By Sid Schwab / Herald columnist
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, surgery 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.
“OK,” 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.
Email Sid Schwab at columnsid@gmail.com.
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