Friday, March 16, 2007

Focus



Referring to the idea that, like athletes, surgeons are engaged in demanding physical work, I wrote recently about having an "off-day." Another side of the same coin is having a tough day: as distinguished from not being on one's game, here I mean to describe what it's like to face an exceedingly difficult and danger-filled situation. Notwithstanding having one's faculties and wits gathered and finely honed, as in command of yourself as you can possibly be, it may test and demand everything you can bring to bear. All the antiperspirant in the world wouldn't suffice. I've been in war, when I feared daily for my life. It's not pleasant, but in some way you can get used to it. In my situation, at least, the odds were with me, so it wasn't too hard to ignore. Fearing for the life of someone in my charge, having to forge ahead knowing the next move could literally be fatal, while knowing I have no personal risk at all -- that's unique at least insofar as I can figure at the moment. Harder than being a soldier, a cop, a firefighter? Surely not. But distinctly different, I'd say. You're in the position of making that fatal move, as opposed to responding to one made at you. I've been in situations where I've failed to save a severely injured person. It feels terrible. I've not made a move that killed someone. But I could have.

On one occasion during my internship, I was holding retractors while a professor was trying to extirpate a large pelvic tumor. I don't remember the details -- probably the ensuing river of red washed them out of my brain. What I clearly recall, as if I were carrying the picture in my wallet, is the shock at how fast the field filled with blood. That's the way it is when the iliac vein is breached: it's big, it's flimsy, it doesn't hold a stitch very well. And it's connected immediately to the vena cava, the biggest and bluest of them all. Whenever you approach it -- as is the case with any big blood vessel -- you want to have wide access to it. You need "proximal and distal control," meaning the parts of the vein north and south of where you plan to work need to be readily available, cleared, and ready for clamping. Dissected out, maybe slung with rubber loops. With a big tumor blocking view, ain't no way. So the surgeon worked his way around the mass while, I'd have to assume, aware and worried about what lay beyond. Whether he lost his way, didn't anticipate the anatomic distortion, or just came up snake-eyes, I can't say. But when he lacerated the vein during dissection blood poured out like a prison break, and the tumor blocked any possibility of controlling the flow upstream. Blindly placing sutures, frantically replacing blood -- whatever was done, it didn't work. The patient bled to death in the operating room, one of the rare times I've seen it happen. Watching such a thing leaves one deeply affected.

I've been there. Working deeper into the pelvis when the view is distorted by a huge tumor, stuck to the sidewalls, the bladder. Forced to do something about a nearly undecipherable mass of indeterminate origin, causing obstruction in multiple parts of bowel stuck to it. Wanting a bailout way of avoiding opening the door to disaster, but finding none. "OK," I'll say. "We could get into big trouble here. Let's take a minute to get everything ready." I suggest to the anesthesiologist that he/she start another couple of IVs. Send blood to the blood bank and get them working on crossmatch. Be sure they've got a bunch of O-negative blood available (In a pinch, you can give it to anyone). Get the cell-saver in here. Open up some vascular clamps. Wait till it's all there. And, because when I want to focus everything I have, I like to open an emergency pack of silence, I tell everyone in the room to stop loose talk, and to shut off the music. (Subject for a future post? Music on the OR. I like it, usually. Except in deep and deepening shit.)

There are other disaster scenarios, but the iliac vein/pelvis thing is especially evocative for me, having seen what I saw those many years ago. I'm sure it's not unique to surgeons, or to physicians. In some things, our approach is shaped by the memory of a single impactful event. I'll say this: it has a way of marshaling all of one's faculties. As frightening as it is, in some measure it's also thrilling to experience oneself become so focused, literally to blot out everything else in the world, and like a living lens to direct all input to a single centimeter of space, to have time become meaningless and imperceptible. Perhaps paradoxically, despite sensing breathing speed up, aware of rising pulse rate and of drips of sweat sluicing down my sides -- even needing to pause for the ultimate cliche, the wiping of one's brow by a nurse (I've dripped sweat into the occasional wound -- and flushed it away with lots of saline) -- my hands don't shake. But yes, dissecting my way into the area as carefully and clear-headedly and patiently as I know how, at some level I'm scared as hell. And although while in the maelstrom there's confidence you can carry on as long as necessary (like sound and extraneous thought, physical discomfort shrinks into insensibility) when the tense part is over, physical exhaustion can well up with surprising suddenness and depth. Neck stiff, bent back and hyper-extended knees sorry and sore.

I guess there's a sense of accomplishment, but it's more like having dodged a bullet, of having lucked out. Knowing it easily could have gone in another direction, feeling like you never want to do that again, it's hard to feel pride. Only relief. As much as I believe that the way to handle complications is to avoid them in the first place, and as hard as I work to follow that path, the feeling -- even when pretty sure there was no option -- is one of second-guessing whether I missed an alternative to skating on such thin ice. I couldn't do it every day.

12 comments:

The Doctor Job said...

While I'm sure other professions have those types of disaster scenarios etched in their minds, only in a few fields like medicine and surgery does it affect actual life. So few non-doctors understand the additional stresses that are added as a result.

happyj said...

Thank you for these wonderful posts! They've helped me to remember the draining, hard work involved in anything truly worth-while (from my point of view and I'm sure my surgeon's point of view). Truly admirable people persevere.

P.S. I'm trying to find out if I can re-do the essay that I failed, and I'll learn the correct MLA format if it kills me.

Lynn Price said...

Wow. Just...wow.

SeaSpray said...

Wow! Excellent and informative post and I am printing this. Again - you are talking to me where I am at and while unnerving, I am also greatly reassured at understanding the precautions taken and the skill involved and how dedicated a surgeon is. I also remember your saying how a patient is never safer than when in the OR as everyone in there is focused on them and watching all vitals, etc.

I do believe that when that person bled out that it was their time. I don't pretend to know why it had to happen then, in the OR - or to understand the timing of anyone's departure to the other side - but, just that sometimes all you can do is your best and life just goes in another direction, literally.

Thank God for all the dedicated doctors - we need you - thank You. :)

Greg P said...

There are many situations in medicines like this. Experience teaches you to take to heart past events you've had and you've heard about so that when you are beginning to travel in dangerous territory you have mental scripts that teach how to meticulously avoid trouble, and what you are going to do if they happen. When they're not obvious like a gushing blood vessel, the trick is to recognize when something very bad is going on.

When faced with someone very sick, I ask myself, "What's the worst thing this could be?"

Bohemian Road Nurse... said...

This is a great post. I truly believe that the job of performing surgery on sick/injured/mangled people is probably the single most stressful one in the world. My experience comes from the ER, and I well remember the nights I helped tired and courageous docs sew people up while wading through rivers of blood. One night I entered an exam room to help a doc who was standing there quietly holding his finger on a spot on the top an old guy's head (the guy had slipped & fallen in a kitchen). I asked the doc why he was doing that and he replied: "Because he busted an artery." I scoffed and said: "Oh come now, doctor, it's just a small lac on the top of the head---surely it couldn't be an artery..." So the doc released the pressure from his finger and the resulting pulsating stream hit the ceiling. (So I shut my silly mouth and quickly set about gathering the equipment he'd need to fix the guy's head....)

Bongi said...

the other day i walked past a colleague. he stopped me and simply said "first do no harm". i knew he had gotten into deep water during an operation. he is an excellent surgeon and fortunately got himself (and the patient) out again. the point is sometimes one stops half way through an operation and thinks why the hell did i study surgery? the thought that a decision you make now may be the difference between the patient living or duying is sometimes pretty huge.

this excellent post (once again) exactly captures the essence of it.

the other thing you touched on was the post adrenal rush exhaustion. i definitely experience it, almost exactly the way you describe it.

master blogger schwab has spoken.

Bongi said...

greg, ofter in surgery there is not too much of a trick to recognising when something very bad is going on. some of the signs may be the anaesthetist swearing and screaming for the defib, the bleeding suddenly stopping without you getting control, the warm moist feel of blood through your clothes running down your leg, etc. the trick then is to do the right thing calmly and quickly even if others around you are losing it. i think neurological conditions generally kill slightly slower.

Sid Schwab said...

Yeah. I think I may have referred to it already somewhere, but on one occasion during training, I noted the anesthesiologist had increased the tempo of his activity, following which he calmly leaned over the ether screen and said, "You guys might want to stop what you're doing and start some chest compressions..."

SeaSpray said...

God Bless you all - really god bless you all! :)

I want to bake you all some cookies, fix you a food platter and give you a hug with a nice thank you note. There you go. You are not my docs but from your writing, I feel appreciation for what you do and even more for the docs that have and will be taking care of me. So, that is my cyber gift - from me - to you. :)

However, this girl at the moment is thinking "YIKES!", and is going to her happy place now. :)

It is a beautiful sunny day (snow all around) so, I am walking, Dr. Schwab - walking, walking and walking! As always, thanks for the insights.

I do know these things and I do believe that things work out the way they are supposed to. Sometimes through a more circuitous route than originally planned, but that they go as they should.

I don't know why I felt a momentary sense of panic regarding the OR after reading the last few comments. I want to know about this stuff. Maybe because today, I woke up with this real sense that the clock is ticking, which is good because I do want answers and I want to get this all over with, one way or the other.

I was someone who had to go through some infertility tests before finally conceiving and so, as you can imagine, was thrilled that I was going to finally, have a baby. However, I remember waking up one night - totally panicked - thinking "I am going to have a b-a-b-y. It's going to hurt. What if..." of course. I wasn't going to cancel the order, nor did I want to - but just had this moment of fear.

So,I guess I am having one of those moments - first time in weeks. fresh air does wonders. :)

Sid Schwab said...

seaspray: these examples are so much the exception as to be not a lot more than good post fodder. In other words, in elective (meaning non-emergency) surgery, the chance of something really serious going wrong is incredibly small. Out of thousands of operations, I have only a handful of "good stories" of this kind, and none refer to your kind of situation. So keep on walkin', yes indeed you're a-walkin', but don't fret. It's only because this stuff is so exceptional that it's worth writing about!

SeaSpray said...

Thanks Dr Schwab. I'm fine. I have actually been feeling good and feeling encouraged based on my own symptoms or lack of, post stent removal.

I think the waiting is getting to me a bit. Ha! Of course, knowing me - as much as I DO want to get this over with, when it finally does become time for the next test, I will be seriously tempted to go MIA. (I'm kidding!..or am I?)

Historically, I have been a patient who does well in the OR. If I do need to go down that road or through those doors, should I say - I know I will be well taken care of.

I don't think I can adequately articulate just how grateful I am to you for your well written posts regarding all the precautions taken to ensure the patient's safety, the skill of the surgeons and other OR staff. Intellectually,I have known this, but still reading these things as seen through your eyes and as based on your life's experience has helped immensely.

I just want you to know that for most of the time that I thought about possible impending surgery that I had put my focus on the the risk factors and then obsessed and viewed surgery from totally negative perspective. However, your informative posts have been one of the key catalysts for turning my attitude around for the better.

Who knows why those stupid little darts of fear sometimes penetrate and invade one's otherwise happy psyche?

You know your taking Trust post is still my favorite followed by your fairly recent one on going into the OR with a positive attitude. (sorry - name of that post escapes me) Surgeonsblog is most definitely one of the best blogs around and one of my top favorites. :)