Wednesday, September 6, 2023


No politics today. Instead, I’ll try to describe what it's like for a surgeon operating in a potentially disastrous situation. Even being as in command of yourself as you can possibly be, it tests everything you’ve learned, everything you can bring to bear. And, on some level, it’s scary. I’ve been in war, feared for my life. It's not the same. In the OR, it’s worse.

In Vietnam, the odds were with me: nightly rocket attacks; large base, small target. Occasional risky flying. By contrast, potentially ruining or ending the life of someone in my care, having to forge ahead knowing the next move could literally be deadly while having no personal risk at all — that’s a uniquely surgical fear, I think; at risk of making a fatal move, as opposed to having one made at you. Sometimes – not often -- I've failed to save a severely injured person. It feels terrible. But never, unless memory fails, have I caused a surgical catastrophe. If I had, I might have quit.

Once, as a lowly surgical intern, I was holding retractors while a professor struggled to extirpate a large pelvic tumor. I don't remember the details -- probably the ensuing river of red washed them out of my brain. What I recall, though, as if I carry a picture of it in my wallet, is how fast the field filled with blood. That's what happens when the iliac vein is breached: it's big, it's fragile, it doesn't hold a stitch very well. And it's connected immediately to the vena cava, the biggest and fullest of them all.

When you approach any major blood vessel, you want to have wide access to it. You want proximal and distal control, meaning the parts of the vein or artery above and below where you plan to work need to be easily approached, exposed, and ready. Dissected out, maybe slung with rubber loops, to facilitate placing clamps if needed. With a big tumor blocking view, those measures can be impossible.

So the surgeon worked his way around the mass, apprehensive, I assume, about what lay behind. Whether he lost his way, didn't anticipate the anatomic distortion, or just came up snake-eyes, I can't say. But when he lacerated the vein, blood poured out like a prison break, while the tumor prevented gaining control.

I've been there. Forced to deal with an unexpectedly undecipherable mass of indeterminate origin, causing obstruction in multiple areas of bowel stuck to it, adjacent to big vessels. Wanting an easy way to avoid opening the door to disaster, but seeing none. 

"Okay," I'll say. "This could be trouble. Let's take some time to be ready." Start another couple of IVs. Get blood in the room, bring in the cell saver (a device for collecting, filtering, and reusing the patient’s spilled blood). Open up some vascular clamps. And, because I want to eliminate all distractions, I also like to open an emergency pack of silence, asking everyone in the room to stop loose talk and to shut off the music. (Music in the OR is nice, most of the time.)

As tense and demanding as it is, it's also thrilling, if that’s the word -- maybe even spiritual -- to leave behind everything else in the world, and, like a living lens, focus entirely, body and mind, on a few centimeters of space; to have time all but stop. Perhaps paradoxically, despite breath speeding up, aware of rising pulse, and sweat dripping down my sides -- even needing to pause for the ultimate cliché, the wiping of a brow by a nurse (I've dripped sweat into the occasional wound -- safely flushed it away with lots of saline) -- my hands don't shake.

But yes, dissecting my way into the area as carefully, clear-headedly, and patiently as I know how, at an incompletely suppressed level I'm fearful. And although, while in the maelstrom, there's confidence I can carry on as long as necessary (like sound and extraneous thought, physical discomfort shrinks into insensibility) when the tension has passed, physical and mental exhaustion can well up with surprising suddenness. Neck stiff, back aching, hyper-extended knees wobbly and sore. (I stood back once, not realizing a knee had gone numb, and went down like a ton of scalpels.)

I guess there's a sense of accomplishment, but it's more like having lucked out. Knowing, like that day decades ago, it could have been otherwise; wanting never to be in that situation again, it's hard to feel pride. Not in the moment, anyway. Only relief.

Because I believe the way to deal with complications is knowing how to avoid them in the first place, and as hard as I work to do that, I can’t help wondering -- even when pretty sure there was no option -- whether I missed an alternative to skating on such thin ice. I couldn't do it every day.


  1. It takes guts Sid, like defusing a bomb; the difference being, that if you make a mistake, you wont know it, and usually there isn't anything left for anybody to worry about. Very different for you, like when my favorite uncle, my mothers beloved older brother, died on the table during an experimental heart valve replacement, the first ever done at Queen of Angeles Hospital. I watched as the surgeon, in bloodstained scrubs, explained to my sobbing, grief stricken mother, that her brother was gone.
    He had to tell her that an unexpected complication was the cause. He told her that he had successfully installed the valve, before it happened. I questioned, mentally, the wisdom of telling her: The operation was a success, but the patient died! She never stopped grieving.

  2. There was more to the story about my Uncle, and his death during surgery. I have never mentioned to anybody the suspicions I had about the surgeons explanation; my uncle was gone, and what I thought about it would have only made things worse for my mother. The unexpected complication he mentioned sounded very strange: He said it was caused by an "Undiagnosed Liver Problem" The moment he said that, I thought "What Liver Problem"? If his liver was sick enough to cause his death during surgery, wouldn't it be obvious, just looking at his skin, wouldn't his skin color or his eyes, have been a clue?
    I told myself: "You're not a doctor"; but my reply to that was: "But you have a brain, don't you?" But, I was a teenager, and I knew it would do nothing but cause more grief and trouble for my mother and family. So I kept it to myself, all these years. I feel better now that I could tell you, and get it off my chest.

    1. I suppose it could have been a bleeding disorder related to liver function, but for heart surgery you'd expect clotting status would have been thoroughly established.


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