The Gross-Out Factor

 
In the garden that is the body, there is little as fertile as granulation tissue. It is a fleshy version of the richest topsoil, a vermilion carpeting that appears within a few days of injury and gives rise to new blood vessels and skin. Wounds that lack this cover never heal, but those that have it almost invariably will. And when they do, it is a miraculous vision. A cavernous hole on the torso will contract and a broad crevice along the arm or leg will narrow, until each has been transformed into the small pucker or raised line we call a scar.

Surgeons work hard to nurture granulation tissue. They are gardeners at constant odds with the weeds of flesh, clearing away all manner of debris to make room for “the good stuff.” Week after week, with tweezers, scissors, scalpels, and a host of ointments and salves, surgeons will groom their plot. They will pull off clingy, yellow fibrinous waste and pick at dried suffocating scabs. Even excess granulation tissue—that exuberant “proud flesh” that pokes out like the soft tongues of infants—gets reined in, the overzealous efforts of a few shaved away for the good of many.

When all of that picking and cutting and scraping is finished, surgeons, like their backyard brethren, will stand and gloat over a job well done. As nurses rush to replace the bandages, these biological gardeners will lean back and admire the gash across their patients’ bodies. “That wound,” they will murmur with great satisfaction, “looks just beautiful.”

*  *  *  *  

I have long known that my sensibilities are just a little bit different from most people’s. It is not that I revel in blood and guts; it’s just that they do not perturb me. I hear discussions about disease manifestations and am compelled to participate. I see injuries and do not cover my eyes. Instead, I feel the urge to move closer and even touch or sniff, if given the chance. And that curiosity is a good thing, because wounds and illnesses and human anatomy are the routine of a surgeon’s life.

I have learned to be cautious when talking about this part of my work. I speak in generalities and keep close gauge of my audience’s reaction. Many people, I have found, have trouble stomaching detailed descriptions. They are not interested in the meaning of the various odors that can emanate from dressings and they prefer not to imagine, let alone hear, all the details of even the most fascinating of lesions. So whenever I begin to sense others moving away, hear them laughing less heartily, or see the color draining from their faces, I stop lest I bring yet another sparkling conversation to a dead halt.

Every so often, however, I’ll slip.

My mother-in-law has been plagued with intractable rheumatoid arthritis for over forty years. There are pictures of her before her diagnosis—
a tall, determined artist with California movie-star looks, impeccable though somewhat bohemian tastes, and legs that go on forever. Over the years, her drive and taste have remained unchanged. She is one of those women around whom you find yourself quietly tucking in your shirt and checking the color coordination of your outfit, and you always leave her wondering how such individual resolve gets fueled. But she is no longer what she was; the arthritis and medications have reduced her once elegant hands to nearly useless claws and the dewy skin on those endless legs to crinkled rice-paper wrapping.

Last winter, when she brushed against her walker, the skin over her left ankle shredded. She soon developed a gaping, tangerine-size wound. Months later, it is still there, though covered by a layer of bright red granulation tissue that bleeds and oozes with the touch of a hand. A nurse visits to change the dressing once a week, but those bandages can become saturated beforehand and, when removed, reek of moist flesh.

A couple of weeks ago on dressing-change day, my mother-in-law was staying with us, a hundred miles away from her regular nurse. My husband and his sister, who was also with us, had anticipated the problem several weeks in advance. Neither of them is a physician, but realizing that something had to be done, they volleyed the dressing-change duties between them. By the time the day arrived, the job had landed in my husband’s lap.

“I’m going to do Mom’s dressing change,” he announced to me that morning.

I looked at him; he was clutching his solar plexus.

When I walked out of my mother-in-law’s room fifteen minutes later, soiled dressings in hand, I found my husband and sister-in-law huddled together in the adjacent room. “How does it look?” they asked, staring at the clump of saturated gauze in my hands and delicately keeping themselves at arm’s length from me.

“There’s decent granulation tissue and it looks clean,” I replied. I opened up the dressings and held them close to my nose. “These don’t smell too bad either.” But when I began to describe what I had seen in more detail, I saw the color drain from my sister-in-law’s face.

I turned to my husband; he looked at me as if I were a stranger.

As he and his sister walked away, expressing their gratitude but shaking their heads in disbelief, I realized that I had once again taken for routine something that was not. I remembered the parties, dinners, and phone conversations when I had felt that tense silence, heard those uneasy laughs, and caught the awkward attempts to change the topic of conversation. Most of the time, I could pass off these difficult social moments as a kind of occupational hazard.

That day, however, I could not stop thinking about the expression on my husband’s face. How could something so difficult for others seem so inconsequential to me? Long after I had thrown out my mother-in-law’s dressings, long after the smell of her wound had disappeared from my hands, I continued to replay that morning’s events in my mind. And each time, I had to ask myself the same question: Why had I misjudged the gross-out factor?

*  *  *  *  

My memory of internship is, for the most part, hazy, but I clearly remember the wounds. Each morning, several hours before the start of everyone else’s day shift, I roamed, a box strapped over my shoulder, from patient room to patient room like some baseball-park vendor. The box contained not hot dogs and peanuts but an intern’s goodies: bandages, gloves, saline solution, and tape. During those early mornings, I cared for healing incisions, leaking drains, and surgical wounds left open; there were dying toes, amputated limbs, and oozing abscess cavities in the most unexpected locations. At each patient’s bedside, I took down the previous night’s bandages, carefully cleaned away any debris, then rewrapped the wound with new coverings from my box.

Over the course of that year, I saw several hundred wounds. And while early on the most fetid ones made me pause, little surprised me by the end of my internship. Instead, the wounds became the welcomed constants in my endless workdays and sleepless nights. By seeing them so often and so intimately, as you would a best friend or spouse, I could predict their behavior. I knew which wounds would heal and which would not, which could be cared for at home and which would require a little help in the operating room. All I had to do was look at a wound, touch its surface, and inhale deeply into the discarded bandages.

And I never noticed if anyone watching me might have flinched.

Several physicians have written “insider’s stories” of the medical school or training experience, and there is the sense when you read these accounts—often entertaining, sometimes horrifying, but always eye-opening—that the process of becoming a doctor is so relentless that young acolytes have no choice but to capitulate completely or quit. In choosing the former, they become witness to the endless variations of human disease, and even the most sensitive young doctors end up impervious to the suffering around them. As they say, “Been there, done that.”

This attitudinal change is often depicted as the most significant result of medical training. That assessment holds a lot of truth. After all, the ability to rise above the gross-out factor is a necessary—some would say the foremost—component of good doctoring. As a patient, you want a doctor who will reserve judgment and transform any situation into a purely clinical predicament. There is great comfort in knowing that your doctor will remain unfazed by how your diseased part might look, feel, or smell. A distracted doctor, frankly, can be embarrassing and, in more critical situations, downright lethal.

The process by which doctors change is one nearly all of us can understand. While most people will never see as much illness and injury as a physician in training, we nonetheless all habituate constantly, even in the most mundane of tasks. We put on socks, for example, and feel the scratchy fibers against our skin; moments later and completely habituated, we are hardly aware of the covering on our feet.

This habituation is a form of memory that we happen to share with the most humble of species. Sea slugs, or Aplysia, can become habituated to touch just like human feet. The Aplysia’s normal response—to withdraw their gills—stops completely if the Aplysia are touched repeatedly. While there are a lot of complicated developmental differences between the average invertebrate and you or me, those biological findings are hard to ignore, particularly when our own habituation feels so innate. After wearing wool socks for a few hours, I cannot even imagine the same scratchiness I might have felt just after putting those socks on. After entering a pool, I can predict that the bone-numbing cold water will soon feel only bracing, then eventually sublime. And at noon every day, I know that my stomach will growl for lunch, whether I am working in front of a computer or standing before a festering wound.

*  *  *  *  

More than simply becoming desensitized to what others may find repulsive, doctors must actually be drawn to their patients’ travails. We need to find these injuries fascinating, compelling, even attractive. And like the process of habituation, learning to find beauty in the gruesome requires some training.

During our few free moments in residency, the other young surgeons and I would gather in our back corridor offices and regale one another with anecdotes about our week. Leaning back in hospital-issue chairs or sprawled across our one vinyl couch, we would take turns, often embellishing on the narratives in order to present ourselves, the pit crew of the hospital wards, in the most flattering light. Occasionally, these storytelling sessions turned into a surgeon-in-training version of “Truth or Dare.” One resident says, “You know, I saw the grossest thing yesterday,” and the accompanying story would fire up the challenge. Each of us would then recount our own recent horror stories in the not-so-secret hope that our tale would outdo all others. The stories passed around those evenings were myriad: bullets perfectly placed during lovers’ quarrels, limbs ripped and torn in auto accidents, flesh-eating bacteria and the rotting spoils left in their wake.

In my mind, however, there was one story that topped them all. One of the surgical residents had gone to the emergency room to see a patient with an infected leg wound. Because these requests were fairly common, none of us was initially impressed as she began her anecdote, even when she described smelling the wound several yards from the patient’s cubicle.

When this resident pulled away the patient’s makeshift dressings, however, she noticed ricelike debris over the entire wound. She rolled her eyes, believing the man had such poor hygiene that he neglected to clean up after himself even after food had fallen into his wound. But upon closer inspection, she noticed the debris moving, wriggling over the surface, poking out of crevices, and devouring dead tissue.

The wound was covered with maggots.

We fell silent at that punch line. And none of us felt any pressing need to hear more about how she managed to pick out the maggots and clean the wound. For all that we had seen or bragged that we had seen, this resident won the prize. All we wanted to do was quietly celebrate our good fortune in not having had that patient on our watch.

The chief resident, the most experienced among us, finally broke our stunned silence. He stood up from his chair and walked toward the couch that was sagging under the collective weight of three other residents and me. He cleared his throat and smiled, as if he had found something humorous in our response.

“You all should think of it this way,” he said, addressing us more as students than as colleagues. “At least all those maggots kept the wound clean.”

*  *  *  *  

In 1960, in the university where I would train to be a surgeon some thirty years later, a young researcher named Stanley Milgram conducted a series of experiments in which local volunteers were asked to test a student’s ability to remember word pairs. The volunteer and student were placed in separate rooms, and electrodes were strapped to the student’s wrists. Each time the student answered a word-pair question incorrectly, an experimenter would ask the volunteer to punish the student with increasingly higher levels of electrical shock, ranging from 15 to 450 volts.

Several hundred local volunteers participated in these experiments; not one of them was aware that Milgram had rigged the entire setting. The student, introduced as a fellow volunteer, was in fact an actor; no shock was ever administered; the screams heard from the student’s room were prerecorded; and the experimenter’s directives encouraging the volunteer to administer the shocks were a series of memorized lines. The volunteer, however, believed that all was real, and therein was the crux of Milgram’s experiment. By creating a seemingly real scenario, Milgram believed he could monitor how normal volunteers would respond to authority, even in ethically trying situations.

Milgram’s results and the results of similar experiments conducted at other universities and sites throughout the US were always the same. The majority of volunteers continued to punish with ever-stronger shocks regardless of their own, often verbalized, moral concerns.

Why did these volunteers persist in delivering such seemingly brutal punishments? As one possible explanation, Milgram offered the following: there is a “tendency of the individual to become so absorbed in the narrow technical aspects of the task,” he wrote, “that he loses sight of its broader consequences.” Milgram postulated that in order to ease their consciences, volunteers assigned moral authority to the experiment itself. Thus, the overwhelming importance of “contributing to science” made it necessary to comply fully, whatever one’s personal scruples. By creating this new moral paradigm, the volunteers liberated themselves from the constraints of their own.

I understand this narrowing of vision as well as anyone. Once in a patient’s belly, I forget all else—hunger, thirst, fatigue—in order to take care of what is at hand. In front of a necrotic, foul-smelling wound, I can pick and scrape and clean until the wound glistens. And while that seems entirely reasonable and even desirable when it comes to being a surgeon, my line of thought is not unlike that of Milgram’s volunteers. Because of the moral authority I, and those around me, give to medicine, I am able to do things that in other circumstances would be unacceptable.

But with a different set of circumstances, could I—or anyone else eager to do the right thing—find myself doing something more?

*  *  *  *  

Two years before he began his experiments, Milgram wrote in a letter to a classmate:

I should have been born into the German-speaking Jewish community of Prague in 1922 and died in a gas chamber some 20 years later. How I came to be born in the Bronx Hospital, I’ll never quite understand.

These words, as much as Milgram’s experiments themselves, have haunted me. Because like Milgram, I feel deeply connected to circumstances beyond my own. I am part of not only my family but also my profession, my fate enmeshed with those of other doctors. Like siblings, we are tied together by a genetic code, our DNA being that shared body of knowledge, training, and ethics.

But again like Milgram, I cannot help but wonder what separates me from those others. We, these other doctors and I, are nearly like clones, in many ways perhaps almost interchangeable. Thus, how I came to be in any way different from the doctors at Abu Ghraib and Guantánamo Bay, I will never quite understand.

Could my professional brethren have committed the unimaginable? Why did they not speak out? I have wondered if these doctors, habituated to the repulsive, were no longer able to recognize the atrocious. Like Milgram’s volunteers, they might have ascribed to a new moral paradigm where the effects of psychological and physical abuse were no different from the signs and symptoms of diabetes. Or perhaps they learned to assign moral authority to a system that condoned and even encouraged torture.

No matter how I have tried to interpret all the reports, I cannot shake a gnawing fear within. I cannot help but wonder if these doctors are perhaps not so different from me.

*  *  *  *  

I have not been able to forget the look my husband gave me the morning I changed his mother’s dressing. Now when I see others blithely misjudging the gross-out factor, I wonder if I am capable of the same or perhaps even more.

The kitchen table serves as the connecting hub to all other points in my house. The day’s mail, the children’s toys, and assorted reading materials sit in neat heaps before finding their way to the appropriate recipient, toy chest, or shelf, usually within a day. However, the magazines and newspapers inevitably linger longer. My husband and I like to poke through the articles over the course of a few mornings, so the magazines will often be opened to an interesting article, perhaps marred by a stain or two, and the newspaper sections will be scattered like leftover napkins from a previous night’s party. We will pick at our morning toast as we read, down our caffeinated beverages as we turn the pages, and get the kids ready for school with the latest headline in our field of vision.

But after that morning when my husband looked at me as he would a stranger, the seemingly ordinary changed. I took note of all that had collected in the hearth of my home and I saw the repulsive. I cringed at the violent war photos and blaring headlines about the newly kidnapped, terrorized, and dead. I shuddered at the editorials about pessimism and hopelessness and lassitude. I realized that what had previously made me despair had, over the course of a few years, become the topic of breakfast conversations. These pictures and articles had become—along with the cheery greetings and hugs with my husband and children—part of my morning routine. Like the surgical intern who becomes less and less impressed by the wounds on the ward, I was no longer moved by the news around me. As perhaps for the doctor in a prison camp, the atrocious had become the mundane.

As much as any of us would like to believe in the immutability of acceptable and unacceptable, we easily and unknowingly slide between the two. While we would like to believe that our personal moral compasses would never waiver, we can grow so accustomed to even the most repulsive crimes that the accompanying horror becomes less vivid and meaningful over time.

Pavlov, of the drooling dog fame, believed that habituation could be simply reversed. Others have asserted that repeat sensitization could interrupt a learned reflex. But for our human quandaries, extricating ourselves from habituation and the inevitable sliding ideals requires another, more complex process altogether.

It requires, as any successful gardener would tell you, being acutely aware of all that is around you. In a garden, that means constantly observing the ground, the skies, and the sudden shifts in weather. In a wound, that means steadfastly attending to the skin, the blood vessels, and the variations of the body itself.

And in our world of ever-escalating challenges, it means never losing sight of just how porous our moral borders can sometimes be.