Curses

[This post is inspired by (though barely related to) one from that eminently readable medical blogger, Dr. Rob.]

If I didn't know better, I'd say there's a curse: when a new surgeon arrives in town, he or she will have a very weird or embarrassing case within a short time, while all eyes are still upon him/her. I've seen it repeatedly. (With me, far as I can recall, it wasn't too terrible: my first operation after I moved to my final destination was a very routine hernia repair. I recall the anesthesia person mentioning something positive about how quick and smoothly it went. And his snarky smirk when, for the only time I can remember with an inguinal hernia repair, I had to bring him back an hour later because of bleeding.) One guy, even more arrogant than the typical surgeon, whom I came to dislike more and more over the years until he went elsewhere, began his career by leaving a sponge in an otherwise routine gallbladder patient. Another, whom I liked from the beginning and whom I admired more and more as the years went on, had, within a couple of months of each other, two patients who presented with peritonitis and suggestion of intestinal leakage, without ever finding the source.

I helped him on the first one. The abdominal cavity was funkified with the fibrinous, gooey and liquid stuff that one sees with perforation. Globular glops of gunk gluing together loops of bowel, thickened stubs of omentum pulled and stretched and stuck everywhere. The normally shiny and slippery-pink surfaces of the viscera were dull and thickly-red. Fully to inspect the entire intestinal tract from esophagus to rectum takes a while under the most favorable circumstances. You can't see the backside of the stomach, for example, without cutting your way into the lesser sac. Normally easy -- and among those favorite secret spots that we learn along our path to competence -- it can be hard to identify, much less work through, when everything is swollen and stuck. Same with the mid-portion of the duodenum and much of the colon: the very act of cutting them loose enough to be sure about them risks damage of another sort.

There's an entity known as Spontaneous Bacterial Peritonitis. Pretty much limited to people with fluid in their abdomen from liver disease, after our fruitless search it was tempting to invoke it as an explanation. Except that there'd been "free air" seen on the man's Xray before surgery, indicating perforation. (To me, it's not inconceivable that bacteria could generate enough gas to show similarly on an Xray.) Try as we might, no definite source was found. We cleaned the man out as much as possible, tucked in a couple of micro-suspicious areas, covered him with big-time antibiotics, and he eventually recovered with no explanation.

"You won't believe this," Dr. J said when we saw each other in the doctors' lounge a few weeks later. I was girding for the day, glugging coffee and reading my mail, the latest directives from the hospital overlords. He'd walked in before heading home, after a long night in the OR. "I just had another case like that first one. Perforation with no source. How many of those can there be? I never saw a single one in training! I spent hours looking, and couldn't find a damn thing. It's like I'm cursed..." And then, vibrating like a dinner bell, tattooing his feet on the floor like a kid ready to go into tantrum mode, hands clenched white, he said, "I hate this. I hate this. I hate this."

I suppressed the urge to laugh: he was so vulnerable, so honest. So... cute. "J.," I said. "I think it is a curse. Seems like every new guy goes through it. And really: if you didn't feel like this, I wouldn't want you to be my partner. Everyone's going to have tough cases and bad outcomes. What would bother me is if you didn't care this much. I'm sorry for you and your patient, but I've worked with you enough to know you're an excellent surgeon. You're gonna be fine. This, too, shall pass."

And, like the curse of the Bambino, it did.