Follow that lumen!



In 1986, I migrated from the U.K. to the U.S. When my immigration papers came through, it was too late for me to apply for a medical residency training position that year through the National Resident Match Program. Hoping for some luck, and saying a prayer, I sent out applications to many residency programs throughout the U.S. Fortunately, my curriculum vitae reached the desk of Dr.Edwards, residency program director at Sisters Hospital, Buffalo, New York, who was a U.K. medical school graduate. Being familiar with my credentials, he offered me a vacant residency position, without even a formal interview! Soon after arriving in California, I travelled to Buffalo, met Dr.Edwards and signed a contract. Sisters hospital had the proud distinction of having Dr.Austin Flint of the cardiac murmur fame as its previous chief of internal medicine in the 1840's. He had also co-founded the Buffalo medical school.

Thus began my training in Buffalo,New York, famed for its hot chicken wings ("Buffalo wings"), fierce winters and one of the natural wonders, the Niagara Falls. I arrived with my pregnant wife and my one year old eldest son, with some apprehension and excitement. Driving on the other side of the road and getting familiar with the American system of therapeutics were some of the initial challenges I faced. My training got off to a rough start during orientation, when to my horror, I started having painful hematuria on my very first day. A trip to the Emergency Department and subsequent workup revealed I had a urinary calculus with infection. A few weeks later, my second son arrived in this world. I survived these and soon hit my stride, thanks to the excellent training I had received in Sri Lanka and in the U.K. I remember the astonishment of my consultant, when I called him from the ER with an admission and confidently said that the new patient probably had a superior vena cava syndrome due to lung cancer! I had seen similiar cases during my Chest medicine rotation in Blackburn, Lancashire! Incidentally, one of my Buffalo co-interns had trained under Dr. Prakash Rudra in Cardiff.

Unfortunately, despite my M.R.C.P. qualification, the American Board of Internal Medicine insisted that I do all three years of internal medicine training. Undeterred, I pressed on. During my medical registrar's job in Maidstone, Kent, one of my consultants, Dr.Stevens, had invited me to his endoscopy sessions. I attended these regularly and developed a keen interest in gastroenterology. During my 2nd year of training in Buffalo, I applied for fellowship in gastroenterology at the University of Buffalo. My consultants backed me strongly. Initially, the fellowship program director was hesitant, partly as I was into my late thirties already. He thought it was crazy that I wanted to train a further 3 years despite going through residency training in three continents and only then start my formal medical practice--- in my forties! But I was determined. My inspiration and role model was my fellow Buffalonian, Dr.Moses Nesarajah, who was our Physiology lecturer in med school. After a teaching stint in the Caribbean, Nesa had come to Buffalo and undergone residency training at a senior age to become an anesthesiologist. Eventually, I was selected to be a gastroenterology fellow.

Starting my new training in 1989 was a lesson in endurance and humility. I was back at the "bottom of the totem pole" and held ultimately responsible for many matters in the gastroenterology unit. As one of my consultants quipped, "S--t always rolls down the G.I tract."! During on call duties, I had to cover three different hospitals in Buffalo for emergencies. When summoned for a"bleeder", I had to come in to assess the patient, direct resuscitation measures and if an endoscopy was to be done, I had to get the equipment ready, obtain informed consent from the patient and then inform my senior fellow and consultant, who would then come in. After the procedure, and after taking care of charting and any treatment measures, I had to wheel the equipment back to the gastroenterology department, wash it and dry it before departing. All the while, I was learning to use the endoscope and find my way around the gastrointestinal tract. Initially, this was quite a challenge, as my fingers fumbled with the controls and the scope would seem to go wherever it pleased. I was also preparing for gastroenterology journal clubs and conferences, studying for my internal medicine board examination and trying to be a devoted husband and father (time permitting!).

During my second month of training, I worked under Dr.Daniel Camara, who hailed from Brazil. He was a vivacious man with a bushy moustache and a Spanish temper with a short fuse. But he was a wonderful person, an excellent teacher and one of the faculty members who had strongly supported my hiring. So I wanted to make a really good impression. Much to my embarrassment and discomfiture, he called me "Sivak", after Dr.Michael Sivak, a distinguished gastroenterologist at the Cleveland Clinic. He would comment that endoscopy was a fairly simple thing and that all one had to do was to stay in the middle of the gut lumen! He would bellow, " Stay in the lumen!", each time I veered into the bowel wall during a colonoscopy. "Do you stick your nose against the picture when you go to an art gallery?" he would ask. When like all new fellows, I initially fumbled when trying to snare polyps, he exhorted me to practice video games or try fishing in nearby Lake Erie!

Midway during that rotation, I was struck by a viral illness. There was no choice or thought of calling out sick. I had to bite my lip, draw on deep reserves and tough it out. So I plodded on. On that fateful morning, I was doing a colonoscopy under Dr.Camara's supervision. I felt lightheaded and my fingers were leaden, resulting in my stumbling into the bowel wall repeatedly. "Follow that lumen!" he roared. Suddenly, the lights in the room dimmed and Dr.Camara's voice faded. The next thing I knew, I was lying on a hospital gurney, with the nurses calling out, "Are you OK?" Out of the corner of my eye, I saw the charge nurse Carol chiding Dr.Camara, thinking he had been harsh to me, causing me to swoon in fright! To this day, I don't know how I escaped hurting the patient who had a colonoscope in his rear when I fainted! About 30 minutes later, I was revived and continued my morning cases with a rather subdued Dr.Camara. He gave me a sheepish smile at the end of the list and did not quite believe me when I explained that I had been under the weather that day.

I worked with Dan many more times during my training, and to my relief, he did not soften his dealings with the fellows, including me. He grew fond of me and was delighted when I passed the gastroenterology board exam two years later, whilst still in fellowship. However, I've heard that he has at times boasted proudly to incoming new fellows that he "once made a fellow faint"! Dan remains a respected teacher and dear friend, and he still calls me Sivak!


A Sivakumar

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