A Column In A Different Vein

My latest newspaper column. Took a break from the horrors of Trump, re-tooling one from Surgeonsblog days.

Never, after doing thousands of operations, did my awe and amazement at the human body diminish. Nor did I ever take for granted the gift I’d been given: trusted by another to breach, in the most literal sense, the boundaries between us. From the simplest office procedure to the most complex of operations aimed at defeating some horrible disease, it was hard not to stop in the middle and wonder at it all. 

Nor did I think being a surgeon conferred status higher than my patients. I had the opportunity to learn to operate and to take care of surgical patients, and I committed to it (at the expense of family time) above all else. Many of my patients could have done the same. Recognizing how rare is the privilege, how great the responsibility, granted entry to the body’s secret spaces, I’ve tried, on my surgery blog and elsewhere, to share it. 

Modified below is one of those efforts, respite from the compulsion to address the political horrors to which we’re being subjected daily; from the frustration that pointing it out is invariably greeted by Trumpists as fake news, responded to with absurdities (“It was warmer millions of years ago, libtard!”) Revisiting my surgical writing reminds me there was a time when it made a difference. So:  

The inside of a vein is perfect. No matter the state of the rest of the body, when you open one it's smooth and shiny. The inner wall glistens, lavishing the eye with a creamy khaki surface. Not that it's common to get into one on purpose: but for things as minor as a cut-down (directly opening a vein to insert a large IV), or as major as a portal vein decompression (a finger-in-the-dike procedure to stave off the effects of cirrhosis of the liver), the lumen of a vein seems impervious to the ravages going on around it. It's like searching a house stacked full of junk and finding a hidden closet, empty, clean, sparkling. A private, preserved space, kept pristine against the odds. (Arteries, not so much.)  

Bile ducts, too, if less certainly. When there's obstruction, or with infection, they get swollen, sticky, and thick, the inner surface knobbly and cobbled. Mostly, though, it's a similar wonder: crisp and shiny on the inside. There's something about these specialized tubes that fosters their own brand of admiration. Springy and soft, yet turgid and tough. Sewing a vein, unlike anything else, (as long as it's not during a mad rescue attempt) is almost meditative. Their thin, fragile walls demand particular concentration. It's quiet work. The suture is finer, the instruments more delicate than typical needle-holders. Sewing requires the perfection of needlepoint: evenly-spaced bites, close, careful, exact. With such concentration (true of all surgery, but especially here) the rest of the world drops away for a while.  

There's rubbery resistance to the needle, which gives way with a little recoil. No tissue is quite like it. If creating, say, an arteriovenous fistula for dialysis, or sewing a vein patch onto a narrowed artery, you go through the vein first with the needle, and the textural difference is striking. Sometimes you hold the slender suture between thumb and index finger of one hand, propping the pinkie for stability, gently tugging upward to tent and approximate the edges, while suturing with the other. Or maybe your assistant holds the suture, and you a pleasingly extra-fine forceps. When you release flow, the vein bulges, and holds. It’s satisfying.  

With a bile duct, you might be closing a previously-made access hole, sewing edge to edge. More often it's to make a connection between duct and bowel, and the two couldn't be more different. (If they were, you probably couldn't connect them at all.) Then, it's more of a puzzle: putting together two structures of entirely different thickness and texture, one of gross and separating layers and another of imperceptible ones. It's a challenge with its own rewards, but not the quiet kind that veins provide.  

A vein, laid open but stilled of flow. A silky surface even when lying next to corporeal corruption. It's not a big thing, really; but seeing it on those rare occasions is somehow reassuring. A signal that things might be made right. If one place in this person is still okay, maybe we can help the rest to get there.   

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From My Better Blog

For irrelevant reasons, I've recently re-read a series of posts I wrote several years ago on "Surgeonsblog," wherein I tried to describe, in as much detail as possible, what goes on in an operation. Some of it is pretty good stuff, and, based on comments, it was entertaining and informative. There was a time when I could be that way.

So, shamelessly, to those who have more time on their hands than they know what to do with, and who may not yet have discovered the pleasures of a surgery blog written for laypeople, I recommend reading it.

It starts here. You need to scroll past the comments at the end to get to "newer post" on which to click to get to the next one. There are nine of them; be warned. Also, being old, most of the links no longer work, but it doesn't matter all that much.

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Stab Wounds

My latest newspaper column, to be published Saturday. Since it has to be sent in before the inauguration, I didn't want to rant about something that might be contradicted by events yet unknown.

Here’s another heavily modified piece from my surgery blog. Entering the Trump era, I need time to let it sink in.

When I picked up my laundry I’d have a little small talk with the proprietor. She always called me "Doctor.” This time, though, she was notably distant, which I didn't understand till I got home and hung up my jacket. On the inside she'd pinned an envelope, into which she'd put a photo taken months before, forgotten in one of my pockets. 

What it showed was a young female torso bearing sixteen stab wounds and the handle of an 8-inch butcher's knife in-stuck to the hilt, a couple of inches below her left breast, ticking, when the picture was taken, with every heartbeat. She’d tried to make herself the second person she killed that day. A cop had accompanied us to the OR. 

Worried that I could cause a catastrophe if I did it blindly, I hadn't removed the knife in the emergency room; the officer needed to maintain "chain of custody." I opened her belly first: with stab wounds to the lower chest, it’s likely there are injuries within the abdomen. Indeed, the knife had skewered her stomach, barely missed her colon, stopping with its sharp edge whispering to her spleen. Holding the spleen out of the way, I withdrew the knife, handed it off to the cop, cool as Steve McQueen: calmly cutting the lady open in front of the officer, handing him the weapon like I did it every day. He tagged it and bagged it, like he did it every day. 

As I attended to the abdominal injuries, the anesthesiologist announced blood pressure zeroing out, cardiogram widening into a functionless sine wave. In the ER, I’d treated her punctured lung with a drainage tube. Now I guessed she’d nicked her heart as well. With no time for tidy entry, I made a fast and ugly, trauma-center-trained, trap-door opening through her ribs. Expecting a blood-filled pericardium, the sac around the heart, I opened that, too, carefully, despite the urgency, to avoid paralyzing the nerve to her diaphragm, which runs along its surface. 

A cut lung can allow air into the pulmonary veins, through which it returns to the left ventricle of the heart, wherefrom it gets pumped out to the body. Departing first from the aorta are the coronary arteries; an air bubble there acts no differently from a blood clot, potentially causing a heart attack. The next exits lead right to the brain. 

While requesting (or screaming, I don’t recall) that the anesthesiologist tilt the table head down so bubbles would rise away from our patient’s head, I clamped the aorta downstream from the vessels going there, called for drugs to raise her blood pressure as high as safely possible, and to run 100% oxygen (in addition to protecting tissues, it speeds up absorption of air). Raising blood pressure might force the bubbles through her heart before doing permanent damage. Clamping the aorta raises blood pressure as well. It's a dangerous combination of maneuvers, but as they say about desperate times... 

Indeed, bubbles were moving through her coronary arteries, lined up like ticket-holders to the Stygian boatman, as frightening a thing as I’ve seen, operating. But, as hoped, they marched on through, and I began, incrementally, to release the clamp; now she was able to maintain her pressure, as she hadn't before. Without obvious signs of brain injury, she awoke later in the ICU, her cardiogram returning rapidly to normal. Sixteen stab wounds, a near-fatal cardiac emergency: not a single after-effect. 

Being young, before experience ground such misconceptions away like centuries of sea on stone, I figured, having rummaged around in her entrails and having held her heart in my hand, squeezing it alive, I of all people should be able to get through to this lady, humbly receiving her gratitude while clearing the demons in her mind. Well, of course, no. Neither could the psych consultant. 

I’d taken that graphic and ill-forgotten picture thinking I might use it in a lecture or an academic paper on penetrating chest injuries, but never did. I kept taking my laundry to the same place, never mentioned the envelope, and our conversations soon found their way back to normal.   

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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?]