I spend my days and nights invading strangers’ bodies. I put my finger in their mouths and gag them, feeling for firmness suggesting tumors; I snake a thin camera through their nostrils and into their throats to see the organ that gives these strangers their voices. I assess bodies impassively, looking for infection, inflammation, hidden cancer. I cut bodies open, dissecting them layer by layer; I suture them back together again using needles curved like hawks’ talons. Strangers’ bodies are where I work and where I learn. I know things about my patients’ bodies that they don’t know and can’t see. I know things about them that they have no reason to know. Some people want to see inside themselves, and they ask if their operations can be filmed, or if they can take their tumors home. “Where do my tonsils go after the operation?” one patient asked me during my training. “Do you keep them in a jar, and once the jar is full, you get to graduate?”
I change my patients’ bodies in meaningful and irreversible ways. I remove tumors that have taken over their tongues, jaws, voice boxes. I rebuild them with pieces of themselves: segments of fibula bone, skin from their forearms, muscle from their thighs. I hope that they will regain use of the parts that cancer took from them, but there is sometimes no way to know. I feel a terrible responsibility for every sensation they feel after surgery, knowing that pain will be part of the contract, not knowing how much each individual will bear.
I tell people to trust their bodies to heal after surgery. “Listen to your body,” I tell them. “Everybody heals differently,” I say when they ask how long it will take to feel a new sense of normal. “You’ll know if there’s a problem. Your body will tell you.”
I tell them this while knowing that my body no longer bothers to tell me much of anything at all.
The irony of my profession is that while learning deep truths about the bodies of strangers, I have ignored my own. I have stood for hours in the operating room, forcing hunger to extinguish itself, willing my hands to stop aching while holding a dissector or a retractor. I have choked down food when I was not hungry, not knowing whether I would have time to eat again on shift. To avoid scrubbing out to urinate, I have kept myself dehydrated before surgeries that I knew would run long. I have worked through migraines, through pneumonia, and after fainting in a patient’s room during a procedure. I have forgotten to take my birth control about a hundred times. I have laughed when I was sad and frowned when I was happy. I have learned that the adrenaline generated from a beeping pager can transform me from a wilting mess in a call-room bunk to a calm professional wielding a scalpel, so what does it really mean to be tired?
In medicine, fluid losses can be categorized as “sensible” or “insensible.” Sensible losses can be quantified: five hundred cubic centimeters of blood lost; a liter of urine produced; two hundred milliliters of fluid removed from the lungs, the sac around the heart, the abdomen. Insensible loss, like sweat from the skin or humidity from the breath, is just as real, just as important, but essentially ignored, because it is not easily measured. Insensible losses accrue undetected — more quickly when a body doesn’t have skin to protect it, or when a body is laid open in the operating room, organs glistening under the bright lights. Insensible losses are liminal, mysterious, imprecise. Somewhere in this immeasurable ether is my connection to my own body.
The tiny emergency department (ED) is divided in half: four rooms for patients coming in with ear, nose, and throat (ENT) problems, and four rooms for patients with eye problems. Always open, it is the only emergency room of its kind in the region. Gray cubicles in the back house clinician computers — two for ophthalmology, two for ENT — and facing the computers, a monitor displays the patients checking in, waiting, or being seen in real time. Eye patients appear in blue; ENT patients, in orange; and unlucky patients with simultaneous eye and ENT complaints, in pink. Right now, though, the board is completely clear.
“Is your black cloud off for Christmas?” the day-shift ED nurse, Jennifer, asks me, eyeing the empty screen.
It is midmorning on Christmas Day in my third year of residency — my first year taking “senior call” at the main hospital — and I am alone, having sent my junior resident home after we rounded on our inpatients and wrote orders for those being discharged today. Sending him home early is tempting fate just a bit, as the holiday census could swing either way — overrun with patients requesting earwax removal because they figured there wouldn’t be much of a wait, or, as now, eerily silent. My nights on call are almost always very busy — a “black cloud” of bad luck trails me — so this could well be the calm before the storm.
On holidays, we residents, already a small group, pare ourselves down to a skeleton crew, making the workload on those who remain particularly brutal. Being “on” over a holiday weekend means passing a grenade of responsibility back and forth between two seniors every twenty-four hours: being the only otolaryngologist in-house; covering the adult and pediatric inpatients; taking on whatever walks into the emergency room, whatever might need to go to the operating room; and answering pages from the phone triage line. Connected to our small specialty hospital is a general hospital, a behemoth with more than a thousand beds, and we cover ENT-related consults from its emergency room and inpatient wards too. Three boxy black beepers straight out of the 1980s weigh heavy on the waistband of my scrubs: one for my hospital, one for the general hospital, and the “STAT pager” — which only chimes if someone calls a rapid response on one of our inpatients.
“Don’t jinx it,” I say to Jennifer as one of my pagers starts to beep: a patient up on our eleventh-floor inpatient unit wants to talk to a doctor before discharge.
“There’s a potluck in the back room,” she says. “Fix yourself a plate before it’s all gone.”
Nobody explicitly asked me to ignore my body. But the reality of surgical training is that, especially at the beginning, it can feel like there is no time to occupy a body, and certainly no time to consider what it might or might not need. Even writing about my own body now feels selfish, transgressive, whiny. Early on, whenever I had to perform a bedside procedure on someone — remove a drain, or replace a dressing, or suture a wound — the patient’s nurses reminded me to raise the hospital bed to a comfortable height. “Save your back,” they would say, and I would demur, ashamed of needing to move a patient around to suit my own needs, so focused on the task at hand that even possessing a body seemed to be a sign of weakness. But then my shoulders started to hurt at home, and I realized that I was standing on my tiptoes in the operating room rather than inconveniencing anyone by asking for a step. I tried to accommodate my superiors by negating my own existence. I thought I was demonstrating my suitability for the challenges of my chosen profession. I thought I was showing grit. Somewhere deeper, I thought of it as penance: for my own good health while I witnessed so much suffering.
I’d assumed that this stubborn refusal to admit discomfort was something instilled in me by my surgical training, but now I think that I’ve always been a child of extremes. My father often chastised me for “burning the candle at both ends.” When I fell ill at boarding school, I ignored my symptoms, not getting the diagnosis of mono until I came home months later. My mother took one look at my gray face as I stretched out on her lap on the couch and called the doctor’s office. “Good thing you didn’t play soccer this term,” said my pediatrician. “Your spleen is gigantic.”
Perhaps extremism is my pathology and surgery its latest incarnation.
This Christmas, my coresident is on call at the other hospital across town, but she isn’t required to be in the hospital at all times like I am — it’s a “home call” system, so she only comes in if she is needed. In the afternoon, she, her siblings, and my partner bring a feast from a nearby restaurant, and we eat dumplings together in the windowless resident workroom, periodically pausing the conversation to answer pages and phone calls.
In the early evening, I start to feel a bit off. It begins as a vague discomfort, unfocused, easily dismissed; I know I would frustrate any doctor trying to collect details. “It’s not pain, precisely — it just feels like my insides are floating,” I would say, and the doctor would try to pin me down: “When did it start? Does it radiate anywhere? How severe is it? Any other symptoms — bloating, vomiting, diarrhea?” I blame it on a combination of holiday-call exhaustion and the smorgasbord of odds and ends I consumed throughout the day — the potluck in the emergency room, the candy on the eleventh-floor inpatient unit, the dumplings — and push through it. I see a few consults at the hospital next door and make my evening rounds, checking on the patient who is undergoing particularly close monitoring, sending a picture to my attending confirming that he looks stable. I go back down to the emergency room to clear the board and say hello to the night nurse, Dirceu.
“There’s still some food left,” he says, and the vague discomfort abruptly locates itself in my abdomen.
I tell him that I’m going to lie down in the call room. “Black Cloud Colaianni,” he says. “Don’t get too comfortable.”
I know a surgeon who operated all day through contractions and delivered her baby that night. I know a doctor who worked a twenty-four-hour shift while febrile to 102. I know a doctor who needed IV fluid resuscitation between seeing patients in the emergency room. I know a surgeon who miscarried during a night on call and didn’t go home. They did this because there was no one to cover them if they called out sick, or because, if there was a backup system, the person backing them up was an overworked colleague on their first day off in two weeks, or because calling out sick simply wasn’t done. They did this because they were afraid to look weak. They did this because it is what the system demanded of them. “That is outrageous,” people say when I tell them these stories, and it is, objectively, outrageous. I feel both shame and pride when I think about the toll my training has taken on my body. I feel tough. I feel like a fool. I feel strong. I feel like a bad role model.
During residency, I saw a film about a man who decided to free-climb a three-thousand-foot-tall rock face in Yosemite. The camera lingered on close-ups of his torn-up hands, bruises after falls, a sprained ankle — stigmata of pushing his body to and past any reasonable limit. A journalist asked him why he didn’t use ropes. “What a stupid question,” he replied. His conviction that he was doing the thing he was meant to do was unshakeable, carved into the core of his being. Sitting in the movie theater, I imagined my own journey as something similar, though I was far less convinced that it was an inevitable path for myself. There was also the inconvenient fact that my own journey was, at times, less explicitly chosen than externally imposed. Still, going to work required a certain faith: a belief in, if not a higher power, a higher purpose. I could vaguely remember living in my body the way the climber seemed to live in his: diving into a cold Maine lake first thing on a summer morning; breathing frigid air so deeply into my lungs that they spasmed, the pain shocking and delicious; the pleasant ache in my legs after a long run. These were living reminders of physical joy. I cried during the film about the climber, not out of relief or excitement when he ultimately triumphed but because watching him do it, I could only see the doors he had closed, what he had given up along the way.
I gave up weddings, birthdays, friendships. Thanksgivings, Christmases, New Year’s Eves. Excursions with groups of friends, camping trips, sending presents on time. Seeing my friends get married and have children. Growing up parallel to them, I deluded myself into thinking that “as soon as” I was done with this phase, this test, this year, this rotation, I would have time to catch up, to sleep, to figure it out, to live, to emote, to heal. When you’re told that what you’re doing is the most important thing in the world — and when it’s literally life or death, who are you to say otherwise? — it’s the easiest thing in the world to deprioritize yourself. Do this enough times and you, as a body, as a full human, as a concept, can cease to exist.
Upstairs in the call room, I kick the thin sheets around, restless, too hot and then too cold, my sense of unease mounting. I feel flimsy and translucent. When my teeth start chattering and my neck turns clammy with sweat, I admit that I might actually be ill and not just a whiner.
Before long, I’m vomiting into the filthy call-room toilet, crying on the floor in between bouts. A nurse pages me with a lab value, and I tell her that I think I have either food poisoning or the norovirus that was going around last week. “Can we call someone in for you?” she asks, but there is no one to call, no backup system; it’s 3:00 a.m., and I am alone and responsible. This is how residency training is; how it has been; how, without intervention, it always will be. She tells me she’ll let Dirceu know in the ED so that he’ll only page me if it’s something urgent.
Two hours go by, and my dry-heaving seems to subside. My head throbs. I wash my puffy face and brush my teeth, again. I crawl into the twin bed and fall asleep with my pager in my hand.
I’m not sure how long I’ve been asleep when my pager beeps me awake. “So sorry :( … active nosebleed in ENT 1,” reads the page. I make my way, a little woozily, to the freezing back elevator, the threadbare call-room blanket wrapped around my shoulders. I can do this, I think. Just push through.
Dirceu eyes me as I walk through the emergency room’s double doors. “Are you sure you’re alright?” he says, and I tell him that I think I’m pretty sure I’ve thrown up everything I possibly could by this point. He gestures toward the exam room, where an elderly man sits, pinching his nose and spitting blood into a basin. “Hi there,” I say, putting on the gown, gloves, and plastic face shield that Dirceu has laid out for me. “Sorry we’re meeting like this. When did the bleeding start?”
“About an hour ago,” he says, a bit of bloody drool stringing from his chin to the basin. “It woke me up. I tried holding pressure, but I keep coughing these clots out.”
“Have you had nosebleeds like this before?” I ask, and his middle-aged daughter, curled in a chair in the corner of the small room, answers for him. “He has, but not this bad,” she says. “He’s on blood thinners for his heart.”
I tell him to release the pressure on his nose, and I suction the blood out, then spray Afrin and anesthetic into each nostril. If there is a small visible vessel toward the front of his nose, I tell him, I will try to cauterize it to stop the bleeding, but if it’s bleeding too quickly, I’ll have to place a “pack” to tamponade it. I pinch his nose again to give the Afrin a chance to slow the bleeding down, but when I move my hand, he starts hosing again. Dirceu hands me the pack, and as I start to place it in the man’s nostril — “Okay, you’ll feel some pressure” — my vision goes blurry, and I feel bile rise in my throat. I shove the pack in and rip off my mask, my goggles, my gown, barely making it to the trash can next to the exam chair before starting to retch. I feel Dirceu holding my hair and putting a cold compress on my neck.
“Oh my God,” says the patient’s daughter.
“I am so sorry,” I say, mortified, when I catch my breath. “I think I have food poisoning.” I make sure that he has stopped actively bleeding before I escape to the staff bathroom to wash my face. My head pounds as I rinse my sour mouth in the sink. They must think I’m inept, my sick body calling gaudy, excruciating attention to itself instead of servicing his. They came to be cared for, not to witness the illness of their caregiver. Will they make a formal complaint?
When I return, the man’s bleeding has not resumed, so I write up his discharge paperwork, print out his prescriptions. “Feel better,” I say, thankful to be rid of him and his horrified daughter. “You too!” he says. He laughs, and the sound is not unkind. I stumble to the cot in the ED’s procedure room and slip into unconsciousness, my pager miraculously silent until the day team comes to relieve me at seven.
In medical school, I saw a woman in her sixties with incurable, widely disseminated cancer of the uterine lining, which sheds every month until menopause. The woman happened to be an experienced internist who had treated her own patients for decades. When she noticed vaginal bleeding, she didn’t take herself to her own doctor for a workup; instead, she treated herself with oral contraceptives for several years. In that time, the cancer methodically worked its way to her lungs, her belly, her bones. Her bleeding was the only early warning sign. “How could she have ignored it for so long?” asked one of the chief residents outside her room. “How could she not know something was wrong?”
By my final year of residency, I had proven to myself that my body was a liar: it didn’t really need the things it said it did. As a result, I no longer trusted myself to know whether I was hungry or thirsty, tired from not sleeping or tired from sleeping too much. This is just how residency is. My answer to any inner complaint had been to ignore it, to work harder, to push through, to keep going. Don’t be a weenie. I spoke with a colleague once about how my migraines were getting worse. “My body is betraying me,” I said, like an idiot. My body hadn’t betrayed me; I had betrayed it. I had gone to work at 5:00 a.m. after waking up at 4:00 a.m. sobbing, repeating over and over to my partner that I was sure I’d fucked up my whole life. It’s fine, I’m fine, everything is fine. I felt like a collection of angry organs, more foreign to myself than the patients I examined.
Immeasurability is vexing to doctors. We want to cut things out that we can see and feel, solve problems that can be fixed. We want the instant gratification of removing a tumor and alleviating symptoms. Insensible losses are frustrating in their inherent refusal to be quantified. Some of my patients are intensely aware of the differences in their postsurgical bodies; they notice every patch of numbness, every thickened ripple of scar, and they demand a solution to the harm I have caused in trying to heal them. But there is no undoing the changes that healing renders; there is only making peace with them. Sometimes I envy these patients, the ones who are so attuned to the internal workings of their own bodies that they imagine they can feel each stitch dissolving beneath their skin. Others remain willfully ignorant of themselves, even when their tissues are screaming to be listened to: one man sought care only because the tumor on his scalp had grown too big to hide under a baseball cap, another because the tumor in his tongue had made it impossible for him to close his mouth. I find these patients equally baffling but somehow more relatable: I, too, have ignored pain, psychic and bodily, to press forward. I, too, have stifled the screaming of my own tissues.
How does one come to embody oneself again? A few weeks ago, as I bicycled across the city where I now live and work, I looked upon a tree-lined street, watching yellow leaves fall slowly to earth, lit by the autumn sun. I breathed in the crisp air and felt it in my nose; I noticed my lungs expanding for the first time in a long time. Underneath a frozen surface, molecules were shifting; I hoped it signaled the beginning of a thaw. I still exist in a culture that denies my body’s right to make demands. My instinct is still to suppress, to smother, to ignore. But beneath that is muscle memory of existence, sensuality, inhabitance. Of stretching and relaxing. Of the rise and fall of breath. There is no going back, no rewinding, no undoing. There is no reversing the changes that my training has wrought. There is only seeking comfort in the now: feet against the pedals, fingers gripping the handlebars, eyes tearing in the brisk wind.
