I started my third year of medical school as a surgery clerk.
With this eight-week clerkship came a flood of conflicting advice from older, wiser peers: "Ask a lot of questions, but speak only when spoken to." "Offer to help, but stay out of the way." "Be friendly and likeable, but not too friendly--or too likeable." For the medical student, such is the mystique of the OR.
Three weeks into my general surgery rotation, I was helping my senior resident to see patients in the clinic and evaluate them for surgery. She grabbed the first chart off the day's pile, knocked on the exam-room door and turned the handle, glancing at the chart before saying, "Hello, Mister--"
"Tran," the patient finished. A thin Asian man who appeared far older than his birthdate indicated was sitting in the corner, hands clasped and gaze directed to the floor, the way defendants on Law & Order look before they take the stand.
As the resident watched, I took Mr. Tran's medical history. He described suffering through weeks of painful rectal bleeding.An easy enough diagnosis, I thought; and upon my exam, there they were: extensive external hemorrhoids.
Presented with the treatment choices, Mr. Tran opted for surgery. The resident left to schedule the procedure, and I stood to shake the patient's hand. As he extended his arm, I noticed a bracelet of wooden prayer beads curled tightly around his wrist, their shine a testament to years of unconscious polishing by his long, worn fingers.
"These are beautiful," I said.
"My mother gave them to me when I leave Vietnam, so I can pray to Buddha if no temple here."
"They must be very special to you," I observed. Mr. Tran nodded.
On the morning of his surgery, a week later, I found him in pre-op, where the anesthesiologist was inserting an IV. She pointed at the bead bracelet.
"You gotta take that off," she said briskly.
After a reluctant pause, Mr. Tran slipped the bracelet off and placed it on his neat stack of belongings.
In the OR had assembled the usual surgical staff: the attending surgeon and his surgery resident, the anesthesiologist and her nurse anesthetist, the circulating nurse (who monitored the proceedings to ensure safety and sterility), the scrub tech and me. Mr. Tran arrived and set our choreography in motion.
The nurse anesthetist positioned Mr. Tran on the operating table. She was a thin woman, with sagging cheeks and eyebrows that had been penciled in too hurriedly.
Securing Mr. Tran's arms with straps, I noticed on the underside of his right wrist a small tattoo composed of six short lines intersecting once in the middle: a swastika. Feeling somewhat taken aback, I then recalled that for millennia before the Nazis had co-opted it, this symbol, called a manji, had been a sacred Buddhist symbol of universal harmony. No time for that now; I refocused my thoughts on the surgery ahead.
The procedure was uneventful, and Mr. Tran's hemorrhoids were successfully removed.
The attending surgeon stepped away from the operating table and signaled the resident and me to finish. As we tore off the surgical drapes, the nurse anesthetist rushed over.
"It's all over, Mr. Tran!" she shouted, waving a hand over his face. "Open your eyes for me."
She suctioned his mouth, checked his vitals, then loosened his wrist restraints--first the left, then the right.
Suddenly she squinted, her expression wavering between curiosity and contempt.
"Judy, have you seen this?" she called.
The circulating nurse, a shorter, larger woman with an air of knowing authority second only to the surgeon's, shuffled over to the table.
"What is it, Barb?"
Mr. Tran moaned softly, his eyes still closed.
Scowling, Barb pointed at the tattoo. I felt a jolt of apprehension: Something strange was about to happen.
Judy raised an eyebrow. "You'd never guess this guy would be one of them, huh?" she muttered.
Barb rolled her eyes. "It's just disgusting."
"And still we take care of them, don't we? Even though they don't deserve it."
Mr. Tran gagged on the endotracheal tube. His eyelids fluttered.
"The little bastard."
I felt myself flushing. Overwhelmed by feelings of shock and betrayal, I tried to steady myself.
Desperately, I scanned the room for some sign, any sign, that I wasn't alone in these feelings.
The resident was wiping antiseptic gel off the patient; the attending surgeon scribbled a post-op note; the scrub tech whistled as he arranged the scalpel handles in neat rows. Who else would acknowledge what I had seen and heard?
As if mesmerized, I stared at Mr. Tran's neatly inked tattoo. He'd probably gotten it back in his native country, only to discover that in his newly adopted home, such imagery was considered not only unpleasant but utterly repugnant.
As I gazed at the tattoo, I noticed its scarred edges. To me, these seemed to telegraph a sad story: Mr. Tran had tried scratching, rubbing, even burning the ink off his wrist. But the manji's traces were as enduring as the faith that had inspired it.
Never before had I wanted to scream in the OR. And never, in the face of such a violation of my training and my profession's philosophy, had I felt so painfully silent and powerless.
What had being on the wards done to me?
I had never before shied from speaking up for what I thought was right. As a longtime community advocate for patients of color, I'd devoted myself to giving a voice to those too disadvantaged to be heard. But here within these confines, where I'd learned to leave my feelings at the scrub sink, the only sound was the suction tube's slow hiss, seeming to hint teasingly at what could have been, what should have been.
With one swift tug, Barb extubated Mr. Tran.
He coughed twice, his eyes blinking to life.
"This guy's dead to me," she muttered, fitting nasal prongs to his face.
Judy had returned to her perch in the corner. "Get him the hell outta my OR."
As I started to steer Mr. Tran's stretcher out of the room, I replayed the preceding thirty seconds in my mind.
I felt ashamed. Not just because Mr. Tran might have heard those names or because the surgical team certainly had, but because I'd wanted to share some knowledge that might have made things go differently, yet I'd felt incapable of doing so. Why? Because the surgeon knew best; because the resident might see me differently; because the veteran staff had seniority; because I was only a medical student trying not to rock the boat.
As we cut off Mr. Tran's wrist straps, I felt that it was I whose hands were tied.
I wheeled Mr. Tran into the recovery area.
He opened his eyes; I cast mine down and turned to leave.
"It goes well?" he whispered.
I turned back to him.
"The procedure went well. It was successful," I said gently.
To Mr. Tran, perhaps this was all that mattered.
But more than surgery had transpired in the OR that day. And still, knowing all that had been left unsaid, I was silent.
About the author:
Kevin Koo is a fourth-year student at the Yale University School of Medicine. "I write because life, and especially life in the hospital, is full of triumphs and tragedies, and it's those events that make the words pour out onto paper." He thanks Drs. Nancy Angoff, Lorence Gutterman and Linda H. Pellico for their guidance and encouragement.