Looking In

After my recent "Family Guy" post, and a comment by the estimable bongi, I've been thinking about sharing. In the new-age sense of the term: letting people in on what you think or do or feel or other nerve-grating uses of the word. Y'know: "Thanks for sharing..."

I digress.

What I mean is that the esoteric world of surgery, so dramatic, and intimately knowable only to a small and generally comprehending audience, is quite isolated from those with whom we might most like to share it: family, close friends. I always wanted my son to see me do an operation (my wife did, once, when I was in training. But it was a small deal, and I wished she could have seen something more complicated). As much a part of my life as it has been, and as much as it took me away from his, I'd have loved to have had him watch it, just once. Demonstrate; explain. Perform, impress. Yet it's nearly impossible for a surgeon really to let people from the outside in on what it is that he or she does. I suppose it's not unique, but I think in most other fields it's more possible, easier to gain access. As thoroughly as it envelops us, as proud as we might be of what we've accomplished in learning it, what we do in the operating room must remain hidden from those we love. The fascination, the beauty, the talent (if that it be!): forced, by its nature, into secrecy. How many are the times I've wished it were otherwise. One of my proudest days was when my father-in-law, an anesthesiologist, came to town and spent the day in the OR with me. But he had business there. He's the only one.

Which reminds me of a story.

After years as a trial lawyer, my dad was appointed to the bench (meaning, to be a judge). As his days in front of the bench were winding down, I -- a freshman in high school, as I recall -- mentioned to him that I was sorry I'd never seen him in action, in court. Okay, he said, how about we have you come? Great!! Don't get your hopes up, he warned. It's pretty boring stuff, not like Perry Mason. As it turns out, he was entirely wrong. Other than the fact that the case was about a taxi and traffic, it was exactly like Perry Mason.

Dad was defending the taxi driver. There'd been some sort of accident in which the passenger was (not very seriously) hurt. It had been determined that the taxi was not speeding, but in Oregon there's this thing called the "basic rule:" when conditions warrant it, speed limits don't apply. If it's snowing, driving at the posted speed limit of, say, 35 mph, might be too fast. Common sense. So the plaintiff was on the stand, being interviewed by her attorney, and at some point claimed it had been raining. I saw the taxi driver lean over and whisper something to my dad. In turn, my dad leaned over and whispered to his Della Street, (actually, her name was Frances) who got up and left the courtroom.

When it was Dad's turn to cross-examine, after taking plenty of time, he got around to asking the witness about the rain: You're certain it was raining? Oh, yes. Do you recall seeing puddles in the street? I sure do. Splashes. Were the taxi's windshield wipers on? Yes, they were. People on the streets, using umbrellas? Absolutely. Umbrellas up the ass.

While he was doing this, Dad paced around the courtroom doing his tongue-of-death maneuver. It's hard to describe. When he was angry, my dad stuck his tongue part way out, flexing it (if that's the word) so that it became as thick as a Porterhouse steak, and clamped down like he'd bite it off if it weren't so impressively muscled. To us kids, it was a sign to head for the hills. One can only wonder what the hell the jury thought.

The doors at the back of the courtroom banged open, some heads turned that way. Papers in hand, the barest hint of a smile on her face, in trundled Della Street. Excuse me, Your Honor, my dad asked. May I have a moment? A nod of the judge's head, a back-flick of his hand. After Dad and Della conferred, Dad looked over the papers, and handed them to the judge. May I have these entered into the record, marked as an exhibit? So ordered.

Tongue active but unbloodied, Dad gave the papers to the witness, and asked her to read the title. They were, she read, from the Weather Bureau. The date? The day of the accident. And what is this column here? Precipitation. Can you find the heading for rainfall? Yes, here. And what does it say? Zero. Do you see the place for hail? Yes. Is any listed? No. Was there any snow that day? No. Was there any precipitation at all, precipitation of any kind? I guess not. Thank you. No more questions.

Well, yeah, okay. No sobbing confession on the stand, no close-up of those buggy eyes. There was no da dah, da DAH. But otherwise, it followed the script pretty well. I was impressed.

Later, I mentioned the tongue thing to Dad. Did he know he was doing it? Sure, just to impress the jury. That I didn't believe, not for a minute. Too creepy for that. Way too creepy.

SurgeXperiences, Learingly

So here it is, the TWENTIETH issue of SurgeXperiences. That this carnival of all things surgical has made it to this milestony moment is testimony to the perseverance of Jeffrey Loew, who birthed it quite alone and without benefit of breathing techniques. If this is how he addresses all his goals, he's sure to become the surgeon to which he aspires. It seems a significant passage. I'm honored (so I've convinced myself) that he chose (forced, cajoled, tricked, shamed) me to mark the occasion. So...

There follow the entries received,
In rhymes I have lately conceived.
I offer to you
The best I could do.
It's over, so I am relieved...


_______________________________________________________________

In general I'd say I'm inclinedta
Avoid making holes in vaginas.
The trend, though, is clear.
You can read of it here.
To explain, Rico's taken the timeta.


__________________________________________________________

That's not the first time it's been said.
It's possible you may have read
When Buckeye spoke out.
And I've had a shout.
Some surgeons have holes in their head.

_________________________________________________________

A surgeon must do what is right.
But there is some trouble in sight.
The first thing to go
As plastic guys know
Is beauty, when money is tight.

_________________________________________________________

This frightening tale is from Bongi
Who tells us he's doctored a zombie.
I believe every word
'Cause I've never heard
A suggestion that he's ever wrongi.

_________________________________________________________

I'm not sure I know what I thought
When I read what technology wrought.
It might just be true
That no one will rue
The day when I'm dumped for a bot.

_________________________________________________________

Before Annie started her journey
Of sharing her words with attorneys,
She was a young nurse
Who avoided a hearse
In an OR once used by McBurney.

_________________________________________________________

Bob Bernstein has something to share,
Although the hirsute may not care.
He'd just like to reachya
About alopecia,
And move around some of your hair.


_________________________________________________________

We learn quite a lot from a guy
Who lets a doc laser his eye.
He gives us the facts;
If you're worried, relax:
He thinks you should give it a try.


_________________________________________________________

From David who writes on an isle,
A lesson in what sort of style
A doctor will need
If he's to succeed:
You listen and try not to smile.
_________________________________________________________________

Another from Dave is right on.
He's singing my favorite song:
For deep in its heart
Our work is an art.
Ignore that and you will go wrong.


_________________________________________________________

When tripping down memory lane,
Rob Oliver hopes to explain
What was going on when
He was two years and ten
In the field in which he's now playin'.

______________________________________________________

From the Philippines comes a post too serious to rhyme: as in boardrooms, jury rooms, employee and teachers' lounges, in the operating room there are sometimes words spoken and behavior manifested best left out of the public realm. But this clearly went way too far.

_____________________________________________________________________

Dave Gorski calls surgeons to task.
Before jumping in you should ask
If the new ways are best
Or might still need a test
Before you slip into your mask.

____________________________________________________________

This article sends out the love
To surgeons who don double gloves.
It's not that it's dumb
But my hands feel numb;
I say "no" 'less there's cameras above.
_____________________________________________________________

Ramona is one of a kind.
If ever you're caught in a bind,
The shirt off her back
You never would lack.
She'd give it and not even mind.

(The preceding has nothing to do with her post; it just happens to be true. In her essay she eyes, in fascinating detail, a little-discussed syndrome. )


__________________________________________________________________

Since the days of our heroes of old
Surgeons have thought themselves bold.
But sometimes it's best
If we give it a rest
And helpfully do what we're told.

(Especially if it helps prevent sterility in cancer patients.)

______________________________________________________________________


In thinking of losing her bits
She's come to the end of her wits.
Less parts in the nether?
She does wonder whether.
At least her new blog will get hits.

(Originally, the last line was "Of course she will still have her... sense of humor." But I decided against it.) And part two of her post is here.

__________________________________________________________

Another post from bongi. The subject seems unsuited to lighthearted verse. We make difficult decisions every day; the hardest are often when it's time to do nothing more.

______________________________________________________

A dentist requests that I act
On this informational tract.
It's less like a post
Than many or most,
But there's data for you to extract.

________________________________________________________________

Readers might say it's uncool
To hype oneself, but there's no rule
Preventing me from
Referring to some
Faves from my memory pool.


_________________________________________________________

Now Bongi once more raised his hand
From his home in a far away land.
Midst branches of nerves
I guess he deserves
To brag how he handled a gland.

_______________________________________________________________

Our carnival ends on this note:
I thank you for all that you wrote.
Were I more a poet
I'd happily show it.
On the other hand, it's admittedly a questionable way to showcase your work, forcing, as I did, a thumbnail into an unyielding format; and if anyone feels their essay got short shrift, I'm sorry.
And I hope that you know it.



The next issue of SurgeXperiences will be hosted at The Sterile Eye and will appear on May 11. I assume there'll be word of it at that site; and if past is prologue, posts ought to be submittable here.

Juggling Brains

The always amazing bongi (I could also characterize him as shiftless, but not everyone would get it) has a post that led me to think about how doctors juggle patients in their brains, and how bizarre it is. The need to switch gears rapidly and completely among clients, customers, or patrons of one sort or another surely isn't unique to physicians. It's just that, given the stakes, with docs it might be the most jarring and otherworldly.

I've always tried to be mindful of -- and here I'm just making up a term -- "disproportionate impression." I walk into a patient's hospital room, or see someone in my office, and it may well be the most important and impactful minutes of that person's day. For me, it's one of many similar encounters, some pretty routine, others of horrendous import. I'm the only surgeon each patient has; each is but one of many for me. My words and reactions likely reverberate in each room for hours or days; but I must move on and reset my brain in a blink. Therein is the unworldly aspect of it: I can't, but I do. I mustn't, and I must.

"Minor surgery," it's said, "is surgery done on someone else." Seeing a surgeon is a big deal, whether for removing a harmless lump, fixing a hernia, or taking out half an esophagus. Everyone deserves a full measure of my attention. If I'm despondent over a patient dying in the ICU, or have a bunch of operations pending later, or am feeling like God's gift to surgery because of some tricky procedure done well, I have to attend properly to the person in front of me. To give a young woman news of her cancer, as bongi wrote, and only a moment later to see a routine post-op, or speak hernia. I guess that's what is meant by "compartmentalizing." I can't quite figure out if it's a good or a bad thing to be able to do it.

In my book, I wrote:

"There are times when I’ve thought that having been inside people’s bellies, touching them more intimately than they’ve ever been touched, knowing things about them that they’ll never know themselves—seeing their liver ferchrissakes!—I ought to stay at their bedside for every minute of every day they remain the hospital. Maybe take them home with me..."

I wasn't kidding. It's such a cataclysmic thing, operating. How can you operate on a person and just move on to the next case? It seems, to paraphrase and borrow from myself, "disproportionate attention." But it's obvious we need to; and somehow, in the process, we must not shortchange anyone. Including ourselves. I can handle it during the day. I just wish it could be turned off when pulling up the covers for the night, which is when the compartments seem to break down.


[P.S: For those of you who noticed and are wondering, I put up a video twice this weekend, and finally took it down because the video, about Barack Obama, kept becoming "unavailable." No hidden meaning to the disappearance, other than frustration.]

Sleeve (Up)

[This is another post that's been sitting around in draft form for a while. It might be obvious why I hadn't posted it. More cleaning of the attic -- or in this case, maybe the basement. It's conceivable that some day one person might find one thing useful.]




In no particular order, and for no special reason, here's a few surgical "tricks." Most are amalgams of observations, teachings, and trial and error. Surgeons will shrug, non-medical types (and non-surgical medical types) will say "who cares." Credulous and ingenuous students might make note and tuck them away, against the possibility -- remote as it might be -- that they'd prove useful in a future life. Whatever.

1: In thyroidectomy, "walking" to the outer parts of the poles by sequentially placing suture-ligatures provides excellent traction for exposure -- much more wieldy than Leahy clamps, the sutures can be pulled any which-way as you work.

2: The same technique facilitates the removal of a breast fibroadenoma.

3: The biggest mistake people make in open appendectomy is placing the incision too far medial. Go lateral to the rectus muscle, come down on the cecum, and you won't have to wave your finger all over the place to find the appendix.

4: At the base of the appendix there's almost always a clear window through the mesoappendix. Poke a clamp through, pull back a tie, have your assistant tie it while you snip the mesoappendix.

5: Developing flaps in thyroidectomy doesn't accomplish much more than increasing post-op swelling.

6: Use marcaine in all incisions: generously, up to 1 cc/kilo of 1/4%. Get the peritoneum. Use it all around the pectoralis muscles for mastectomy. Use lidocaine when infiltrating the sac in inguinal hernia, in case you flood the femoral nerve.

7: Sweeping a finger circumferentially around the surface of the peritoneum and behind the fascia in open appy, before entering it, greatly facilitates closure later.

8: In the proper plane, sweeping a finger in front and behind a thyroid lobe allows it to be flipped forward and out of the wound.

9: There are two ways to handle the laryngeal nerve: be sure you see it, or be sure you don't. I prefer the latter.

10: Squirting marcaine into the gallbladder fossa reduces the chance of "phantom" biliary pain in the recovery room.

11: Nearly any umbilical hernia can be repaired using a curved incision within the umbilicus.

12: Nearly any adult umbilical hernia is best repaired with mesh.

13: To make a nice mastectomy scar, draw one side of the elliptical incision, then "measure" it with a tie, placing it in the jaw of a clamp at one end of the incision, laying it onto the marked arc, and clamping it at the other end. Then use it to lay out the other arc: each will be the exact same length, eliminating bunching on closure.

14: Use curved Mayo scissors to develop the flaps in mastectomy; grab bleeders with a Debakey forceps and cauterize them.

15: For tracheotomy, place 2-0 silk sutures vertically on either side of the first tracheal ring before dividing it vertically. Use them for traction when inserting the tube, leave them for several days in case the tube needs replacing before the tract is firm.

16: Non-inflamed/infected sebaceous cysts can be removed through a tiny hole by poking them with a 15 blade, squeezing the gunk out, and continuing the squeeze to expel the sac.

17: Don't shave around a scalp cyst. Tape the hair apart with paper tape.

18: When draining an abscess under local, keep injecting with one hand and make the incision with the other, into the blanched area.

19: When operating on the chronically ill, if not giving TPN, add multivitamins to the IV; and use post-op nasal oxygen for healing.

20: Make rounds at least twice a day. Sit down in the patient's room (on the bed is OK.) Read the nurses' notes, preferably before seeing the patient.

20a: Sit down when seeing a patient in your exam room, too.

20a, i: Don't make the patient undress any more than absolutely necessary.

21: If, after many years in practice, you can only come up with this many items, you probably should have kept your mouth shut (hands in your pockets). I think there were more, but it's been a long time...

Body Talk

"Do you want a foley?" nurses frequently ask before the beginning of abdominal operations -- referring, of course, to the patient. "No," is my invariable reply. "I peed before I got here." "Hah hah." I'm guessing at least a few people wonder: do surgeons ever need to, you know.... The answer is a resounding "occasionally." Many of us, after all, are physical beings.

I've had to take a bathroom break only once or twice in a pretty long career. And it was for the other, er, number. Certain intestinal disorder, don't you know. And yes, it's embarrassing. The leave-taking, the walking past the front desk ("Done already, Dr. Schwab?" "No, uh, taking a little personal time. Be right back. Gotta go..."), the looks on faces at my return. Eyes and foreheads are pretty expressive, above surgical masks. Nurses, being decent human beings, are likely to worry, "Are you OK?" Anesthesia folk, ever witty, can be counted on to say something pithy. Nigel or Lynn, especially. "This should be refreshing. Finally you're less full of it." I can take it.

More common is flagging during an especially long, physically and emotionally taxing case; particularly late in the day, or during or after a long night on call. More than a few times I've asked for a shot of orange juice. It never tastes better, nor has more power of rejuvenation. Some poor nurse has to hie to the fridge in the lounge, scout up a straw (the bendy kind), and wiggle it behind my mask (first making an opening with a finger), while I lean toward her or him to keep from contaminating my gown, and use prehensile lips to try to arrest the tip and insert it into my mouth. Glug, glug. When it's cold, it's sesqui-orgasmic. I've also had candies digitally inserted behind my mask and guided to my lips. I always assumed the nurses didn't find it particularly appealing to do; but I've never been more grateful.

Angels of understanding, there's a couple of nurses -- ones with whom the relationship goes way back -- who've ascended a step-stool and given me a neck rub after I've stopped for the second or third time, leaned back from the table, and stretched. Oh man!! I flap my foot like a belly-scratched dog, and swear devotion till death.

Eschewing cold medicine, I've put a layer of gauze in my mask, under my nose. Drips. And, slightly off topic but nose related, I've gratefully accepted a swipe of benzoin (for its aroma) onto my mask when encountering a particularly putrid pus-pocket, or a well-rotted intestinal infarction. (Actually, I've used it pretty rarely: I've always thought draining pus was among the more noble things a surgeon does: and when it stinks up a room to the point of turning green those who must stay, and driving away those who can find an excuse to exit, there's no need to wonder if you're doing good for the patient. So, in a way, I like it. Dead bowel? Not so much.)

In the operating room, I've been poked, stabbed, cut, and cauterized. My left index finger bears the scar of a scalpeled flap, a centimeter at its base, equally tall: the result of an episode in training that sent me to the ER with a spurting digital artery, and after the sewing-up of which I returned to find my attacker/assistant (it was one of those rush-jobs: as I was ten seconds into opening the belly in the midst of a flood of blood, he reached to pinch off the aorta, banging my elbow...) happily repairing the patient's iliac artery as the attending looked up with amused eyes skrinkling above his mask.

Somewhere along the line, I converted my hepatitis antigens: probably from a needle-stick at San Francisco General Hospital, only a few years before HIV ravaged the place. Digging my way behind the rectum in a deep and narrow male pelvis, I've shaken cramps out of the palm of my hand. The backs of my knees have ached and the fronts wobbled as I leaned for hours into a tough dissection. I started wearing support hose in the OR way before middle age. Stasis dermatitis (mild) made itself known while I was Chief Resident.

If there's a point here, it's this: much as I like to emphasize on this blog that surgery is a thinking person's sport, there are times when it's all about the body.

Operation, Deconstructed. One: preamble

With as much detail as is useful, and as descriptively as I can manage, I'd like to relate what it's like to do an operation, from before laying knife on skin to after placing the bandage. I'm a general surgeon, so I choose sigmoid colectomy as my prototype; it's always been one of my favorites, although the particular operation isn't the point. The idea is to let the reader into the operating room as much as possible. I figure it'll be several parts. Let's see how it goes.

First stop: the pre-op holding area, where my patient -- and most often family -- and I exchange greetings minutes before the operation. If I've done my office-job well, the patient is likely to be relatively calm and optimistic. I touch a hand, a knee, a belly, say something like "Seems like a great day for a colon resection." To the oft-said "Hope you're not hung over, Doc," I respond with a raised hand, deliberately shaking, saying "Steady as a rock." Laughs all around. Then more seriously, "Any questions since we talked, anything you want to go over again?" And a reminder of the plan: "You'll meet the anesthesia person any minute. You'll be sound asleep for the operation; we'll be making the incision right here. I'll numb it up with local before we're done so when you wake up there should be little or no pain. It does wear off, though, in a few hours, and we'll hook you up to a little push-button device so you can give yourself pain medicine whenever you want it.

I expect you'll be up walking in the halls tonight. ("Tonight?! Really??" "Yep! It's the best thing there is for you. Gets the circulation going, gets those lungs working.") [To the family:] OK, I figure the operation will be give or take an hour, little screwing around before and after, I'll come out and talk to you soon as we're done -- probably an hour and a half. Don't get worried if it's a little longer. [To the patient:] See you in the OR." Exit, stage left.

I like that part. I suppose some of it is the awe-inspiring "I'm here and you're there" sort of thing. But really, it's about re-establishing rapport, giving a final injection of confidence, and, of course, making sure everyone's on the same page. Because for elective surgery I've hand-carried the paperwork the night before, there's rarely the cold shower effect of "Uh Doctor, we can't seem to find the lab work..." Occasionally I get the rhythm-interrupting "Did he get a preop EKG?" to which I reply "Yes. See, it's right here in the chart." Annoyometer needle rises just above zero.

As important as any of the steps is being there when the patient goes to sleep. I feel terrible on the rare occasions (emergency call, etc) when I'm not. (Reassuring as it may be, of course, the patient likely won't remember any of it.) Often, I'm already in the OR when they get wheeled in, because I've gone in to check that the instruments I need are there, maybe magnanimously tie up the scrub nurse's gown, bother the anesthesiologist. I help the patient onto the narrow table, checking to make sure the rear end is south of the table-break, just in case we need to change position for a staple-job. I don't expect it in this case, and prefer to have the patient flat, instead of in the modified lithotomy position. But the equipment's in the room. While the anesthesia person is doodling around, I talk with my patient. Small talk or big.

My acquiescence to the time it takes to get off to sleep is inversely related to the acuity of the case and the number of operations I have scheduled to follow. And to whether my patient starts looking around nervously: why aren't I asleep, am I supposed to be asleep by now? As I see the mother's milk of morpheus going in, I say "Have a nice dream. We'll take good care of you."

The oxygen monitor beeps rhythmically in time with the heart and tonally in relation to oxygen levels. During a tough intubation it can descend an octave or more. I stand by, quiet, helping if needed. Pull out the cheek with a finger hooked in the mouth to widen the view; push the trachea this way or that. During the operation, those sounds are beyond my notice, unless they change.

As I've revealed previously, I'll likely do whatever shave is necessary, as soon as the patient is asleep. Today it'll be a lower midline incision. A few pubes might have to go, but I'll keep it to a minimum. If it's a male, I usually put in the urinary catheter if I want one. The reason is mainly to keep the bladder from filling up and getting in my way. Pretty routine a while back, I used them much less as time went on. I let the nurses do the women.

If I expect to be working into the dark recesses of the pelvis, I put on a headlight. Hold my thumbs together at the level of comfortable vision, make sure the beam is focused just there. Tighten the headband too tight, get a headache half-way through the case. All of this seems like pretty grown-up activity. Gray as I've gotten, I still can't quite believe I'm enough of an adult to do this stuff. Am I really allowed? Something there is that loves a dress-up party. But this is the real deal, and I never got over having a part of me watch the whole process in amazement, from just across the room. Yes, I think it's pretty cool.

The scrubbing ritual, done with intent, but also with that third eye, watching: grab a pre-packaged brush, impregnated with my favorite flavor of soap. Given a sufficiently brisk squeeze, it rends itself open with a very satisfying "pop." The champagne cork that starts the party. Done right, heads will turn and nod appreciatively. Hit the knee-controlled water switch. Quick on and off, just to get wet: I don't like to waste water. It used to be a ten-minute scrub, timers even, right above the sink. Now, couple of minutes will do, unless you get caught up in conversation. Orthopedist at the next sink: "Hey Sid, what's the real surgeon doing today?" "Yeah, general surgery, the queen of the surgical sciences. Little colon resection. How about you?" "Elbow. It's a living."

There's a favorite nurse scrubbing across the hall: "Bridget, what's the deal? Hiding from us today?" "You know I'd rather be with you. They have me doing eyes." "The dark-room. Bummer." House-keeping aide walks by: "Dr Schwab! What's up?" "You are! How's the kid?" All this while cradling each finger with the flexible brush, flipping it from the scouring side to the soft side, one at a time, zooming the gap between each finger ("Johnny, Johnny, Johnny, Johnny, whoops Johnny, whoops Johnny, Johnny, Johnny, Johnny, Johnny"), then down the arm. (I like seeing my arm-hairs getting soapy. Again, from some distance...) Bang the water-trigger once more, dip a hand into the stream, scooping it upward, fingers apart, elbow last. Then the other. Knee-knock the water off, back my way into the OR door, dripping water off the elbows. (Now we have hand-sanitizer goo. Couple of pumps and the whole thing's over. Still do the water-zen first case of the day.)

Some OR doors have handles, requiring a certain agility of the backside to part them. Needing more than one push definitely diminishes the drama of the entrance. The scrub nurse flips me a towel: it's lengthily rectangular, allowing the use of one end for one hand and arm, the other for the others. From the fingers down, elbow last; then laying the dry end over the wet hand, once more. Stepping into the gown, both hands in at the same time; little shoulder-shrug to get it settled, little rub of the elbows at the waist to seat the cuffs. The scrub holds the right glove open with two hands (except Jeanne: she always proffered the left. Her way, I always thought, of laying down the law. Or maybe some sort of superstition. She never told me.) I dive my right hand in, stretching the glove half-way to my elbow, and she lets it go with a satisfying snap. (Missing a finger hole is a spell-breaker -- less likely if the scrub waits half a beat before the up-move. Maybe she'll tug on the empty finger as if it were a deflated cow, or maybe I'll fix it after I get the other glove on.

With that one, I can help: taking my gloved right hand, I pull the left cuff outward as I couldn't with an ungloved one. Bigger target, deep dive, no worries. Someone snaps or ties the back of the gown together -- often the anesthesiologist will leave the machinery to do this; some, I think, consider it too demeaning. There's a belt-like tie attached to the front, with a cardboard tag on it: the tag can be held even by a non-sterile person. I fold it for strength, hand it with my right hand to the designated holder, and pirouette on my heel, left hand down and rotated back and outward to catch the tie at the end of my spin. That's brought the gown fully around me, and I tie the tie to another tie hanging on the front. Sometimes the cardboard slips away before the ballet is over, and the tie drops: another flicker of the annoyometer, but not a big deal. I lean to the left, the errant belt falls away enough to be grabbed and tied, unsterile, behind. Not perfect, but ok unless I plan to back into the wound.

Draping the patient -- a daunting task during internship because we used multiple cloth drapes and each surgeon had his own way of doing it, differing wildly among various surgeons for the same operation -- is now a simple final step before commencing. Pre-packaged, shaped with various holes for various operations, containing adhesive strips at the edges of the holes, they simply require laying them on the middle of the patient and unfolding, first north and south, then east and west. It's a choreographed move, as my assistant and I move in unison on opposite sides of the table, each with a hand on the edge of the drape -- her left, my right -- fluttering it down the legs, then over the head.

The anesthesiologist clips the head end to IV poles. Rhythmic gymnastics. Once every seventy-five or ten cases the drape gets handed to you wrongwise, causing the parts designed to cover outstretched arms to end up dangling instead at the feet, semaphoring stupidity. They actually have a little humanoid cartoon on them to show proper orientation, but these things happen... Finally, suction tubing and cautery pencil wires get distal ends handed off, proximal parts secured to the drapes. Back when we used steel towel clips, the sturdy clicking in place was like a signal of readiness, a one-minute warning. Now, it's velcro straps that come attached to the drapes.

Ka-chickachick supplanted by zzzrrrrrippp. And finally comes the sshhush of the suction hose as it gets hooked up; like a cleansing breath, it's the last sound heard before I ask for the scalpel. More often than not, we clamp the hose off for silence until it's needed. When that's forgotten and remembered later, the sudden quiet is a surprising lift, like removing a heavy pack at the end of a hike. But now, we're ready to go...

Plumbing the Depths

Our shower has been acting up lately. It's happened before, but this behavior was different. Not wishing to hijack my own post, suffice it to say I came up with a clever solution. These little domestic victories, when they occur, find parallels in my mind with surgery. Finding solutions to unusual problems is very often what it's all about. Every once in a while I allow myself an inward smile, and tell myself I have a brain with certain kinds of software -- and feel surprise that I found my way to being a surgeon. It was, in the subject sense at least (and in others, not so much), a good fit. I'm able to figure certain kinds of things out with efficiency, and I think it's a talent not given to everyone. Not even every surgeon.

It's not unique, of course, and I'm truly not trying to boast. It's just that I'm sometimes amazed at having wandered into surgery from a series of serendipitous situations, discovering after the fact that I can actually do it, that my thought processes are suited to it. Given the body's amazing ability to heal itself and to withstand various insults, I'd say most people who don't faint at the sight of blood could be taught to do a large portion of what surgeons do. Nor is the talent, or whatever it is, to which I refer unique to people who do surgery. Artisans of all sorts surely have it. What I'm trying to describe is the ability to find ways out of unfamiliar situations. You can be taught how to use certain tools, how to accomplish a particular job. It's when encountering problems for which there's no road map that a certain (probably indefinable) way of looking at things is a great help. The body continually surprises; or, as I used to say, there's a lizard under every rock.

"We're bogging down, boys," was a thing I frequently uttered during a difficult operation. When working through a tough bit of anatomy, distorted by scar tissue or tumors or infection, if I sensed progress wasn't swift enough, I'd find a different avenue. That's in no way unique, of course. But it's critical that you get that vibe before crossing a line into tiger country. Likewise, there's some sort of spatial sense that allows some people to look at a surgical field and see what the perfect tool is; or to be able to position a needle in a needle-holder at exactly the best angle in a deep hole before trying it another way and having to change. Letting the scrub nurse know what you'll next be using, especially if it's not going to be something typical, far enough ahead that she'll be able to get it ready, is something not everyone does easily. When assisting, it frequently happened that I'd see where the surgeon was headed and assume a certain approach would ensue, a particular instrument would be called for, only to be surprised. And often, after watching futile diddling, finally see (or suggest) that other approach.

Only so much can be taught; only so much can be assimilated later. To some degree, it's about pre-existing wiring. I hope the reader will accept that when I say I think I had it, it's not for self-tooting. It's in abject amazement, because I had no reason to suspect it before I chose to be a surgeon, or even while I was in the early stages of learning. It's a "who knew?" sort of thing. (While in training, I first heard the quote from an unknown [to me] author, describing the necessary attributes of a surgeon: The eye of an eagle, the heart of a lion, the hands of a woman. I used to describe myself has having the eye of a needle, the heart of an artichoke, and the hands of a clock.)

For the life of me, I can't paint or draw anything that looks like something. I couldn't sculpt my way out of a canvas bag. Building a glob of clay into a recognizable work is a talent entirely out of my ken. Even more mysterious is the ability to hack a chunk of marble until it's the Pieta. (Who was it that said "I just cut away everything that doesn't look like a duck" -- or something similar? Might have been big Mike himself.) Given the choice, I'd absolutely, in a heartbeat! opt for that kind of art -- which is truly a gift -- over some sort of ability (real or imagined) to smooth out some surgical rough patches. But there have been times when I was glad to settle.

Update: the shower is acting up again.

Rationale

I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point of this post. As much as I love it when able to do surgery in a way that I consider some sort of artistry, and as much as I realize that being able to do so is the result of the efforts of nearly countless people, there are times when I've had a moment of disconnection (or is it clarity perhaps?) and have wondered if it's all insanity.

For an operation of anything more than the most minimal magnitude, the team consists of at least five people -- and often more: anesthetist, surgeon, assistant, scrub nurse or tech, and circulator (meaning the person who runs around getting stuff, more or less) but it's always in fact way more than that: anesthesia tech, people in the sterile core, in the pre-op holding area, admitting, in the recovery room. Central supply techs, assistants to set up and turn the rooms over between cases. Schedulers, people at the front desk keeping the day in synch. And these are just some of the folks surrounding the operation itself. One-on-one or one-on-two nursing in the intensive care unit, around the clock. Nurses, aides, assistants on the surgical floor; physical therapists, social workers, unit managers and clerks. Pharmacists, lab techs. The number of people involved in supporting an operation on any individual is staggering. Clearly, for the patient and his/her family, it seems worth it. But is it crazy to wonder if it makes sense, economically? Or even, given limited resources, ethically? Thinking of so many people involved in the care of a single individual makes me wonder, sometimes, if societies would be better off if that effort and treasure were directed in ways that would benefit more people. Is surgery an example of our fundamental instincts to help one another; or a sign of misguided priorities? Do we allow such lop-sided economics because, at bottom, we want that effort when it's our turn, damn the cost? I'm no philosopher, nor an economist. I don't suppose societies ought to behave only on the basis of cost-effectiveness: some values are reflected in ways that don't fit bottom-line thinking. Still, there are times when I look at all the effort involved in supporting what I do, and it gives me pause. Funny thing is, I've never regarded any patient -- famous or infamous, wealthy or destitute, brilliant or slow -- as unworthy of that effort. It's only when I think of myself lying on an OR table, and of all the people called upon to do whatever they'd be doing to accomplish whatever operation I'd be getting, that I think of it as somehow unseemly. But that's just me, I guess.

* * * * * *

Well now, as luck would have it, while I'm putting the finishing touches on this post, there appears an article in the local paper about an eight-year-old boy receiving an intestinal transplant. So maybe it's destiny that this becomes about something larger (as I implied in a recent post, we're not in charge of our thoughts anyway.) The pictures show it: he's a really cute kid, and he's looking forward to being able to eat. It's heartwarming; it really is. And yet. The operations that gave me pause above are in the most minor of leagues compared to this sort of thing. Dozens of OR personnel, people involved in the harvesting, the maintenance of the organ; lab folks. The immediate post-operative care is highly labor-intensive; the drugs, the after-care. And oh, the dollars.

I recall watching Ronald Reagan many years ago, as he made a very public show of donating to the fund for a liver transplant for some cute little kid, during a time in his presidency when he'd been loudly decrying the costs of health care. There's a huge disconnect: who isn't moved by this beautiful child, who would admit to begrudging him whatever it takes? And who, if in a darkened room away from prying eyes and ears, if not given the particulars of any individual, if crunching numbers trying to balance budgets, would argue for paying a million bucks or more for a procedure whose long-term survival is discussed in terms of three-year alloquots? But if it were their child...?

It seems inevitable that at some point the US will join the rest of the western world and provide some form of universal healthcare. I wonder when, in the process of discussing it, the R-word will finally be raised and addressed head on? Unless there's agreement that healthcare is the sort of priority that gets all the money it takes to provide all the care possible to everyone in need no matter the details, sooner or later "RATIONING" (call it whatever you prefer) has to be part of the mix. Somewhere along the line, we will have to say THIS is how much or our federal budget we're willing to spend on healthcare; THESE are the things we're willing to pay for; and HERE is how we'll pay it. It's way too important to leave to the insurance companies, and it's way too difficult to think politicians would tackle it seriously, let alone with an eye to finding actual solutions. (They're all too busy electing themselves and playing power games -- and have been for several years.) If anyone asks me, I'll tell them we need to convene a dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers. Maybe lock 'em in a room with hardtack and water, don't let them out until they come up with a plan and a price; maybe a couple of them. And then let everyone think about it for awhile, and put it to a vote. It's long overdue. Meanwhile, out of concern for your money, I promise not to have an intestinal transplant.

The Gambler

An anonymous commenter on one of my pancreas posts said "I think ... surgeons tend to see things from a "look to the past" view as opposed to "look at the future" when it comes to individual patients..... I don't expect a surgeon to be God....but I do wish he could be God-like and consider the past, present AND future." He had undergone extensive surgery after which he was evidently left with severe side effects, and a miserable quality of life. As I understand it, he seems to be saying he wishes his surgeon had given some thought to what he was about to do to the man, and -- I infer -- not done it. The implication -- well, the clear-cut statement -- is that this person believes surgeons do what they do with no thought at all about the consequences. If you can cut, do it; the more, the better. Period. Nothing could be further from the truth.

Bottom of the ninth, game seven of the World Series. The pitcher has struck out the first two batters, looks like he's in the zone. Up comes Casey, who's already gotten a homer and a double, and who has a .480 record against Lefty. Manager brings in Righty O'Doul, who strikes out Casey. The crowd goes wild, carries Righty and the manager off the field. Great manager: brilliant moves, knows the game, damn genius.

Casey hits an arching 450-footer into the stands, dead center field, the Cephalopods lose. Beer cups rain down, sports-writers foam at their laptops, the manager loses his job. Bad manager? Didn't think about the consequences of his move, didn't have cold sweats over it then, and after? Trivial analogy?

In my book, (yeah, time for another plug!) I said that what we do is a sophisticated game of odds-playing. We have had lengthy training; we keep current on the latest developments; we have our experience on which to draw. My commenter knows we aren't gods, but wishes we'd be god-like in looking at the future. And exactly makes my point. Obviously, we can't. We can guess, hopefully in the most educated and well-grounded ways. We can bring to bear every bit of our knowledge and use all of our experience; listen to our "gut," even reflect it all against our sense of right and wrong. Some doctors undoubtedly pray over tough (or easy?) decisions. And inevitably, we will have some lousy outcomes, some patients injured as a direct consequence of our decision making. If I know with 99% certainty (rarely is any outcome that sure) that if I do A, B will occur, and if I do A a hundred times, the odds are I'll have one very unhappy (or dead) patient. I will have been right every time. Tell that to the one patient.

If my commenter were my patient, I'd feel horrible. I feel bad for him as it is. In fact, it's entirely possible that his surgeon screwed up, made a bad decision, or did exactly what my reader infers: figured there was an operation that could be done, and did it, because that's what he does. But I doubt it. We're an eclectic bunch, us surgeons, but most of the ones I know are thoughtful and careful -- exactly because we know that what we do is imprecise and unpredictable at best. We understand what improves the odds: meticulous technique, careful planning, knowing as much as possible about all the options, thorough knowledge of what's going on with our patients. To use "anonymous"'s words, we look to the past for our knowledge, to the present to assess what's going on, and to the future to make the best choice possible for the situation at hand. That we're not always right -- or more likely, that we made a careful and thoughtful decision the outcome of which was lousy -- doesn't mean that the process was flawed in the way my reader implies.

Perfect surgeons (if there were such a thing, and there isn't) will have imperfect outcomes. And I wouldn't deny for a minute that there are some bad docs out there. The nature of surgery is that bad surgeons can do especially bad things. I'm not making excuses. I am, I think, stating the case as it is: yet no matter how happy the ninety-nine are, it doesn't change a thing for the one who came up on the short end of the odds. And here's the part I'm not sure I can say without sounding callous: I have an obligation to do everything I can to get as close to perfection as possible, including thinking long and hard about the possible outcomes of every choice I make. But if I were to dwell too much on the admittedly deeply disturbing and regrettable folks like my anonymous commenter, I couldn't do what I (used to) do. And lots of people would be the worse for it. Assuming I am in fact fulfilling my obligations to try to be the best surgeon I can be (and assuming my best measures up), at some point I have to accept there will be failures, and to hope that on some level, patients will, too. Or else I'd jump off a bridge. There were times when I came close.

That's a couple of downer posts in a row, on more or less the same subject. Got a good one coming up. Y'all come on back, hear?....

God of the Operating Room

It's an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. "What the hell was that?" someone asks. "Why does that doctor get cuts?" "Oh, that wasn't a doctor," Pete says. "It was God. He just likes to play doctor once in a while."

But it's no joke. Whereas I don't buy the "playing God" aphorism, I've had to make life-and-death decisions on occasion, and I don't like it. I mean "life and death" literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance -- looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable -- is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?


Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it's fatal. In operating, one may find -- depending on the cause and the anatomy -- a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it's conceivable that two people might make different decisions; ergo, it's subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you're not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

These people don't come to see you in the office, don't participate in a leisurely give-and-take about their illness. They show up in the ER in pain, sick as hell, in no position -- much less able -- to philosophize. Nor do they come to you because they like what they've heard about you. Luck of the draw: they show up when you're the guy on call. Their lives are in your hands because of the most random of circumstances. But there's no avoiding it.

It doesn't take long to realize the power of influence you have. In fact, it's my impression that often people -- patients, their families -- WANT to be relieved of the responsibility. Grandma has been in a nursing home for a couple of years. Ninety years old, not always recognizing everybody, she suddenly is complaining of abdominal pain and is now in the ER with signs of some sort of abdominal catastrophe. "We need to get her to surgery right away," you can say. "Or she'll die." Clearly that stacks the deck toward going ahead, and, frankly, it's the easiest way out -- for the surgeon. I know many who always take that approach, and I think it's neither that they love to cut above all, nor that they want the money (what little they'll get from medicaid.) It's just that it avoids all the moral wrestling; with the people, with yourself. But it is, of course, just as subjective.

"It's obvious something serious is going on, something that would require an operation to fix. It may or may not be fixable; she may or may not be able recover from what we'll have to put her through. This could be too much for her no matter what we do; so I want you to know that it's possible to be sure she's entirely comfortable, to be sure she doesn't suffer in any way, and to let her go. You know her better than I; you know her life. I'm willing and comfortable with either approach. What do you think?" That's another way to handle it, one which I've done many times. And sometimes, either when such an approach doesn't lead to consensus, or when even before I've said such a thing I see a family in turmoil, I'll ask, "Would you like to know what I think?" That's where it gets hardest of all.

"We can take a look. I can see what's going on, and make a judgement: if I think it's a solvable problem with a reasonable chance of recovering, I'll do what I can. Or I'll come and talk to you before making that decision." "I think whatever is going on in there, it's too much for her, given her condition, and I think making her comfortable would be a kindness." I've said each of those, more or less, on many occasions. Some people think that if there's a one in a million chance of recovery, it should be taken: as a general rule; as a moral principle. I don't share that idea, but I can't say it's objectively wrong. If a patient in a one-in-a-million situation got me as their surgeon, they'd be more likely to die without an operation. If another surgeon, they'd likely die with one. Should that be a matter of chance? From one point of view, always going for the one-in-a-million chance seems the purest, cleanest, most honorable (life-affirming?) approach. From another, it looks like the ultimate moral cop-out, an abdication of responsibility. Can anyone say for sure?

It doesn't end, of course, with the decision for surgery. In the case of the dead bowel, you'll likely be confronted with operative uncertainty. In the example of the old lady, if virtually all her gut is dead, it's nearly automatic: take a look, and close up. ("Peek and shriek," is an oft-used phrase.) But what about a twenty-year old? It could happen, as a result of blood clots. Most likely you'd remove the bowel and do everything you could to get the person through the crisis, knowing they'd be facing a very abnormal existence. Having the whole gut gone is pretty rare. Having most of it gone, though, is not; enough that you could hook a foot or two of small intestine to a foot or two of colon. Again, it's not something I'd do with an elderly and sickly person; but I did it once with a young person. In both cases, it was entirely up to me, and I made the decisions -- necessarily, far less than fully-assured. And if not ninety, but yes twenty, then where's the line? Sixty-seven? Or what accompanying factors? Heart disease? How many vessels? More than that: what factors am I bringing to bear from within myself? Experience, knowledge of what I can (or can't) do, what decision I'd like made if it were me? Am I allowed those colorations? Given that there are no clear answers, it's not hard to understand how some surgeons would take the approach always to operate, and always to do what's technically possible, no matter the consequences.

A commenter in one of my recent pancreas posts described the misery of his life after a big operation, implying, I think, that he wishes the surgeon hadn't done it, hadn't saved his life. No one that I can recall has ever said that to me, not even the lady I left with severe short bowel syndrome. But I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways. I'd not be surprised to learn that she's said it to someone, since. If it were to me, I'd feel really, really bad.

Skin to Skin

Above all, interns love the fast surgeons. The longer an operation takes, the less time to do your work when finally released from the tiled temple. A whole OR day with a plodder guarantees a night without sleep. There are other reasons to appreciate fast surgery, and to consider why some surgeons are so much faster than others. But before doing so, let this be made clear: speed, per se, is not a sine qua non (or even the sine qua not much) of good surgery. Doing it right is paramount; a slow and careful surgeon is better than a fast and sloppy one.

An operation done fast, when done well, is better than a proper but slow one. Not often, necessarily: but given the ill effects of anesthesia, the additive impact of tissue trauma, fluid shifts, exposure of uncovered tissues to the elements, all other things being equal, the less time in the OR the better. Over a lifetime of procedures, I think it fair to say fast surgeons will have fewer complications than slow ones. Especially with critically ill or elderly patients.

Although I like much better the other images it conjures, "skin to skin" refers to the actual time of an operation -- from cutting the skin to finishing sewing it up. (Total OR time is longer -- often much longer -- depending on OAFAT and other issues.) Usually only invoked when it's good news, it's like this: "How'd the Whipple go?" "Two hours, skin to skin!" When not so good, it's "Oh man, it took forever..." Skin to skin -- as it should -- connotes goodness.

Vic Richards was the fastest surgeon I'd known. (Lots more about him in my book.) Former chief of surgery at the Stanford program when it was still in San Francisco, he'd gotten his MD at age 19 (!) and was chairman at age 30. Right after getting his degree, too young to do much else, he worked in an anatomy research lab, where he ended up teaching surgery residents much older than he. In the process, he figured out subtleties of anatomy previously not well-known, and thought about how to do things in the operating room based on his anatomic insights.

By the time I knew him he was well-established as one of San Franciso's premier surgeons, loosely associated with UCSF, where I was training. I spent some months with him as chief resident, and he opened my eyes -- although I think it wasn't until I'd been in practice at least a couple of years that I really understood what he'd shown me. "Slow down, Dockie," he'd say. "You're going too fast. I'm the slowest surgeon in town...." In one sense, he was: his hands were not a blur; he didn't tie knots so fast you couldn't see the moves, didn't flash his knife like a Ninja. His speed -- usually he took half the time of the professors who'd theretofore taught me -- came from his head, not his hands.

I can't quantify it. Fast surgery is greater than the sum of many important parts. Every move ought to make sense, and flow logically from the previous one. For that to be true, you need a global idea of what it is you need to do, and the idea has to be a good one. That's for starters. Clearly, you need certain basic skills; you need to understand the relevant anatomy; but also you need -- here it gets a little nebulous -- an instinct for economy of movement and for what makes sense. To clarify what I mean (if not necessarily to shed more light): I've assisted many surgeons on complex operations wherein we came to a point at which I felt I knew what the next move ought to be, only to see the surgeon go somewhere else. "Look at that!; isn't that something?; he had it and he lost it! He's not seeing it!"

That's what Vic would have said, in his non-stop running commentary on everything I was doing under his tutelage. Assisting, in those early practice days, I'd say nothing and do what I could to help with the new path. Eventually, the paths converge. It's not as if there is one and only one sequence of events for a given operation. The surgeons who take four steps where one might suffice are not bad surgeons, generally. We all benefit from the incredible resilience of the human body. If we get things pretty close, it'll do the rest.

But little things add up. Some surgeons are so wedded to specific instruments, for example, that if it's not available they'll stop everything in the middle of an operation while someone gets it. It's almost always the case that something else would do. It's desirable to have a predictable routine for any operation; it's not desirable to be unable to deviate from it. On the other hand, some routines themselves are counterproductive. You can make a midline abdominal incision, as an example, and be into the peritoneal cavity literally in a minute or less; or you can do it in a way that takes ten, using cautery, slow-cooking your way through the fat, leaving non-viable (yeah, but non-bleeding, they'll tell you) tissue in your wake. Any operation provides many such opportunities.

Maybe most important of all, and least understood, is knowing when you are in exactly the right plane, as opposed to close enough. The interface between tissues is (absent prior surgery or other damage) subtle but distinct: soft, easily separable, and comparatively bloodless: it will allow you in and welcome you like the gentlest of innkeepers on a cold night. If in exactly the right place, you can separate things easily, in ways that seem indelicate but are in fact the opposite. A few cell layers can make all the difference. When perfectly positioned, you can use your finger, the back end of a scalpel, the closed tips of scissors, and expose your target in a flash. Off by a bit, you'll need to dissect, probe, stop a bleeder here or there, be a little rough, before you've conquered the intended area. And never know the difference! You can spend a whole career unaware there's another way. The gods of surgery will let you pass; but they won't be singing you through the gate.

I've said before, and I'd say again: doing surgery is not really mysterious: those of us who do it are not extraordinary. People can learn it. But I think some are fortunate enough to have certain cerebral software that allows them to see the operative field more clearly; to understand instinctively how to avoid struggling. Among the good point guards (and mid-fielders! -- but you probably don't like soccer as much as I do), some just seem always to make the right pass at the right time: they see the whole game as it's being played out, know what's about to happen. A coach would say that can't be taught. Some just have it.

To a small extent, surgery and surgeons separate along similar lines. Can I say that I had some, without sounding too self-absorbed? The irony is that it surprised me to find it out. I didn't sense it when I chose to become a surgeon, or even as I was learning it. Like a rosebud, it opened with time. And in other ways, surgery was a poor fit for me: it drove me crazy because I couldn't stand imperfection to any degree: even a keloid scar made me feel like a failure. Every night, I lay awake stewing; I was overly paranoid. But I could do the operative work; that I could do.

I owe a lot to the fact that when I first started practice I was in a semi-lousy situation: a town with way too many surgeons. As the new guy, it took a long time to get a following. On the other hand, for lack of much else to do, I assisted every other surgeon in town, many times. Having trained in an in-bred place (meaning the majority of attendings had trained there) I was well-trained but exposed to a narrow range of techniques and surgical philosophies. In my first practice experience, I saw things I'd not seen before; both good and bad. My operative approach became an amalgamation of ideas I picked up from many sources; and as time passed, I added my own.

Because of Vic, I placed a nearly obsessive premium on efficiency, on considering everything I did from the point of view of whether it made sense -- whether there might be a better way. And over the years, I found some. I won't list them, but I was always either figuring out or stealing little tricks here and there for every operation I did, all for the better. Most surgeons do, I'd add.

So yeah, I was one of the fast ones. Faster, eventually, than Vic himself. Sure, I tie knots ok, but you'd definitely be able to see the fingers without blurring. I admit it: I liked being fast. Hearing people mention it. Appreciation from anesthesia people, scrub nurses. Taking some sick patient to the OR from the ICU, doing something serious, wheeling the gurney back to the Unit myself, hearing the nurses say, "Wow, you're back already?!" Being able to do more surgery in my assigned block of hours than anyone else. (That, of course, has obvious remunerative benefits as well.)

There were times I actually delayed talking to families in the waiting room because I figured they'd either wonder if I took some sort of dangerous shortcut, or decide the operation was so easy I shouldn't be charging for it. One of those times was when I removed a gallbladder, including taking an intra-operative bile-duct Xray (cholangiogram) in twelve minutes. Skin to skin.