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.