I wanted to see how my hands worked. I wanted to hold an ophthalmoscope, and look into the back of an eye. I wanted to hold an otoscope and look deep into an ear. I wanted to percuss a chest and abdomen and hold a stethoscope as I auscultated the sounds of the body. I wanted to hold a reflex hammer and watch the involuntary movements of arms and legs. I knew I was smart enough. I knew I had the strength to keep going. I wanted to hold the instruments and learn the tricks of the trade right then. I hoped that my hands would work well. Would I be a natural, or would I try over and over? I wanted to practice clinical medicine. And I wanted to do it now.
But first-year medical students don’t get to practice medicine. The demands of study occupy all of your time. Still, I wanted to actually see some patients, take a history and do an exam. I was tired of practicing on people paid to act as patients. To protect actual patients from inexperience and harm, access has an order. Patients are admitted to a professor or attending physician, then there are fellows, residents, interns, and finally students. The best I could hope for was standing at the back of the line waiting my turn. But I was older than the other medical students and had been a teacher for several years. I didn’t want to wait.
I started looking for opportunities to volunteer in a free clinic. Poor, desperate people with no other options come to these understaffed, understocked offices open primarily at night. These patients can get away from their service jobs as gardeners and maids only after long days of hard work. The disenfranchised sit and wait. Sometimes it takes all night to be seen; other times the place shuts down as exhausted volunteers head home leaving patients to come back the next day.
I signed up at a clinic where a third-year student I knew said they needed help. I did my first delivery there. I had never even assisted at a delivery before, but a patient arrived in early labor and I was there. The first rule of obstetrics is “do not drop the baby.” I delivered the baby, cleared the mucous from her throat, and wiped her dry. I held the baby up and handed her to her mother. I did not drop the baby, but I did fumble the repair. I looked down at my hands. I could see what I needed to do. I saw my hands move the needle holder in and out of the field. Finally, I guided it to the apex of the vaginal laceration. “Stitch, tie, then run and lock,” I said to myself as I followed the instructions of the nurse standing over my shoulder. The clinic did not have enough local anesthesia to last long enough for me to finish the repair. There was nothing I could do but keep sewing. “I am sorry,” I said. She clutched her crucifix but did not flinch.
“What will you name the baby?” I asked. My patient looked at her baby and said, “Paloma.” I asked what that meant in English. The nurse, relieved that I made it through, said, “It means Dove.” It had happened so quickly. I wondered if I might have delivered this Dove by sleight of hand, like a magician releasing a white bird from his hat. I looked at my hands and wondered. My patient was happy, it was over. I had finished my first procedure without violating the first rule of medicine: “Do no harm.”
I wanted more. I heard of an opportunity in the mountains of Jalisco, Mexico. The Huichol Indians, an indigenous people, live deep in remote areas hidden from civilization. They weave brightly colored yarn into shapes called the Eye of God, the symbol of their spiritual life. They do not speak the language of those who conquered their country. They are withdrawn from others, and the government provides no systematic health system for them.
My contact was a missionary who had established a relationship with a small tribe of Huichol Indians in the Sierra Madre Occidental Mountains. He had crashed three planes trying to get to them. I wasn’t sure if he was a pilot who happened to do missionary work on occasion or a missionary who flew a plane when there was no pilot willing to take him where he wanted to go. He made his first connection with this group by rolling oranges downhill toward the Indians keeping their distance. Over the years they became more accustomed to each other, and eventually, the missionary established relationships with remote towns in the area as well.
These people needed medical attention, and anyone who wanted to help was welcome. There would be no departments of radiology, no lab, no referrals. I would be on my own. No one would be standing in front of me, between me and the practice I wanted.
When I arrived at the airport in Guadalajara for a four-day mission, four other students wanting the same opportunity were already there. We shook hands and headed to the plane. It was small and I had my doubts that it could hold us. The Sierra Madres towered in the background. The pilot loaded us up before we could back out. The plane struggled to lift off, and we headed toward the mountains. The warm, humid air currents pushed us down as we neared the top of the first mountain. The pilot banked quickly and tried to circle higher. “Hope we make it next time,” he mumbled to himself. It was at this moment that he told us about his crashes. I wondered if he was trying to scare us to Jesus.
On the third try we crossed over the top between two peaks, the other side of the mountain dropping away, and with it, civilization as I knew it. I had no idea what waited for us. The landing strip was an uphill clearing—requiring a slow dive, a last-minute nose-up, and then more speed before we found the ground under us.
The moment the plane touched down, the pilot became a missionary. He showed us to an abandoned adobe hut at the end of the village. “No one will live in it because the Huichols think it is haunted,” he explained, “so we get to use it whenever we make a trip.” Before I could ask for the story behind this superstition, we were already through the open door, blinking into the darkness, waiting for our eyes to adjust. It was a one-room hut, with an open fireplace, six army cots, and no electricity or running water. I picked a bed, rolled out a sleeping bag, and examined my brand-new medical bag stuffed with brand-new instruments. My equipment looked out of place. I wondered if my medical paraphernalia would be accepted by my patients or if they would think it was a bag of tricks.
We opened the back door to let in light and walked out to check the bathroom facilities. There was no plumbing, but next to the well hung a bucket with holes. This was the shower.
The flight had been nerve-wracking so I decided to clean up. I tested the water—ice-cold. I couldn’t get undressed, pull up water, jump under the bucket, and shower before the bucket ran dry, so I asked one of the other medical students to pull up the bucket and hold it over my head. One pailful was enough. I decided I could wait until I returned to Guadalajara from the long weekend mission to take my next shower.
My first patient was an old woman who, the translator said, couldn’t hear. I asked about any injuries. “Her husband beats her when he is drinking,” the translator said. Brain injury, I thought. Subdural hematoma (bleeding that forms a clot under the skull resulting in increased pressure on the brain), I thought, as I started my exam. I tested her eyes and then looked in her ears. There, deep inside the canals, stuck in wax, were cotton balls. Apparently when her husband drank he became loud, and the cotton made life more tolerable.
I opened my doctor’s bag and rummaged through the instruments. I placed the stethoscope around my neck. I laid the reflex hammer on the table. I found the forceps, and carefully introduced the instrument into the canal and closed it on the wax-impacted cotton. The woman did not move. I pulled gently, then tugged and rotated, freeing the material from her ear.
“Well, there you have it.” I said. I took the cotton wads in my hand and showed them to her. She took my hands. “Magic hands,” she replied through the translator.
I was suddenly humbled, almost embarrassed, like I had pulled a fast one. Was I someone who flew in on a plane, spent a couple of days, did his magic, and took off? I looked at my hands. Had I just completed a trick like pulling a quarter from behind an ear? I thought about medicine men in tent shows. Was I merely a practicing prestidigitator? Was I someone standing on a platform who knew something, taking advantage of those in the audience who did not? My first patient could hear again. I did not believe I had any magic. Magic is performed at children’s birthday parties and in the neon-lit joints of Las Vegas, not here in medical consultation.
Throughout history, we’ve been called high priest or shaman. But when our incantations turned to science, we became physicians. Now the government has taken even that title away. We are called health care providers. But I was none of these. What I had accomplished required little skill. It had required no training. I was not ready to wear the mantle, the long white coat. I was just lucky.
I left the mountains knowing that I could use my hands and the instruments. There was no need to return. I would find people to help and places to learn without placing my life in the hands of a missionary pilot with a poor flight record.
I returned to school and went back to work in the free clinic. I finished medical school in 1979 and matched for graduate training in obstetrics and gynecology. I began residency. I kept up with the books. I learned protocols and procedures. I did not think about magic.
During my second year at Albert Einstein Medical Center in Philadelphia, I was on the labor floor when a patient in obvious distress was wheeled in. She appeared to be around thirty weeks pregnant. She was accompanied by her mother. Neither of them spoke English well. The translator told me they were recent political/religious refugees from Russia. The Jewish community in Philadelphia had helped them emigrate. She had no prenatal records, and the translator was unable to find out if she had received any care during her pregnancy.
She was wearing a Star of David around her neck. I wondered if the pendant had been a family heirloom worn under many layers of clothes or held hidden in a secret place. Maybe it was a welcome gift from one of the women who helped her find her way to Philadelphia. Could this be the first time she had ever worn it openly? The nurse handed her a plastic bag for valuables and a gown for an exam. I walked out and pulled a curtain between us. I waited for her to lie down on the examination table. When I entered the room, the plastic bag was empty and the star still there around her neck.
I placed monitors on her abdomen, one for the fetal heart rate, one for measuring contractions. I began a complete exam. Her vital signs were normal. There was no fever; her abdomen was not tender between the contractions, so chorioamnionitis (infection inside the uterus) had not yet occurred. I placed a speculum and found bulging membranes filling the vagina. Avoiding a digital exam and possible introduction of bacteria, I rolled the sonogram machine into the room and took a look. Twenty-nine weeks pregnant with hourglass membranes, the cervix open enough to allow the membranes out but not open enough to permit descent of the baby. I estimated the fetal weight to be two pounds. The baby was vertex: headfirst, so we wouldn’t have to do a stat section.
I put my patient into deep Trendelenburg position (head down, feet up), hoping gravity would help, and started magnesium sulfate to stop labor. I ordered cultures and blood work. I ordered steroids for fetal lung maturity and hoped for the best. There was no obvious etiology for her premature labor. I presented the patient to the chief resident and the perinatologist. I asked the neo team to come down and talk to her about what she might be facing.
I wondered what she had gone through to get out of Russia, how this might have affected her condition. I wondered how she got from there to here.
I had no personal knowledge of living conditions in Russia. I grew up during the Cold War in Cortland, New York. We had nuclear bomb drills in elementary school. We hid under our desks. My parents talked about digging an underground bomb shelter next to the house; newspaper headlines spoke of spies—theirs and ours. My mother and I stood in a civil defense shack spotting airplanes with binoculars. Mother couldn’t identify the planes by name, so she just wrote down and reported the number of engines on each craft. Over the years I had heard stories, I had read the headlines.
But still, I could only imagine what had happened to this woman behind the Iron Curtain.
I hoped we could hold the labor off long enough for the steroids to work. I hoped she would not become infected. But hope, when one is in this condition, rarely holds. Her hope did not last the day. Precipitous labor ensued, and I was called to the room. There was no time for a delivery room, no time for an epidural. I put on gloves and placed my right hand above her rectum and below the vagina. I held my left above the vagina, waiting to deliver the baby. A woman in labor sends her mind to another place when the pain is too much, when she cannot take it any longer. Her eyes do not focus. She cannot hear. Her body lifts up and she pushes.
I delivered a two-pound baby girl. There was no baby warmer, no isolet. The neonatal team had not yet arrived. I cut the cord. I wrapped the baby and held her next to her mother. Arms came around the baby and me. “Magic hands, you have magic hands,” she said. I wondered where the words came from. Had they come from her—or me?
The next day, the new grandmother brought me a porcelain figurine from Woolworth’s—a Victorian lady with a hat, its bow flying free. Why this gift? What did it have to do with me? It had nothing to do with money, what she could afford, or what she already possessed. Maybe her Russian culture demanded a talismanic gift to someone who had helped her family. Maybe it was some cryptic symbol of what the grandmother hoped her granddaughter would find in America. I will never know.
I am not a hoarder or a collector, but I still have that figurine. Every time we get ready to move, my wife asks me if I am over it yet. I am not over it. I wrap the figurine and place it in the bottom right-hand drawer of the china cabinet with the other good stuff.
I know about my hands. I know that patients want me to examine them, to touch them. They want me to tell them my exam has found the source of their problem. They want to know what it is that I have found, what can be done. They want me to check them every day until they are better, until they are ready to go home.
This time I did not discount my patient’s words. I looked at my hands again. The secret of the magic comes from listening to the patient’s story, telling me where to look and what to look for. The magic begins when patients give themselves up to me, trusting me. The laying on of hands cannot be taken lightly. There are no cursory exams.
My hands, when I open a patient and introduce them deep into her abdomen and pelvis, can see. I can read with my hands. I feel for the tumor. Before I mobilize and elevate it, before my assistant says, “Look at that,” I know that its firm smooth wall is consistent with a benign fibroid. When my fingers sense a rough surface with little cauliflowerlike growths, I know I am contending with ovarian cancer. When my hands move and dark chocolate oozes up, I know there is a ruptured endometrioma, a cyst that causes pain and infertility. Sometimes, when my hand opens an abscess, I can smell the diagnosis. My hands move without thought. They become instruments with a mind of their own. Clamp, cut, tie, clamp, cut, tie. The back of my hand holds back the bowel, protecting it. The front of my hand dissects a new plane between a tumor wall and the adherent bladder. I watch the magic.
I know that after I wash my hands and leave the operating room to talk to a patient’s family, they will take my hand before I tell them what I found. My hands offer them relief. They have not seen my hands inside the body of their loved one. They have not watched. Still they believe in the hands.
Magic hands. Yes, I have magic hands.