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February 5, 2003


JAMA. 2003;289(5):615-616. doi:10.1001/jama.289.5.615

It was the middle of the day near the end of my surgery rotation, and I had just finished assisting in a five-hour operation—much of which I couldn't see. While the surgeon meticulously explored a deep incision, and the resident's shoulder obscured the view, I hung on to the retractor like a water-skier holds on to his line. I was exhausted and hungry. Afterward, with 30 minutes before the next case, I ran toward the cafeteria. "Boris, don't you speak Russian?"—a nurse intercepted me. The curse of an obvious name. "A friend of mine is a colostomy nurse and she needs help communicating with a Russian patient." There goes my lunch and a few minutes of peace, I thought, but I was intrigued. After feeling incompetent for weeks, I suddenly had a skill needed for patient care.

I greeted the nurse and we talked on the way to the patient's room. "He is a 90-year-old man who speaks little English. From what we could understand, during World War II he was severely injured, had a big operation and a colostomy constructed in the field. He seems to prefer to manage it with napkins and seems not to want us to make a bag for him. I was hoping you could confirm that this is really what he wants, and we'll leave him be." Sixty years without a bag! The idea seemed preposterous. I could straighten this out in minutes.

He looked his stated age, completely gray, wasted away and thoroughly wrinkled. "Dobroe utro—Good morning," I said in Russian and his sunken eyes widened as the toothless hint of a smile resurrected the deeply fissured face. I extended my hand and he grabbed on and spoke in Russian, rapidly running out of breath. "Doctor, what do they . . . want . . . from me? Let me go . . . home . . . " He was in quite a hurry. So was I, with only 25 minutes for lunch and a couple of errands. I realized he had been waiting for a translator for a long time, and I could spend hours getting a thorough history. My stomach growled.

"I need to talk to you about the colostomy," I tried to lead him to the issue at hand. "I am told you've had it since the war." "Sixty . . . years . . . Shot with a machine gun . . . through my stomach and back . . . and the doctors found me . . . saved me . . . later they were hit . . . no one was there . . . to fix them . . . all died, but I've lived with this . . . " he pointed to his abdomen covered with a sheet, "for sixty years!!""Can I see it?" He closed his eyes as if asking me to close mine and pulled down the sheet. I picked up a stack of paper towels and took an involuntary step back—from the view and the smell. God knew, as did the patient, what an awful expression graced my face for a second as I regained control. It was here in all its glory, a large crater in his abdomen, red and raw and slowly exuding boiling lava. Repulsive, yet remarkably functional, it was a monument to its creator, the surgeon who amidst the hell of war did a fast and dirty job and did it well.

My awe was interrupted: "Tell them to . . . leave me alone!" I recalled my reason for being here. "They want to help you. Would you like a bag for the colostomy?" He looked up at me and painfully smiled. Emotionally, breathlessly, he tried to tell me the story of his colostomy; also a story of his life. Yet his memory was failing him, his thoughts were disorganized, his story incoherent. I understood that he hated living with the colostomy, and that he stopped using the bags because they were too expensive. But he also insisted on being discharged home to his wife, while the nurse had said he lived alone. As a clinician-in-training, I ran the differential of delirium and dementia; as the grandson of an occupation survivor, I spun myself a story of survival and heroism. My imagination compensated for what his tired mind could not provide.

Could it be that after the war, his life spared by a chance encounter, he stood trial for treason? Lying in the battlefield, with his torso torn up by bullets, but with a strong pulse and good blood pressure, he caught the eye of a young German surgeon who wanted to try a new procedure. The surgeon operated and recorded the details in his journal, hoping to publish the new method after his tour of duty. But the young doctor was killed soon after in a Soviet raid on the hospital. What if a Russian intelligence officer found the doctor's journal, and became suspicious? Why would the Germans spare this soldier? Was he a spy to begin with, or did he trade information in exchange for his life?

Maybe he was convicted and imprisoned for many years, during which a dirty cloth belt covered the colostomy but did little for the mess and the smell. Disliked by the guards and isolated from other inmates, he cursed the surgeon for saving his life while making it not worth living. Even after he was released, he struggled with relationships because of the colostomy. And then? Only after coming to the United States did he finally find love and when, after 20 years, his wife became demented and bed-bound in a nursing home, he continued to visit her every day, though she no longer remembered who he was. He now lived near the nursing home, alone, no longer able to afford new colostomy bags. Covering it with napkins was enough. For the past couple of weeks he had become too weak to leave the house and his neighbors called an ambulance. His angry voice brought me back. "Now let me go home . . . I love her . . . I should be by her side . . . Not here. She doesn't have . . . much time left . . . Let me go!"

I stood by his side, fighting back tears and still holding his hand. The story that he could only begin and that I had finished with imagination and my grandfather's tales had left me speechless. My beeper's shrieking cry pierced the silence. I was late to the OR. "I have to go now. They'll give you a colostomy bag. I hope you recover soon. Take care." I slowly let go of his hand and walked out of the room. The colostomy nurse found me slumped against a wall, rubbing my eyes and sobbing as I collected myself and mumbled, " Please try to set him up with a colostomy bag and many refills. A Russian-speaking social worker would be most helpful."

Suddenly, I realized there was one more thing I needed to do, for him and for myself. I rushed back into the room, not worrying that he'd see my red eyes and wet face, only hoping that he would listen. "Thank you for fighting in that war. Because of you and others like you, my grandparents survived, and I am alive today. Anything worthwhile that I do, will be in part because you fought for me." My beeper went off again. I was in trouble and we were both in tears. I slowly let go of him and sprinted to the OR. I ran, humbled because my job will never be more important than his was 60 years ago, and finally felt deserving of him calling me "doctor."