Hands, Mantles, and Vocations

St. Teresa of Avila wrote,

Christ has no body but yours,
No hands, no feet on earth but yours,
Yours are the eyes with which He looks
Compassion on this world,
Yours are the feet with which He walks to do good,
Yours are the hands, with which He blesses all the world.
Yours are the hands, yours are the feet,
Yours are the eyes, you are his body.
Christ has no body now but yours,
No hands, no feet on earth but yours,
Yours are the eyes with which He looks
Compassion on this world,
Christ has no body now on earth but yours.

As I've moved along the journey to being a physician, I've often looked at my hands and marveled at what they have and will do. I am (almost) used to the strange permission persons grant to me with their bodies. As a hospital volunteer, I was allowed to change the diapers of total strangers; as a phlebotomist, people I'd never laid eyes on allowed me to insert needles into their arms; as a medical assistant, patients would tell me about their medical histories; as a premedical student, people allowed me to watch their encounters with their doctors; as a medical student, people allow me to examine them so that I can learn to discover fibrocystic changes in breast tissue and nodules in thyroid glands.

A doctor's knowledge and capability is bestowed on him in a series of thin mantles of study and experience. These mantles are invisible: they impress and are incorporated into our souls. And it is these mantles that I marvel at occasionally when I look at my hands. How God has clothed them with incredible graces, and how much more will come of what He has given already!

I received a remarkable mantle last semester as I learned to perform a physical exam in Clinical Skills class. However, my school teaches the male and female genital exams at the beginning of second year (about three months after the rest of the body). I was disappointed when I learned this, because I expected it would retard my experience in the preceptorship between first and second year. I thought, as a future OB/GYN, that it would be good to receive this mantle as quickly as possible.

God has His own timing. He put the learning off for a few months. However, last week, I received this mantle: I was permitted to perform a pelvic exam for the first time.

This layering of mantles isn't unique to medicine; all of life is like this, as we receive graces and our souls are shaped into the saints God has in mind. However, the changes in a student doctor are particularly demonstrable, and as I receive each permission (like [scrubbing] and [suturing]) I take notice and thank God.

All this language of receiving mantles reminds me of religious habits! My career closely resembles a religious vocation: a religious sister is visibly clothed because of her special relationship with God, I am invisibly clothed becaus of mine to patients; her habit changes as her vocation matures, as does mine; she restores God's image in souls as I do in bodies; she sets aside everything but Jesus by vows, while I set aside everything but patients by profession. Of course, I should probably say that my career is even more analogous to a married woman's: she doesn't always wear her wedding gown (as I don't always wear scrubs or a white coat), but she is invisibly changed by the intangible desires, vows, and actions that called her to marriage and keep her in it.

Medicine, marriage, and consecrated life...becoming a saint and doing God's will is so beautiful!

Tough Case 1

I met "Lisa" right before her surgery. She is not much older than I am. She was surrounded by her parents, her sister, and her young husband.

Her physician had seen something suspicious on an ultrasound, and so the procedure she was scheduled for was a "ovarian cystectomy, possible myomectomy, possible RSO." In other words, she could be in for a 45-minute removal of a cyst, a several-hour removal of a fibroid, or the loss of an ovary at a very young age.

In pre-op, the surgeon promised her that "in somebody so young" the ovary would only be taken out if it was absolutely necessary.

Once Lisa was moved to the OR, anesthetized, and prepped, the surgeon asked me to feel her mysterious mass. To my surprise, I could feel it (medical students usually aren't good at that). I didn't feel how large it was, but it was as hard as an uncooked potato.

The procedure began, and once the camera was placed in its trocar, the assistant raised Lisa's uterus and, with it, the mass. It was a fibroid, almost as big as the uterus itself, and attached at the uterotubal junction. The surgeon began making shallow cuts into it, and called for methyline blue, a dye.

A fibroid at the uterotubal junction is very bad news for a young woman. Fibroids are bad enough: they're painful and recur throughout life. But Lisa's fibroid was growing where her fallopian tube met her uterus, so it was possible that that tube was blocked, and very likely that this would be difficult surgery. I pictured her young husband and wondered whether they were planning a family. The surgeon was calling for dye to inject it into Lisa's uterus and see whether the affected tube was patent.

The surgeon kept cutting, and I mentally cried out, "Stop! Wait until the dye arrives."

I didn't speak because of the difference in status and personality between me and the surgeon. By the time the dye arrived, there was a decent-sized cauterized area. The dye entered Lisa's uterus and turned it a bright blue. But dye dribbled out of the cauterized area, indicating that the surgeon had cut into the uterotubal cavity while waiting for the dye. Beyond the fibroid, the affected tube was pink, indicating that it was not receiving any dye (either because it was blocked, or because dye was flowing out of the cauterized area before it reached the ampulla of the tube).

Worse, the opposite tube was likewise pink, indicating that it was also blocked.

Lisa was infertile, unless the diseased tube was still patent at some point along its length and was reattached to the uterus at the open uterotubal junction. This would be a time-consuming and technically demanding procedure. I expected (correctly) that this procedure would not be performed.

Thus, Lisa was infertile. The suddenness of the discovery shocked me. Infertility is something that people usually have time to become aware of. Here, in an instantaneous and unceremonious way (a glance at a picture, an absence of color) Lisa's condition was announced to a roomful of relative strangers. She would probably be the last to know. My heart broke for her and her husband. And I wondered: would the dye result have been different if the surgeon had waited? Did this surgeon just cost Lisa her fertility?

If the tube had never been patent, then there was only the tragic discovery of infertility for this young woman. There was nothing lost by the surgeon's too-early cauterization. Perhaps because of this, the surgeon began to voice aloud what I knew was impossible as she continued to dissect the fibroid away from the uterus. "Strangest anatomy I've ever seen...the tube connected to the fibroid and not to the uterus." Lisa, said the surgeon, was probably born like that. (That is highly unlikely, according to what I know about embryology and fibroids.)

This denial made me more certain, in an irrational way, that this surgeon just lost the patient her only patent tube. Admittedly, there was no clear evidence of destruction of a tube which was patent along its entire length; there was only evidence that the surgeon diminished the validity of the dye study by opening the uterine cavity and making it possible for a patent tube to remain pink even when dye was injected into the uterus.

The fibroid and tube, assumed to be useless, were removed. The ovary (which was to be protected "in a woman so young") stayed behind; nevertheless, it lost its most exalted purpose.

To the surgeon's credit: later in the surgery we spoke more about the patient's anatomy and (after some mention of embryological orgins) the surgeon said that the tube must have emerged from the uterotubal junction and the tube was originally connected. The surgeon told the Lisa's family that the fibroid "dissected the tube away from the uterus" as it grew, an explanation that I think is likely.

If I had been operating, things might have been different. I would have waited to cut so that the dye study could show for certain whether both tubes were blocked. And regardless of the result of the dye studies, I would have attempted to save Lisa's fallopian tube, since tubes can be reopened. Perhaps this surgeon assumed that the tube was blocked and ordered the dye as an insurance policy for the removal of the tube. Or, perhaps the surgeon was not bothered by an inconclusive dye study. Or, perhaps the surgeon didn't see any reason to save a tube for recanalization when the patient would probably just get IVF.

But what if the patient (or her husband) were Catholic? What if they were too poor for IVF?

I left the OR feeling sad for Lisa and her family, and sad for this surgeon.