Surgery: The Flip Side (And Trump)

This is gonna be my last newspaper column for a while, but I'll still post stuff on my blog. Sorta tired of pissing into the wind.

Implicit in the ability of a surgeon to do good is the potential for harm. If dwelling on it can be paralyzing, ignoring it is dangerous...  

Imagine being parents of a perfect newborn. The joys and worries of pregnancy have resulted in a beautiful boy. He coos, wraps his hand around your finger as you feed him. You’ve never felt such love.

Then, at six weeks old, your baby begins vomiting, keeping almost nothing down, not gaining weight. Hypertrophic pyloric stenosis, the surgeon calls it, speaking Greek, or Martian, telling you an operation is needed. Like a raw doughnut tossed into a fryer, the circular muscle at the bottom of the stomach has grown, too fast, preventing the stomach from proper emptying. Pyloromyotomy is the curative operation. 

Think of a tight ring over a gloved finger. The aim is to cut and open the ring, but not the glove; to see the glove fabric bulge up through the ring, indicating it's free. But if the fabric itself is pierced, it’s a bad thing. The glove is the inner lining of the stomach, so a hole in it causes leaking stomach contents. 

It’s necessary to divide the entire muscle or the operation won't be effective; too deep, there’s the hole. The local anatomy is tricky, increasing the chance of damage, and everything is tiny. If recognized, a hole is sewn up. The danger is not noticing. That can be deadly. And it’s up to me. 

In a fog of fear, the parents listen. I tell them about the possible problem and what’s done to avoid it. I caution that their child might still vomit for a few hours, but in all likelihood, he'll be home in a day or two, doing fine. They agree, of course. 

There's something outlandishly disproportionate about a little baby on a big table in a huge OR. I could cover the entire person with my two hands. All the machinery, the tools, the drapes, the surrounding team seem grotesquely outsized. It's like a joke, except it's real and the stakes are high. Ignore the reality and focus on the job at hand. Tiny incision, toy-like instruments, fine little sutures at the end. It goes perfectly. 

"S#!t," I say, as the phone jars me awake at two a.m. It’s my usual response, whatever the call. Now a nurse informs me the baby has a fever of 103º and his abdomen is rigid, an ominous sign. "I'll be right there," I tell her, forcing words through my suddenly constricted throat. 

It's easy to describe how I felt, because it happens again whenever I think about it. Had my wife awakened, I’m certain she'd have seen me appear ghost-white. My stomach was acid; my hands were ice. I could barely tie my shoes, those cold hands shaking, not following commands. An algid force gripped my neck; I could hardly swallow. 

After splashing water on my face, I ran to my car. As I drove, hands so tightly on the wheel that they were getting numb, I told myself I'd do whatever was in my power to save the child, whatever it takes. Stay by his side till it was over. And then never, never, ever, ever do a pyloromyotomy again. And if he did poorly, I'd never operate again. This was a baby. Someone's precious baby. 

Not waiting for the elevator, I took stairs two at a time to the pediatric floor, saw the nurses standing by, felt as if a million eyes were on me, accusing and angry. (They weren't. But that's how it seemed.) And there he was. Fussy face flushed with fever, but moving around actively, looking otherwise okay. His belly was soft as, well, a baby's belly. An X-ray appeared normal. Whatever that fever was, it was gone by morning. 

Nearly limp, still shaking, I drove home barely able to control the car, wrung out like a wet sock. Exhausted, I crumpled onto the bed, relieved, but absolutely spent. An hour or so later, I dragged myself to work. And next time a pediatrician called me about a kid with pyloric stenosis, I took a deep breath, recalling that night, and said... "I'll be right there."  

And now, for a sad return to current events, read this eulogy for America. Vote for decency and against Trumpic cruelty in November, or it’s lost. There’s nothing more to say. 
 

It's The Little Things...

Taking a brief break from the horrors of Trumpism, here's my latest newspaper column, ripped (and modified) from the pages of my better blog, Surgeonsblog

Much as I find doing surgery exhilarating and fun, in the back of my mind resides the awareness that it's a dangerous thing I do. A mentor of mine liked to say, "The patient takes all the risk, Dockie." But to harm another is worse than harming yourself. The danger is shared. 

Imagine being the parents of a perfect baby. All the worries of pregnancy and expectations of birth have resulted in a beautiful boy, thriving. Looks like his dad. He coos, he looks lovingly back at you as you feed him. And now he's six weeks old, and you're being told he needs an operation.
Having fed quite normally for the first month or more, the baby is vomiting, more and more forcefully, until it seems he's keeping nothing down, and isn't gaining weight. Hypertrophic pyloric stenosis, the surgeon says, speaking Greek, or Martian. Like a doughnut tossed into the fryer, the circular muscle, the pylorus, at the bottom of the stomach has expanded, but too much, and it's blocking the stomach’s outlet. The treatment is surgery, a fancy word: pyloromyotomy.

As operations go, it's quite simple. You make a small incision on the baby's belly, find the enlarged muscle, and slice into it, split the fibers and spread them apart. Imagine a tight ring over a glove on a finger. You want to cut the ring, but not the glove. You want to see the glove fabric bulge up into the cut you made, indicating it's free. But if you cut the fabric, you've done a bad thing. The glove is the inner lining of the stomach: a hole in it means leakage of stomach contents. You need to cut the entire muscle or the operation won't be effective, but if you go too far, you make a hole. That can be deadly. 

There's something completely wrong about a tiny baby on a big table in a huge OR. I could cover him entirely with my two hands. All the machinery, the tools, the drapes, the surrounding team seem terrifyingly outsized. It's like a joke. We're playing dolls. Except it's real and the stakes are high. As with all operations, there’s a point at which one must put out of mind the surreal transgression being undertaken and just focus on the job at hand. It went well. 

At two a.m. the phone rings. The nurse tells me the baby has a fever of 103 and his abdomen is rigid. "I'll be right there," I tell her, the words barely squeezing out through my suddenly constricted throat. It's easy to describe how I felt, because I feel that way again whenever I think about it. Heart pounding, my stomach was hollow, my hands white ice. I could barely tie my shoes, fingers not following commands. I splashed cold water on my face, made it to my car, raced to the hospital. As I drove, hands so tightly on the wheel that they were getting numb, I was thinking I'd do whatever was in my power to save the kid, never leave his side until it was over. And then I'd never, never, ever, ever do a pyloromyotomy again. And if he did poorly, I'd never operate again. Could I even live? This was a baby. Someone's precious baby.

As I headed to the pediatric floor and entered the child’s room, saw the nurses standing by, I felt as if a million eyes were on me, accusing and hateful. (They weren't. But that's how I felt.) And there he was. Fussy face flushed with fever, but moving around like a baby, looking not so bad. His belly was soft as, well, a baby's bottom. Who knows what that fever was? It disappeared as quickly as it came, and the kid was fine. 

I drove home nearly limp, still shaking, barely able to control the car, wrung out like a wet sock. I lay on the bed exhausted, relieved, but absolutely spent. An hour or so later, I dragged myself to work. And next time a pediatrician called for a consult for a kid with pyloric stenosis, I took a deep breath, considered it carefully, and said... "I'll be right there." 

[The photo, marginally related to the post, really, is of my grandson, a week ago, on his second birthday. Cute, huh?]