Surgery, Part One

Firstly, let me thank you all for your very kind and very helpful responses to my last post. I will let you in on a little secret, one which you may have guessed: I like to exaggerate in order to make a point. Upon rereading that last entry, I see that I… made my point quite well. It does speak to my level of exhaustion and exasperation, and our house is a real disaster, it’s true, but you don’t have to worry for our actual safety or health.

(Unless you count this morning at 4:45 when I was leaving for work and ran into a bucket of laundry that Patrick had left in the hall. I know I should be glad that he actually does the laundry, but the giant bruise on my shin is not feeling grateful.)

In medicine, we like “clinical vignettes”, where a case is presented with typical findings of a disease or problem and you theoretically remember the learning points better because it was in the context of a pseudo-real case. I will employ this technique now to attempt to demonstrate the two sides of surgery that I experienced over the last month.

1

It was my first actual surgery. Of all things, it was a liver transplant, a huge, long, dramatic case. It was my first time to scrub in and be expected to learn something since starting the rotation two days before and I was more than a little nervous. Though they were telling me why one technique of hepatectomy (liver removal) was superior to another, I was actually trying to figure out what was sterile and where to put my hands, why the nurse kept squirting the surgeon’s hands with water, and why in the world they spent so much time moving stuff around and just looking into this cavernous hole they’d made in this poor person.

Without any doubt, the best part of a liver transplant is the moment that everything is hooked back up and the floodgates are opened. The surgeons have sewn together all the vessels from the person to the new liver and the unclamp them to let blood flow through the new liver for the first time. What makes this moment so great is not just the “sink or swim” excitement, it is the fact that, as the blood makes its way through the new organ, the liver turns from the pale gray color it got being on ice while being transported to a dark reddish purple. The color advances over the curve of the liver as a wave. It is stunningly beautiful.

On this particular night, things were going well, people were generally happy, and I watched this rebirth with my mouth hanging open. I thought that I’d never seen anything so incredible and it occurred to me that it was like watching a sunrise, the blood pulsing through this life-saving organ and giving this lucky patient another day to live. I was thoroughly moved and exhilarated.

The lead surgeon picked that moment, the same moment that I was taking deep breaths and blinking back tears at the majesty of it all, to throw a complete fit. “How am I supposed to throw a stitch there, with my eyes closed, you jerk? Get your hands out of the way!” I tried to focus. Was he talking to me? No, I wasn’t touching anything. Instead he was talking to his colleague, another surgeon on staff. “Move! What are you doing? Can you not see that you are in my way?” He threw his instruments down and stepped back from the table. “I can’t work like this.”

He actually said that, really. He said, “I can’t work like this” and folded his arms over his chest, glaring at the other surgeon who never even looked up. The lead surgeon pouted in the corner like a little girl in a sandbox who has had her shovel annexed by the other kid. I have nothing against little girls, love them, used to be one. But little girls in sandboxes do not belong in the operating room.

Eventually, he came back to the table and finished the case. As he left, he clapped the other surgeon on the back, saying, “Nice job today, thanks for your help,” and walked out, whistling as he went.

It’s just another example of the well known sentiment: Surgery would be great if it wasn’t for the surgeons.

2

I had the unbelievable luck to be invited to go on a liver procurement. I joined the team at a local private airport where we boarded a chartered plane and flew about an hour to an outside hospital. As they say, organs had “become available” and we went to get them.

It was fascinating to visit another hospital and see how things are done elsewhere. For example, they keep their gloves out of the room, which is much smaller than the rooms I have become accustomed to. The place had been recently remodeled and the dressing rooms had squishy chairs to sink into after a case. Also nice was the fact that the people at this hospital didn’t know I was the lowly medical student tag along, lower than anyone else, and so I was treated just the same as the others. I was not made to wait until the staff and fellows had been gowned and gloved until I was, nor was I told to stand in the corner and not touch anything. Instead, I walked right up to the table and was treated like I owned the place. It was a nice change.

The procurement went well. The patient had been in good health, but only the liver had been offered, so we were the only team there and could take our time. The attending was incredible. He took the time to identify all of the anatomy for me and quiz me on several different important vessels in the abdomen. I was doing pretty well, and I was so pleased to be doing pretty well, but we inevitably came to the end of what I remembered from my classes.

“What two vessels make up the portal vein, and what vessels make up those?”

Nothing came to me. I searched my brain, pulled up pictures in front of my eyes from books, but those spots were mysteriously blank. I started to sweat.

“Er… I used to know this, like seconds ago I knew this… Umm…”

The lights were so hot. The patient’s entire body was splayed in front of me and I was overwhelmed. Nothing looked even vaguely familiar, no landmark whispered hints to me, it was as if it were my first time thinking about anatomy. I could feel the surgeons and the nurses listening for my response and I thought I might stop breathing.

The attending chuckled softly. I thought he was laughing at me and I felt my stomach knot. But then he looked up at me, directly into my eyes, and his eyes were smiling.

“Don’t worry, there’s no pressure. You’re among friends.”

And suddenly I felt fine. I took a deep breath and let go of all the ridiculous tension I had just built up in my body. I could see again and feel my legs again. I was among friends.

I still didn’t remember the answer, but it didn’t matter. They told me and showed me and I saw and understood. (In case you’re ever asked: the portal vein is made up of the superior mesenteric and the splenic veins. The colic veins make up the SMA and the inferior mesenteric joins the splenic.) After the procurement of the liver and knowing of my interest in OB, he proceeded to talk me through a hysterectomy and point out the major places where complications might occur. “Don’t let them make you afraid of the OR. You can do amazing things in the OR, save people’s lives or make them worth living again. Practice, study, and have confidence in yourself.”

And, once again, I found it rather difficult to breathe.

To be taught in that manner, in that patient and accepting way, made all the difference to me and helped to make the evening one of the most enjoyable, educational, and memorable ones in my medical career. (Also, the plane ride was fun.) This particular surgeon enjoys the surgeon stereotype, crass and hardened and perpetually exhausted, which makes his generosity all the more impressive and appreciated.

I have been told that, upon deciding that one does not want to be a surgeon, the surgery rotation is about learning how to communicate with surgeons. I think it is good that I’m only halfway finished with my rotation; after dealing with these two extremes, I don’t think I’ve learned that lesson just yet but I think resilience and confidence are a good place to start.