6.01|02 Good Mourning & Goodbye
According to Elisabeth Kubler-Ross, when we're dying or have suffered a catastrophic loss, we all move through five distinct stages of grief. We go into denial because the loss is so unthinkable we can't imagine it's true. We become angry with everyone, angry with survivors, angry with ourselves. Then we bargain. We beg. We plead. We offer everything we have, we offer our souls in exchange for just one more day. When the bargaining has failed and the anger is too hard to maintain, we fall into depression, despair, until finally we have to accept that we've done everything we can. We let go. We let go and move into acceptance.
In medical school, we have a hundred lessons that teach us how to fight off death, and not one lesson on how to go on living.
The dictionary defines grief as key mental suffering or distress over affliction or loss. Sharp sorrow, painful regret. As surgeons, as scientists, we're taught to learn from and rely on books. On definitions, on definitives. But in life, strict definitions rarely apply. In life, grief can look like a lot of things that bare little resemblance to sharp sorrow.
Lexie, Mark, Alex, Izzie, Derek, Bailey, Owen, Meredith, Arizona, Callie, Richard: Grief may be a thing that we all have in common, but it looks different on everyone. It isn't just death we have to grief. It's life, it's loss. It's change. And when we wonder why it has to suck so much sometimes, has to hurt so bad, the thing we gotta try to remember is that it can turn on a dime. That's how you stay alive. When it hurt so much you can't breathe, that's how you survive. By remembering that one day, somehow, impossibly, you won't feel this way. It won't hurt this much. Grief comes in it's own time for everyone, in it's own way. So the best we can do, the best anyone can do, is try for honesty. The really crappy thing, the very worst part of grief, is that you can't control it. The best we can do is try to let ourselves feel it, when it comes. And let it go when we can. The very worst part is that the minute you think you've passed it, it starts all over again.
There are five stages of grief. They look different on all of us. But there are always five: denial, anger, bargaining, depression, acceptance.
6.03 I Always Feel Like Someone's Watchin' Me
Paranoia gives you an edge in the OR. Surgeons play out worst-case scenarios in their heads. You're ready to close, you got the bleeder. You know it but there's that voice in your head asking. What if you didn't? What if the patient dies and you could have prevented it? So you check your work one more time before you close. Paranoia is a surgeon's best friend.
We're all susceptible to it, the dread and anxiety of not knowing what's coming. It's pointless in the end, because all the worrying and the making of plans for things that could or could not happen, it only makes things worse. So walk your dog or take a nap. Just whatever you do, stop worrying. Because the only cure for paranoia is to be here, just as you are.
6.04 Tainted Obligation
We begin life with few obligations. We pledge allegiance to the flag. We swear to return our library books. But as we get older we take vows, make promises, get burden by commitments, to do no harm, to tell the truth and nothing but, to love, to cherish till death do us part. So we just keep running up the tap 'til we owe everything to everybody and suddenly ... what the.
The thing about being a surgeon, everybody wants a piece of you. We take one little oath, and suddenly we're drowning in obligations. To our patients, to our colleagues, to medicine itself. So we do what any sane person would do. We run like hell from our promises, hoping they'll be forgotten. But sooner or later, they always catch up. And sometimes you find the obligation you dread the most isn't worth running from at all.
When you get sick, it starts off with a single infection. One lone nasty intruder. Pretty soon the intruder duplicates. Becomes two. Then those two become four. And those four become eight. Then, before your body knows it, it's under attack. It's an invasion. The question for a doctor is, once the invaders have landed, once they've taken over your body, how the hell do you get rid of them?
What do you do when the infection hits you, when it takes over? Do you do what you're supposed to and take your medicine? Or do you learn to live with the thing and hope someday it goes away? Or do you just give up entirely and let it kill you?
6.06 I Saw What I Saw
In order to get a good diagnosis, doctors have to constantly change their perspective. We start by getting the patient's point of view, though they often don't have a clue what's going on. So we look at the patient from every possible angle. We rule things out. We uncover new information, trying to get to what's actually wrong. We're asked for second opinions, hoping we'll see something others might have missed. For the patient, a fresh perspective can mean the difference between living and dying. For the doctor, it can mean picking that you're picking a fight with everyone who got there before you.
When we're headed toward an outcome that's too horrible to face, that's when we go looking for a second opinion. And sometimes, the answer we get just confirms our worst fears. But sometimes, it can shed new light on the problem, make you see it in a whole new way. After all the opinions have been heard and every point of view has been considered, you finally find what you're after - the truth. But the truth isn't where it ends, that's just where you begin again with a whole new set of questions.
6.07 Give Peace a Chance
Derek: Ask most surgeons why they became surgeons and they usually tell you the same thing. It was for the high, the rush, the thrill that comes from cutting someone open and saving their life. For me it was different, maybe it was because I grew up in a house with four sisters. No, definitely because I grew up in a house with four sisters because it was the quiet that drew me to surgery. The operating room is a quiet place. Peaceful. It has to be in order for us to stay alert, anticipate complications. When you stand in the OR, your patient open on the table, all the worlds noise, all the worry that it brings disappears. A calm settles over you, time passing without thought. For that moment, you feel completely at peace.
Derek: Ask most surgeons why they became surgeons and they usually tell you the same thing. The high, the rush, the thrill of the cut. For me it was the quiet. Peace isn't a permanent state. It exists in moments. Fleeting. Gone before we knew it was there. We can experience it at any time, in a stranger's act of kindness, a task that requires complete focus or simply the comfort of an old routine. Everyday we all experience these moments of peace. The trick is to know when they're happening so that we can embrace them, live in them. And finally let them go.
6.08 Invest In Love
It's impossible to describe the panic that comes over you when you're a surgeon and your pager goes off in the middle of the night. Your heart starts to race. Your mind freezes. Your fingers go numb. You're invested. There's someone's mum, someone's dad, someone's kid. And now it's on you because that someone's life is in your hands. Surgeons, we're always investing in our patients. But when your patient's a child, you're not just invested, you're responsible. Responsible for whether or not that child survives, has a future. And that's enough to terrify anyone.
They say the bigger your investment, the bigger your return. But you have to be willing to take a chance. You have to understand, you might lose it all. But if you take that chance, if you invest wisely the pay off might just surprise you.
6.09 A New History
Doctors live in a world of constant progress and forward motion. Stand still for a second, and you'll be left behind. But as hard as we try to move forward, as tempting as it is to never look back, the past always comes back to bite us in the ass. And as history shows us again and again, those who forget the past are doomed to repeat it.
Sometimes the past is something you just can't let go of. And sometimes the past is something we'll do anything to forget. And sometimes we learn something new about the past that changes everything we know about the present.
The best gift I ever got was for Christmas when I was ten - my very first suture kit. I used it until my fingers bled, and then I tried to use it to stitch up my fingers. It put me on the path to becoming a surgeon. My point is sometimes the best gifts come in really surprising packages.
Everyday we get to give the gift of life, it can be painful, it can be terrifying, but in the end it's worth it. Every time. We all have the opportunity to give. Maybe the gifts are not as dramatic as what happens in the operating room, maybe the gift is to try and make a simple apology, maybe it's to understand another person's point of view, maybe it's to hold a secret for a friend. The joy supposedly is in the giving, so when the joy is gone, when the giving starts to feel more like a burden, that's when you stop. But if you're like most people I know, you give till it hurts, and then you give some more.
We assume the really serious changes in our lives happen slowly, over time. But it's not true. The big stuff happens in an instant. Becoming an adult, becoming a parent, becoming a doctor... one minute you're not, and the next you are. Ask any doctor and they can point to the one moment they became a physician. It usually isn't med-school graduation day. Whatever it is, nobody forgets it. Sometimes you don't even know anything is changed. You think you're still you and your life is still your life. But you wake up one day, look around and you don't recognize anything. Not anything at all.
6.12 I Like You So Much Better When You're Naked
Number one rule of surgery is limit exposure. Keep your hands clean, your incisions small, and your wounds covered. Number two rule of surgery is when rule number one stops working, try something else. Because sometimes you can't limit exposure, sometimes the injury is so bad you have to cut, and cut big.
In surgery, the healing process begins with a cut, an incision, the tearing of flesh. We have to damage the healthy flesh in order to expose the unhealthy. It feels cruel and against common sense, but it works. You risk exposure for the sake of healing, and when it's over, once the incision has been closed, you wait. You wait and hope that your patient will heal. That you haven't in fact, just made everything worse.
6.13 State of Love and Trust
Derek: We ask a lot of our patients. We put them to sleep. Cut them open. Poke around in their brain and guts with sharp instruments. We ask for their blind trust. Irony is, trust is hard for surgeons, because we're trained from day one that we can't trust anyone but ourselves. The only instincts you can count on are your own. The only skills you can count on are your own. Until one day, you leave the classroom and step into the O.R. You're surrounded by others, a team of others. A team that you have to rely on whether you trust them or not.
Derek: I know it's been a long day, and you're all anxious to get home. But I feel like we got off on the wrong foot this morning. I don't expect to win your trust overnight. But I want each of you to know you have mine. Which is why I felt it was important to personally come in here and apologize. I am neither pro nor anti merger. From this point on, everyone has a clean slate. I am not focused on the past. I'm looking to the future to all the promise this hospital has to offer. I plan to honor Richard Webber and his legacy, not undo it, which is why I'm both humbled and honored to be your new Chief of Surgery.
6.14 Valentine's Day Massacre
The surgical scalpel is made of sterilized, carbonized, stainless steel. This is a vast improvement of the first scalpel which was pretty much a sharp stick. Medicine is constantly reinventing itself, which means surgeons must keep reinventing themselves. There's a constant pressure to adapt to changes. It can be a painful process. But, without it, you'll find yourself moving backwards instead of forwards.
We have to keep reinventing ourselves. Almost every minute, because the world can change in an instant. And there's no time for looking back. Sometimes, the changes are forced on us. Sometimes, they happen on accident. And we make the most of them. We have to constantly come up with new ways to fix ourselves. So we change. We adapt. We create new versions of ourselves. We just need to be sure that this one is an improvement over the last.
6.15 The Time Warp
I've seen a lot of surgical residents come and go on my time. And they're all addicted. To surgery. It comes before food, before sleep, it becomes the most important thing. The only thing. What they don't know is that living on that high can eat them alive. Some make it through. They come on other side. They survive with the sanity intact. They become better doctors, and stronger people. I didn't. I'm broken. I didn't kill anybody and I give thanks for that every day. But I hurt people and scared the hell out of myself. I am 45 days sober today. I'm Richard and I am a grateful and recovering alcoholic.
6.16 Perfect Little Accident
Surgeons are detail oriented. We like statistics and checklists and operating procedures. Our patients live because we enjoy following the steps. But, as much as we love to always rely on the numbers, the plan, we also know that some of the greatest medical discoveries have happened by accident. Mold- penicillin, poisonous tree bark- a cure for malaria, a little blue pill for high blood pressure- impotence preempted... It's hard for us to accept that's not always the hard work or attention to detail that get us the answers we're looking for. Sometimes, we just have to sit back, relax and wait a happy accident.
No matter how many plans we make, or steps we follow, we never know how out day is going to end up. We'd prefer to know of course, what curve balls would be thrown on our way. It's the accidents that always turn out to be the most interesting parts of our day, of life. The people we never expected to show up. The turn of events we never would've chosen for ourselves. All of a sudden, you find yourself somewhere you never expected to be. And it's nice, or it takes some getting used to. Still, you know you'll find yourself appreciating it somewhere down the line. So you go to sleep each night thinking about tomorrow, going over your plans, preparing the lists and hoping that whatever accident come in our way will be happy ones.
Surgeons aren't complacent people. We don't put our feet up. We don't sit still. Whatever the game is, we like to win. And once we win, we get a new game. We push ourselves, residents, attendings, it doesn't matter how much we achieve. If you're climber, there's always another mountain.
They take pictures of mountain climbers at the top of the mountain. They're smiling, ecstatic, triumphant. They don't take pictures along the way, 'cause who wants to remember the rest of it? We push ourselves because we have to. Not because we like it. The relentless climb, the pain and anguish of taking it to the next level, nobody takes pictures of that. Nobody wants to remember. We just wanna remember the view from the top. The breathtaking moment at the edge of the world. That's what keeps us climbing. And it's worth the pain. That's the crazy part. It's worth anything.
6.18 Suicide Is Painless
Owen: Dying isn't easy. The body was designed to stay alive - thick skulls, strong hearts, keen senses. When the body starts to fail, the medicine takes over. Surgeons are arrogant enough to think - there is no one we can't save. Like I said, dying isn't easy.
Owen: Living is better than dying. Until it's not. But even if letting a person to die is the right thing to do, it's not what surgeons are built for. We are arrogant and competitive. We don't like to lose. And death feels like a loss. Even when we know it's not, we know it's time, we know it's right. We know we did everything we could. But it's hard to shake the feeling that we could've done more.
6.19 Sympathy For The Parents
Psychologists believe that every aspect of our lives, all our thought processes and behavior patterns are the direct result of our relationship to our parents. That every relationship that we have is just another version of that first relationship. It's just us trying over and over again to get it right.
It's the most important job in the world. You probably should need a license to do it, but then most of us wouldn't even pass the written exam. Some people are naturals. They were born to do it. Some have other gifts. But the good news is biology dictates you don't have to do it alone. You can waste your whole life wondering, but the only way to find out what kind of parent you'd be is to finally stop talking about it and just do it.
6.20 Hook,Line and Sinner
We're doctors - we're trained to care for human beings and we're pretty sure we know what to look for. Cuts, infection, genetic mutation...
As doctors we have an arsenal of weapons after any. Antibiotics to kill infections. Narcotics to fight pain. Scalpels and retractors to remove tumors and cancers - to eradicate the threat. But just the physical threat, for every other threat - you are on your own.
6.21 How Insensitive
The skin is the largest organ in the body - it protects us. Holds us together. Literally lets us know what we are feeling. The skin can be soft and vulnerable. Highly sensitive, easy to break. Skin doesn't matter to a surgeon. We will cut right through it, go inside, find out the secrets underneath. It takes delicacy and sensitivity.
No matter how thick skinned we try to be, there's millions of electrifying nerve endings in there. Open and exposed and feeling way too much. Try as we might to keep from feeling pain, sometimes it's just unavoidable. Sometimes that's the only thing left - just feeling.
6.22 Shiny Happy People
It's a common belief that positive thinking leads to a happier healthier life. As children we are told to smile, be cheerful, and put on a happy face. As adults we are told to look on the bright side, to make lemonade, and see glasses as half full. Sometimes reality can get in the way of our ability to act the happy part though. You're hope can fail, boyfriends can cheat, friends can disappoint. It's in these moments, when you just want to get real, drop the act, and be your true scared unhappy self.
Ask most people what they want out of life and the answer is simple - to be happy. Maybe it's this expectation though of wanting to be happy that just keeps us from ever getting there. Maybe the more we try to will ourselves to state's of bliss, the more confused we get - to the point where we don't recognize ourselves. Instead we just keep smiling - trying to be the happy people we wish we were. Until it eventually hits us, it's been there all along. Not in our dreams or our hopes but in the known, the comfortable, the familiar.
6.23|24 Sanctuary & Death and All of His Friends
For most people, the hospital is a scary place. A hostile place. A place where bad things happen. Most people would prefer church, or school, or home, but I grew up here. While my mom was on rounds, I learned to read in the OR gallery, I played in the morgue, I colored with crayons on old ER charts. Hospital was my church, my school, my home; hospital was my safe place, my sanctuary. I love it here. Correction: loved it here.
Derek: The human life is made up of choices. Yes or no. In or out. Up or down. And then there are the choices that matter. Love or hate. To be a hero or to be a coward. To fight or to give in. To live. Or die. Live or die. That's the important choice. And it's not always in our hands.
Derek: Yes or no. In or out. Up or down. Live or die. Hero or coward. Fight or give in. I'll say it again to make sure you hear me. The human life is made up of choices. Live or die. That's the important choice. And it's not always in our hands.