In which I tie the knot(s).

In Genesis, God telegraphs to the universe His heart and His purpose by creating man in His own image, meant for dominion. He prepares this person to receive everything that He is and has, placing him in front of the tree of life. Then Satan sets to work abasing and degrading man into his own form: he injected man with rebellion, jealousy, violence, and spite, to the point at which man was utterly useless for his original purpose: to contain God. It doesn’t seem like God does much to stop man’s fall. He just watched, all-knowing, omnipotent yet not doing much that I could see to thwart His enemy. By the time the tower of Babel was erected, a literal attempt to fly in the face of God, man didn’t seem to be able to fall any farther. It was as if God were waiting to see the depths of man, almost to say, “Satan, is that all you can do? Are you ready for My turn?”

God’s turn starts with calling one fallen man, Abraham. He carefully shepherds this man and cares for him through mistakes and failures, and He promises to make Abraham into a great nation, to give this nation a good land to dwell in, and to bless all the nations of the world through his seed. Genesis follows God taking care of Abraham’s descendants, and ends with Joseph bringing all the children of Israel into shelter in Egypt from famine.
Plot twist, Exodus starts with those sheltered children of Israel stuck under slavery for centuries; God frees them through Moses to finally claim what He promised to Abraham, the good land. To the fanfare of miracles, doom, and glory, Israel marches free out of a plundered Egypt and proceeds to spend the rest of Exodus complaining and making idols for themselves to worship.

Despite their foibles, Israel somehow makes it to the very edge of the good land in Numbers. It’s at this point they reach the lowest of their lows. Before this, they had seen with their own eyes the power of Jehovah, but still pooled their resources to make a golden calf and call it God. Even that wasn’t enough to disqualify the people from entering the good land they were promised. But at the border of the good land, they undergo their greatest failure: they see the riches and glory of the good land, but also the giants that dwell there, and doubt their own ability to conquer the people who dwelt there. Never mind that at this point this group of people had seen God bazooka the way for them out of Egypt, part the Red Sea, and lead them by a pillar of freaking fire and cloud. Suddenly they fixated on their own abilities and inabilities, and not on God.

Their consequence? Their own prophecies were fulfilled. God did not allow that generation to enter into the good land. He took them on a 40-year detour around the wilderness to allow the entire generation to pass away, and a new, young generation, raised on manna, whose hands had never labored for Pharaoh, who had never touched the golden calf, who had never seen the first tablets of the law, to become adults. And God once again leads them to the good land, ready for take two.

It’s with this stage set that Deuteronomy begins. Moses, now an aged father to his people (I believe he was 120 at this point), looks at the eagerly assembled children of Israel, ready to do things right where their fathers failed. His heart is full of yearning concern. Like God, Moses wanted nothing but the very best for this people, but he knew God’s righteousness. Without a proper fear, a proper foundation in God’s ways and laws, God would have no choice but to limit their longevity in the land, lest they just become like every other group of people on earth. Moses could repeat the law to them, could admonish them, could make them write the law on their heads and hands and doors, but could he write the law on their hearts? Could he safeguard them adequately to really receive everything God had to offer them? Moses could not go into the good land with them. They would have to carry on on their own. What a keen yearning he must have had! What greater yearning must have been in God’s heart!

When I was in middle school, my dad had a series of episodes of acute abdominal pain. At some point it was determined he had an inflamed gallbladder, and it had to come out emergently. My sister, mom, and I took turns talking to my dad before he went down for to the presurgical area. None of us knew whether he would make it through the surgery. Would these be our last words? I don’t know what he said to my mom or sister, but when I approached, I thought he’d say something like, “I love you. Don’t forget that I love you.” But instead, he said, “When you come into the house, don’t forget to put on slippers. And when you wake up, keep a jacket nearby so you don’t catch a cold.” I laughed. In such a serious situation, why would he just nag me with his usual reminders that I ignored? I thought he was being facetious to keep me from worrying. But now when I look back, I realize what he was really saying. He was saying, “I love you, but please choose to be healthy instead of choosing the easy way out. I love you, be safe. I love you, and I might not be around that long, but I hope you live very very long.”
Of course now in medical school I realize cholecystectomies are a dime a dozen, and mortality is rare. But everything, down to the dawning morning light in the room and the brown and grey striped shirt I was wearing, was etched in my memory.

Moses’ heart must have been this way for Israel. God’s heart is this way for us today. As we read the law recorded in Deuteronomy, as we feel God’s prohibition in our conscience, or His limitations in the Body, it’s like God saying, “I love you. Don’t choose your own way; choose life. I love you. Your opinion is not safe, but being restricted with Me is safe. I love you. If you don’t spend this time with Me, you won’t have enough grace to get through today. Choose life. Choose Me.”

I’m writing this from a gloomy Megabus station in Austin after missing my bus by four minutes. But nothing can rain on this parade! On Friday I finished my final final exam of clerkship year, the surgery shelf. After spending the day working in a hospital and my evenings studying with no summer vacation or spring break for an entire year, it feels surreal to suddenly give myself permission to do nothing productive at all. I decided to give myself a week off to bounce around Texas and visit churches and friends and eat more than I’ve eaten in ages. Each night, going to sleep, I reflexively reach for my phone, maybe to flip through flash cards or do a few practice test questions — — then I remember, I don’t have to do those anymore!

Everybody has been asking me what surgery rotation was like. I try to reach for stories, but they come less easily than any other rotation. Isn’t that strange? Isn’t surgery the most dramatic of medicines, even being performed in a theater? Isn’t surgery Hollywood’s favorite branch of medicine? On the medical student side, I felt I didn’t have that many stories because I spent more time in the operating room than at the bedside. (I guess that’s sort of the point.)

Some patients did stick with me. One poor girl, 9 years old, came in the night before with acute lower abdominal pain, probably the worst of her life. She had acute appendicitis, words that didn’t mean anything to her except a lot of people giving her shots. Her nails were perfectly manicured; at least 4 nurses (and I) complimented her on it, to take her mind off scary things like surgery and medicine and shots. She barely paid any attention to us, face creased, tears running. The next morning, I checked in on her, one appendix lighter than she was last night, and she was unrecognizable. She smiled, even though I was waking her up at 5:15 AM, and was excited about breakfast. Her room was festooned with pink birthday balloons. Appendicitis and all, she had turned 10. It wasn’t until I got home that night, around 6 PM, that I realized we could have wished her an appy birthday.

Another patient I remember was from my day in the breast cancer clinic. Since her diagnosis with breast cancer four years ago, right after coming to the US, she had gotten a bilateral mastectomy. Her chest had two almond-shaped, smooth tracts of skin over where the nipples would have been. She was in that day because of four tiny pimple-like furuncles in her right armpit, a drug-resistant bacterial infection called MRSA. After my attending carefully went through the whole history and exam, prescribed her medicine, and was wrapping up the appointment, when the patient said something strange. “Now you’ve taken care of my little problem, but I need help with a big problem. Can you help me?” It turned out that two weeks ago, she had gone on a trip to Niagara Falls with her family, a cousin’s family, and her mother visiting from Guatemala, but they had accidentally taken a wrong turn and gotten on a bridge to Canada. At the border, she was detained by ICE and put in jail. She told the officer, “You can put me in jail, but I just have one request. Can you not handcuff me in front of my mom? You can do it when I’m inside, but my mother is old and has enough stress from just being diagnosed with cancer herself.” As she was being interrogated, she had one more request. “I don’t mind however long you decide I should stay in jail, but I am a breast cancer patient, and I just need to go to my appointments at the breast cancer center. I have this infection with a very dangerous bacteria, MRSA, and if I don’t get it treated, I will die.” The ICE officer was dumbfounded. He went to talk to his supervisor; he had never heard such a story before. This woman was supposed to stay in jail there until her court date; they ended up letting her go home with her family after being in jail for 4 hours. They had no guarantee that she’d show up, but they trusted that she would independently show up at her court date when it came up. So now here she was, at our breast cancer clinic, asking for a letter detailing the needs of her breast cancer care, especially the need for medical follow-up to monitor for recurrence. She smiled when she said, “I am the only person who can say MRSA saved my life.” I was shocked at the story; my attending was shocked. Hadn’t this woman gone through enough? Cancer had ravaged her body, had struck in her mother’s, and now the world was conspiring to separate her from her husband and children. My attending wrote the letter for her, but we both were silent in her office after the patient left. I think we both felt helpless. We gave her a piece of paper for the little problem. We gave her a bigger piece of paper for the big problem. But they seemed like flimsy nothings in the face of a cruel world.

The operating room itself was fascinating in its novelty. I never knew that fat was so tightly packed beneath taut skin, ready to bloom out from underneath the scalpel. Or that brains gently pulsated when open to the air, as if they breathed. Or the sickening crunch of bones snapping in a rhinoplasty. Or how neurosurgery, specifically work on decompressing the spinal canal, sometimes felt more like dentistry with the filmy clouds of bone dust flying and the high pitched squeal of the bone saw.

If I told non-medical people I was on my surgery rotation, they’d invariably ask, “Wow, did you get to cut people open?” I don’t know what they imagine being a medical student is like, but in liability-culture-New-York, I did little more than tie knots and cut the strings at the end. Sometimes I sewed the incisions closed. For me, surgery was mostly a spectator sport. Over and over again, the residents gave me their caveats and warnings about pursuing a career in surgery. “Some people say they want to do surgery because they love the OR. But the reality that people don’t tell you is that you have to love the OR more than you love your house, your hobbies, your family, and your children. It’s not that the OR is your favorite place in the hospital; it has to be your favorite place in the world.” But sometimes I saw the same residents in the OR, their favorite place in the world, enduring the gamut from snippy remarks to straight-on rebuke: “How could you still be tying knots like that? Are you a medical student?” “I keep telling you to pull the stitch all the way through. Are you listening at all?” “No, no, NO! Stop! Tilt it to the left — NO. Just stop. Let’s switch sides.” Stakes are high, tempers are high, patience is short, time is short. What else can we do? I heard rumors of surgeons throwing instruments, yelling, cursing. On the other hand, I also saw many role models of surgeons staying calm in the face of mistakes and complications. I saw arguments between surgeons of different services, blaming each other for patient deaths. And many residents four or five years in warned me not to go into surgery when we met up at 5 AM, bags under our eyes. For me, this was just a two month jaunt. For them, it’d be six grueling years, and then the rest of their lives. It’s more than loving the OR. It’s more than the OR being their favorite place in the world. It’d have to be love enough to cover a multitude of sins.

Finally, what’ll haunt me for life. One of my services was an elective surgery service: that is, the surgeries performed are done by choice, not as a life-saving necessity. At the clinic, patients would weigh their options: surgery, with necessary risks, or no surgery, and achieving their objectives by other routes. If they choose the surgery, they sign an informed consent form that includes all the possible complications. Neatly nestled in among a long list of consequences like bleeding, bruising, damage to surrounding structures, and nausea, there’s a small word: “death”. The doctors would give them the form and ask the patient to read it, and ask if they had any questions. No one ever asks about death. But one of my patients on this service was a man who had signed that form many months ago. He must have had some undiagnosed clotting disorder; after his procedure, he suffered devastating thromboses (clots) to vital organs. He had a huge stroke and brain hemorrhage; his spleen was clotted off as well, and various limbs. He stayed in the hospital the next four months, unresponsive, a frequent flyer to the neurosurgery service as they fought to control the brain swelling. Another woman had had a surgery for weight loss gone very very wrong; in two months, she dropped from 280 pounds to 98; she had nutritional deficiencies and looked cachectic. Her skin hung off her in folds; she was getting infections from fungus tucked away in flaps she couldn’t reach. Her hair was falling out in clumps. She got aggressive nutritional rehabilitation and backed off from the brink of death, but she had to accept that her life now on included constantly eating very dense meals to stay alive. All for a surgery that was a choice, an optional risk.

This was my fourth and last rotation block of a very long year. My dense schedule had already become rote; but by midway through my surgery weeks, I felt like I was holding too many eggs in my pitiful basket. Not only was I studying for the surgery exam, but I was beginning to prepare for what January had to offer: studying for Step 1, applying to away rotations, scheduling my fourth year of medical school, deciding my specialization (Emergency medicine!), writing personal statements, combing out the tangles of my life. I had to step back from some of my services in the church and back out of social events. In my last week of surgery, I had four exams, and I was studying furiously every night. But Wednesday night, my dad came home with a bunch of DVDs he got from the library and asked me to pick one to watch together. I realized that in all my work, I had been neglecting my family. Exams are exams. They’re important, but how much longer do I get to spend quality time with my parents? How long will I get to live with them? Part of me wanted to reject the movie. Two and a half hours of effective study time, to watch yet another Star Wars sequel? But another part of me didn’t want to let my dad down. He probably had seen me more stressed than usual, and in his own way, was trying to help. I ended up choosing to watch the movie. Exams are exams are exams. But bringing my dad joy? So much more precious than any points.