Friday, August 03, 2007
There's something irresistibly horrifying about doing an amputation. I did several during training, and a few in practice, before eventually turning such cases over to people who did it more. In a way, it's a microcosm of the perversity and beauty of surgery; of the screaming contradiction that one must somehow accept to be a surgeon. Removing a limb is so many things: failure, tragedy, cataclysm, life-saver, life-ruiner. Gratifying.
Stark and sudden, an above-knee amputation done in the "guillotine" fashion for infection is shocking. But, if you're a surgeon, you can -- maybe you must -- find pleasure in it; and I don't mean some poetic sense of helping one's fellow man. I mean in the actual act of doing it. Which is why I say it's a microcosm. Some things we do are terrible. And yet, within walled-off portions of the mind, divorced from the suffering of the patient, there's a place to go wherein satisfaction comes from the the work itself; the physicality, the artistry, even the transgressive brutality.
The foot, dying, has been wrapped in towels and covered in a sterile plastic bag. The leg, painted in iodine, protruding through a paper drape with a rubberized hole in it, is all you can see of the patient. With the knee bent, you place the covered foot on the table, and it holds itself in place. Holding in your hand the rough handle of a huge amputation knife, you reach as far as you can under the thigh and bend your arm back over the top toward yourself, curling the knife blade around and under the thigh as much as possible. Can you see what's going to happen? You're going to uncurl your hand and arm, drawing the knife, as deeply as you can, completely around the thigh; slashing -- if it works -- in a single circular motion all the way down to and around the femur. If there were normal circulation, you probably wouldn't be doing this; so there's often not much bleeding. Still, you need to be aware of the femoral artery and be ready to clamp it quickly. Maybe you've placed a tourniquet of some sort above; or maybe you have a strong and big-gripped assistant who's squeezing the leg between both hands. In any case, once the bone is visible around its entire circumference, you reach for the gigly saw -- that's what's pictured at the top of this post. And, while someone holds the leg down, you place the wire under the femur, grab the handles between the middle and ring fingers of each hand, and stretch the saw nearly straight. Back and forth, fast as you can, making the toothed snake rise through the bone, which it does with surprising ease. It's a whirring sound, more than grinding -- high-pitched, err err err err. White until you get to the marrow, the fragments coming off are like gruel. And then the wire springs up with a flap and a splatter as it rises out the top. Start to finish, it's been only a couple of minutes. (Somewhere I read of the fastest such amputation, done in a few seconds, including the removing of a couple of the assistant's fingers.)
It's awkward lifting the leg off the table and handing it away. The balance point is hard to find. There's an awareness of mutual discomfort in this act -- in the giving and the receiving. (A gallbladder plops into a pan, free of emotion. Handing one person the leg of another: that's an exchange for which there are no words.) It's a relief to return gaze to the stump: concentric and clean. White bone, red muscle, brown skin. The anatomy is there, on end: hamstrings, quadriceps, neurovascular bundles. It's not a commonly seen slice.
Before the operation, there's been pain -- physical and emotional. There've been sad talks, bargaining. Nothing to feel good about, for anyone. After, there's the stark realization, the encouraging words that ring hollow. The relief -- mine -- of turning much of it over to rehab specialists, prosthetists. But there, for that few moments in the operating room, there's a separate, private, and possibly unspeakable pleasure. (And I must say the same can be said about other amputations I did throughout my career, hundreds and hundreds of times, as a breast cancer surgeon.) The dissociative and dramatic doing. The fact that, for an instant, I can remove from my consciousness the horror and find enjoyment in my craft, can see beauty even here -- that's something almost too terrible to admit, even now.