Monday, October 08, 2007

Brittle Beauty

Image from

I think my first real amazement in med school may have been learning about the nephron. Don't ask me to recount it in detail; that part of my brain has long since been emptied and refilled with concern about fiber and bladder trabeculations (another good med-school word.) Looking at it one way (a perverse way?) the essence of medical school is the building of a sense of wonder at the complexity and beauty of the human body, and the essence of becoming a surgeon is the realization of how breakable and disposable it all is.

If you follow the link I made to the word (I sometimes hesitate to link to Wikipedia, given its, er, vulnerabilities, but this one seems OK), you can see what a marvel the nephron is: tubules coming and going, membranes, feedback loops, regulatory perfection. It's but a small example. The brain and its corpora and olives; the endocrinata. Muscles and mitochondria. And wow: the liver. It's simply astounding. Whereas the amount of new information raining down during those years is more than enough to swamp even the most absorbent mind (and notwithstanding the sense of dooming of the looming), it's impossible not to be thrilled and exhuberated by the glimpses you get of the wondrous workings of the human body.

And then you're in an operating room, staring deep into a stellate smash of livid liver. It oozes discontinuous destruction. Fragments of hepatic mush are strewn and coddled among clots of blood, stained with bile and mixed with stool. The beauty of the enzyme pathways is nowhere to be seen; Dr. Krebs is not in the building. Weak indeed is the capsule holding it all in, split apart like broiled bratwurst. How little it takes!

Grey bits of brain on a stretcher in no way reflect the neatness of neurotransmitters, or of ions flashing across axons. A hand, with its marvelous pulleys and cables, when rent apart by a saw or a slash, looks frail and helpless and pathetically flimsy.

There are times, when driving, or riding my bike, when wielding a knife in or out of the operating room -- or just breathing! -- that I suddenly think of how tenuous it all is, how easily smashed and torn apart is this wonderful work of nature in which we find ourselves. It's gelatin; it's a paper bag. I don't suppose the thought is unique to surgeons, or even health-folk in general. But we get a damnably intimate view, and there are times when it haunts me.

Cinch your seatbelt, tighten the shoulder harness, keep two hands on the wheel. Wear a helmet. And for God's sake, look both ways when you cross the street.


rlbates said...


Midwife with a Knife said...

Great post!

One of my favorite things about the liver and the kidneys is how well they come back from fairly massive damage.

Almost anybody, if they don't die in the acute injury phase, can recover from destruction of a large majority of their liver.

That's really cool.

Anonymous said...

I'm a massive worry wort. Becoming a parent didn't help. This post so beautifully summarizes a lot of the reasons why. Even our hard, mineralized bone is no match for the thousands of pounds of steel that we find ourselves vulnerable to daily going at velocities upwards of 30m/s....much less our delicate tissues.

mscriver said...

It strikes me sometimes how much we're like sea creatures inside. Some of them are more colonies than structure, so they can be put through a sieve and still reconstitute -- maybe a liver is rather like that. They're meant to float, to be cradled, encased, suspended. And yet we fling ourselves around, slam our heads and chests, twist and tear.

On the other hand, obsess about it too much and nothing at all will get done.

Prairie Mary

me said...

Man is a galaxy of cells, and a cell in a galaxy.

Which is why I think the abdomen is a really neat cavity - the way each organ packs itself into its designated corner... the way you could throw back a bunch of intestines in the most chaotic and randomised manner, and chances are it will not twirl upon itself.

It's beautiful.

Yet many people are ignorant of what's lurking beneath the visible. Like a walking timebomb, the body can withstand only that much abuse before giving way.

And when it does, it's a sorry sight.

Great post!

Eric, AKA The Pragmatic Caregiver said...

I refuse to believe in the existence of this so-called "liver". It just seems like something to get in the way of a good buzz.

But, oh, the nephron! I am truly amazed how humans can regulate electrolytes so exquisitely, through such an intricate pas de deux. We rarely eat the same thing two meals in a row, we live in an astonishing array of climates, we have wildly varying activity levels. And yet, for the most part, it all works.

Knowing nothing about liver surgery, but knowing a fair amount about poultry liver....if you excise something nasty or poke holes through a human liver, does it just grow back together sans suture?

Howard Luks MD said...

I share your moments of paranoia. The feelings of which seem to wax and wane based upon my previous nights experiences in the trauma bay.

I stopped skiing because of all the ACL's I reconstruct... I pay people to clean the gutters on my house because of all the calcaneal and spine fractures we see from roof falls... and I can go on.

Another wonderful post.

Anonymous said...

And if more human beings thought of this glorious, tenuous ride we are on, perhaps kindness and compassion would rule the day.

Sid Schwab said...

me: nicely written. You should have a blog. And yes, letting a handful of bowel slurp its way back into a belly is one of the more sensually and visually gratifying things...

eric: for the most part, yes, the liver self-heals. The main goal of liver surgery for trauma is to stop the bleeding. Sewing it neatly back together, other than as a way to stop bleeding, isn't done. For one thing, it doesn't hold a suture all that well. The latest approach to a badly bleeding one is to stuff in a bunch of packs and remove them, carefully, on another day. If there's no bleeding there need not be much effort to re-approximate all the edges.

west/ortho: yes, I believe an orthopod, of all people, would see the frailty and be moved

oneh/p: amen!

rlbates said...

Dr. Sid, since I can't seem to leave a comment on the post referenced by Ground Rounds today. Let me just say here--leaves me in tears. Very well said.

Sid Schwab said...

ramona: thank you. I went to the post and found commenting enabled and available, so I don't know what the problem was...

SeaSpray said...

Our ER had a pt brought in who didn't appear to be in any distress from being in an MVC. Pt was laughing and talking, etc. It wasn't until the CT that staff knew the pt had to get flown down to a larger hospital. Pt died on the OR table.

The pt's liver was seriously dmaged beyond repair. Hospital and emergency squad sued.

All so sad.

DC Med Student said...

Great post Dr. Schwab!

Thought I would share my post along similar lines.


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