She had only been in the hospital twice in her life: once when she was nine and now, 60 years later.  She had gotten tonsils out then.  She was getting tumors out now.

Her abdomen hurt when she was awake.  Her abdomen would also hurt during exploratory surgery, although she wouldn’t be able to feel it under general anesthesia.  Her body would feel it, though, and could respond by dangerously spiking or plunging her vitals.  She needed an epidural before surgery to keep the pain under control.

In the pre-surgery holding area–a busy room with twelve beds and dozens of doctors and nurses–we pulled a curtain around her bed.  She ungowned, naked in the back and naked in the front.  Two anesthesiologists stood at her back, setting up the epidural kit, feeling her back for bony landmarks, and scrubbing the area of insertion clean.

She bowed her head, waiting for the “pinch” that the doctor said she couldn’t promise wouldn’t hurt.  She held out her hands, and her adult niece knelt in front of her, squeezing them.  Her niece quietly spoke about people and places they knew.  ”Do you remember Sarah?  Did you know that on her first day as a nursing student, she fainted when she saw blood?  She must have toughened up since then, don’t you think?  I hope so.”

On the rear side of her, the needle missed.  Another shot of local anesthetic was given–another “pinch.”

“You’re being so good.  Things have changed a lot since you were last in the hospital, haven’t they?  You know what we can still do, though–get ice cream when you’re out.”

Whispers, instructions, and concentration from the back.   More slowly, the needle went in. It didn’t miss.  The catheter was threaded in soon after and taped in place.

“Look, that wasn’t so bad, was it?  Just a pinch going in.  And now it’s done, and soon enough you’ll be back from surgery, and I’ll be able to see you right after.”  Her niece didn’t let go of her hands.

I stood at the foot of the bed, splitting my gaze between the technicalities at the back and the interactions at the front.  Trying to glean how pain control came from both ends.

The patient regowned and lay back in bed.  Her mouth politely smiled but her eyes stayed anxious.  The anesthesiologists walked away for a moment to do their final preparations.  The patient and her niece looked at me.  ”So, do you know what you want to do with your life?” the niece asked.

Some combination of front and back, I thought.  How and what remained vague.  But I knew one thing for certain.

“Something where patients are awake.”

“We won’t tell them,” the niece said.

Note: Minor patient details have been changed to preserve anonymity.

Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit.