Wednesday, April 13, 2016

From The Mind Of A Surgeon



 Here's my latest newspaper column, ripped from the past, i.e., from my Surgeonsblog days:

Tiring of nonstop politics, I plan occasionally to insert essays from my “Surgeonsblog” days, when I wrote about the life of a surgeon. Warning: this one is graphic in parts. 
There's something irresistibly horrifying about doing an amputation. In a way, it's a microcosm of the perversity and beauty of surgery; of the screaming contradiction that one must somehow accept to be a surgeon. Removing a limb is so many things: failure, tragedy, cataclysm, lifesaver, life-ruiner. Gratifying. 
Stark and sudden, an above-knee amputation done in the "guillotine" fashion for infection is shocking. But, if you're a surgeon, you can -- maybe you must -- find pleasure in it; and I don't mean some poetic sense of helping one's fellow man. I mean in the actual act of doing it. Which is why I say it's a microcosm. Some things we do are terrifying. And yet, within walled-off portions of the mind, divorced from the suffering of the patient, there's a place to go wherein satisfaction comes from the work itself: the physicality, the artistry, even the transgressive brutality. 
After draping, the leg is all you can see of the patient. With the knee bent, you place the covered foot on the table, and it holds itself in place. Holding in your hand the rough handle of a huge amputation knife, like a skinnier and longer chef’s knife, you reach as far as you can under the thigh and bend your arm back over the top toward yourself, curling the knife blade around the thigh as much as possible. You're going to uncurl your hand and arm, drawing the knife, as deeply as you can, completely around the thigh; slashing -- if boldly enough -- in a single circular motion all the way down to and around the femur. If there were normal circulation, you probably wouldn't be doing this. 
Maybe you've placed a tourniquet of some sort above; or maybe you have a big-gripped assistant who's squeezing the leg between both hands. In any case, once the bone is visible around its entire circumference, and after controlling bleeding, you reach for the old-fashion gigly saw, a gnarly wire with handles at each end. As someone steadies the leg, you place the wire under the femur, grab the handles and stretch the saw nearly straight. Draw it back and forth, fast, making the barbed snake rise through the bone, which it does with surprising ease. It's a whirring sound, more than grinding -- high-pitched, err err err err. White until you get to the marrow, the fragments coming off are like gruel. And then the wire springs up with a bit of a splatter as it rises through the top. Start to finish, it's been only a couple of minutes. (History asserts the fastest such amputation, done in a few seconds, included the removing of a couple of the assistant's fingers.) 
It's awkward lifting the leg off the table and handing it away. The balance point is hard to find. There's awareness of mutual discomfort in this act -- in the giving and the receiving. (A gallbladder plops into a pan, free of emotion. Handing one person the leg of another: that's an exchange for which there are no words.) It's a relief to return gaze to the stump: concentric and clean. White bone, red muscle, Betadined brown skin. The anatomy, on end is, yes, beautiful: hamstrings, quadriceps, neurovascular bundles; a sight allowed only to a few. 
Before the operation, there's been pain -- physical and emotional. There've been sad talks, bargaining. Nothing to feel good about, for anyone. After, there's the stark realization, the encouraging words that ring hollow. The relief -- mine -- of turning much of it over to rehab specialists, prosthetists. But there, for that few moments in the operating room, there's a separate, private, and possibly unspeakable pleasure. (And I must say the same can be said about other amputations I did throughout my career, hundreds and hundreds of times, as a breast cancer surgeon.) The dissociative and dramatic doing. The fact that, for a while, I can remove from my consciousness the horror and find enjoyment in my craft, can find beauty in ugliness -- that's something almost too terrible to admit, even now.



10 comments:

Oblio said...

Tough but honest... thanks for sharing this slice of reality. I totally get it.

Dr Strangelove said...

Thank you.

Having watched "Mercy Street" on PBS and seen the leg amputation scene, it's a little surprising that your brief, contemporary description of the procedure, at least the part that you have described, is so similar. We're so accustomed to seeing dramatic medical advances that sometimes place the Dark Ages at only a few years ago.

Three weeks ago I had arthroscopic meniscus repair. I'd had it done to my other knee a few years ago, but that didn't stop my wife from periodically teasing me in the weeks before the operation. She'd ask, "Now, tell me again, when is your operation?" And as my attention shifted to her, she'd make a circular cutting motion in the air with suitable sound affects. "Mercy Street," she reminded with a cruel grin.

I wonder if we'll see a letter to the Herald's editor from someone expressing relief from your political essays. Or from a squeamish reader?

Sidney Schwab said...

Thank you, Doctor.

Sidney Schwab said...

And, moments after reading your comment, Doc, I received this email:

Dear Hearld Editor and Dr. Schwab,

What the hell is going on there? WHY did we need a disgusting and gleeful account of how to amputate a leg? Especially in light of your story on page A3 of local woman Ingrid Lyne getting dismembered with her body parts scattered? SO insensitive and completely unnecessary!

Yes, you gave a warning, which I missed. But WHY do we need this information in our newspapers? This is not news. And the step by step account feels like a "how to" for future nut jobs. I couldn't even read the whole thing because I felt ill.

This was very bad judgement. For both of you. Shame on you.

Allison Wilhelm
Edmonds

Dr Strangelove said...

Unfortunately timing is everything and really all that anyone needs to connect dots. Ms. Wilhelm couldn't read the whole thing, but she still managed to read enough to twist her stomach. I suspect that had she seen the warning it would have been a welcome mat for her anyway. It's so hard to turn away.

I hope to see more of these surgical intermissions that share your insights, thoughts and reflections. It's pleasure and a privilege.

dan said...

I suppose I could submit a piece on the rehabilitation process of an amputatee but I don't suspect Ms Wilhelm is reading the newspaper for a nuanced insight into medicine.

dan said...

As much as an art and science much of medicine is beauty and terror.

Smoothtooperate said...

Part #1


"Mercy Street," she reminded with a cruel grin."

That's hilarious...So is this...

"I wonder if we'll see a letter to the Herald's editor from someone expressing relief from your political essays. Or from a squeamish reader?"

Next thing we know...lol

"This was very bad judgement. For both of you. Shame on you."

Allison Wilhelm
Edmonds

Yikes!

Let's not talk about religious zealots with abortion picket signs my kids get to see without any warning or say in it, twice a day during school season (all year basically). Their warning was walking to school that first day. There are no signs warning us like they do for deer. "Weird people, unreadable pamphlets and gross pictures next 6 blocks". Allison sounds like she touched the burner twice. Just an opinion. I wouldn't go so far to say she's out of touch with reality. I wouldn't say that.

I can't watch the knee surgery documentaries...OK...ANY surgery documentaries. I pass out if I see my blood drawn. So I hold the nurses hand and she talks to me through it all. I live the glamorous life.

I felt ill half way through reading the editors warning. Right on que, my tummy got all rumbley and I got a little wobbly too...Yet I pressed on and somehow made it to the end. Hey, I knew the article was dangerous before I read it. I am better, and smarter for reading it. GO ME!

My kids mom had her leg amputated exactly as Sid described. She completely neglected her diabetes. She died of a massive heart attack at age 39. She was warned, and decided to neglect her diabetes anyway. Now my kids got no mom. I am intimately familiar with people who touch burners more than once.

My kids were all C-sections. My 1st boy was 10 lbs. 8 oz. Our first C-section of 4. The nurses had the sheet up, so I wouldn't pass out. Everything is going smoothly. I am talkin' to mom, she's doin' great. The medical team is talking about the concert they saw over the weekend and other random water cooler yakking. The team suddenly and abruptly goes dead silent. Mom says "Is everything OK?".

I knew the job was dangerous when I took it. But nobody warned me of what I was about to experience.

Smoothtooperate said...

Part #2

I instantly popped up and looked over the sheet, trying to look as if I am without worry and staying as conscious as possible.

I'll never forget what I saw next...
The incision was too small. Broad shoulders runs in the family. They were pulling on his head, trying to get him past the incision. The entire tummy/middle lifted up with every attempt to free Willie. So this thing has it's head, and nothing else is stickin' out. Moms organs laying just outside the spot where all the action was taking place. The nurse jams the turkey baster down Sir Williams throat a few times as the Doc was making the hole just a bit wider. Scalpel in hand cutting very very quickly. Understand...Mom was morbidly obese. Let that sink in a sec...

This is all in about 15 seconds time so far. Before I even had a chance to thing "OK, the worst is over." It got worse...

Willies' head is all I see and he's crying. Que the scary music and you got the stereotypical Alien horror movie type birth scene. Almost simultaneously, a final tug, and out comes my baby boy. As he rose from his happy place, there was a long, heavy stream of Willie's first poo poo pouring directly introduced into the cavity. It was easily a stream 18-24 inches long and Willie is wailing away. Then, from literally out of nowhere, what looked like a 5lb. bag of flour was *Woosh* *POOF* dumped into the cavity.

That whole thing at the end was about 30 seconds. They'd put a F1 pit crew to shame...Anyway...

The team started laughing and I sat back down behind the sheet and said. "Looked pretty routine to me mom, Congo rats" and we cried a bit. Before we knew it, Mom was holding Willie. The end...

It's just my opinion...

Beef is the dirtiest industry on the planet. People don't want to know that. They don't want to know how any meat or fish, food, ends up on their plate. Just ask the "red slime" industry. Simply showing the public how it's made killed the industry. Me personally...I like my burgers and stuff...Red slime and all. I know exactly how it all arrives on my plate.

My point is this...

When it really matters, perspective changes. Everything changes. Most people are stronger than they'll ever know. That's my observation.

April 14, 2016 at 4:15 PM Delete

Dr Strangelove said...

@Smooth -

Thank goodness you added Part #2. I was beginning to worry about the USMC's hiring practices and whether they should add an additional, unconventional blood test.

Thanks for sharing that.

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