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.