get I want my child to WALK!!!! Beyond the inattention to fine motor or whatnot the other issue is what happens when the child doesn’t walk??? Well then he or she has failed and don’t think they won’t feel that way to at least some degree. The parents certainly feel that way.  If you spend 6-8 years of life trying to learn how to walk and then don’t…what does that do for a you as disabled kid who already is going to have to confront some huge pyshcosocial and idenity issues (with or without the magical mystical superpower of walking).

WALKING DOES NOT EQUAL WHOLENESS. What is this mystical quality that walking has??? Why in our society/culture/etc are we obessed with walking? The disability activist in me says this is not my problem as the disabled person, its more of a problem of the wider world preception of me, of us.  A wheelchair (or a cane or insert your device of choice here) does not mean we failed, it does not mean we are somehow a lesser being, it does not mean we gave up.  It means we get to get out of bed today and see the world from an upright position, it means we are particpating in our communities, in many cases it means we can go to work or school safely, it means we can carry our laundry to the drier, be social, cook our meals, it means we can play sports, go for a walk (roll), it means we are out living life.

The fact that society and dare I say medical science does not see us that way is not  the disabled person’s fault. Its certainly not the 3 yr old with CP who dreads PT every day and begs to go home the whole seesion who cries after trying to walk in the bars for 20 solid minutes.  But its the kid who loses the most with this preception. What if instead of failing we could give him some freedom and acceptence to suceede?

I am not saying we should not encourage kids with mobility impairments to walk. By all means PT is essential for pain control and to maximize strength. And every child should have the chance to be as mobile and yes to try to do it in the convetional manner.  And PT is hard and painful and we shouldn’t give it up because of these things. But it should be realistic, fruitful and not defeating.  PT and walking is not the end all of early intervention for kids with physical disabilities. And as a future pediatrican it won’t make the top of my list of concerns for a disabled child. I am much more interested in their physical health (like eating, sleeping, breathing health), ADLs (activities of daily living), their mental health, their social health and that their childhood is not one of defeat and failure but one of joy and empowerment.

23 yo White Female with chronic abdominal pain, insomina and an obession.

There is an ache in the pit of my stomach. Its familiar although not comforting. Its the sort of ache that wakes you from a really wonderful dream  and you sit up in bed and wonder if holy snark I was supposed to be at work an hour ago.  Then you look over at your alarm clock and see Oh Thank God its only 3Am I can sleep a little longer. But the thing is you don’t want to sleep anymore because of the ache and the adrenaline now flowing in your veins.

I get this ache when I see something that is frighteningly awesome and completely unavailable to people who really need it. It wakes me from my American, middle class, over-educated dream to the reality of oppression, poverty and injustice. I had this on Saturday at the free clinic with the little girl who needed intervention and parents couldn’t afford it.  I had this ache on and off for the past month.  Part of my pediatrics rotation is a community health project. Mine focuses on chronic illness and disability. I have visited special education classroom, an augmentative communication lab, home health visits for kids on vents and NICU follow up.

I can’t help but look at these kids and see faces (and some facies), glimpses of lost children who live a half a world away.  I can’t help but compare. I can’t help but mourn the lost of so many who had thoughts, ideas, lives to share with the world. I can’t help but feel the wieght of the prejudice as I see what can happen in a world where it doesn’t exisits. I know that there is a lack of resources and I don’t expect American early intervention and rehab technology to translate perfectly into Eastern Europe and the former Soviet Union (or elsewehre for that matter).  But of a lack of resources does not justify the horror of letting a child with a heart murmur (insert: Downs, CP, Not Cute (seriously), Sticklers, Clef Lip, Deaf, Club Feet) rot developmentally in a institution.

That horror is ever more acute and repugnant when contrasted with what could be, with what is in another world.

Its an ache thats not going away.

pediatricians do it better

really why would I ever want to do anything but Peds: in no particular order

1. Kids are less smelly than adults.

2.  Actual acknoweledgement that 60% of medicine happens outside of the world of science in the realms of family, community, culture and ecnomics.

3. Kids don’t do it to themselves.

4. You can tickle your patients and not get charged with assult.

5. You get to help parents be beter parents.

6. BABIES.

7. You actually can have a life outside of medicine if you want it.

8. There is still time to help your patients make good healthly longterm choices.

9.  Your patients are resilient, most often happy and will forgive most painful procedures with the offering of a sticker.

10. Part of your physical exam includes tossing balls, hopping on one foot and drawing.

11. Your patients will outlive you and so will your life’s work.

12. Did I mention that they let you play with babies?

13.  You actual get to be a little bit creative from time to time.

…and now I have to go to clinic but I could go on for hours.  yep life is sweet. So sweet that during my pediatric clinical skills exam today, I actually marveled at the fact that I was having a good time taking a test. Seriously….