Worries seem bigger when patient is tiny

Editor’s note: Taking a break from politics, Herald columnist Sid Schwab gives an another account from his career as a surgeon, retold from his Surgeonsblog column. A warning: The column discusses surgery and some may consider it graphic, but it provides insight into the work of surgeons and into the marvels of the human body.

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 O.R. 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 2 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.”

Email Sid Schwab at columnsid@gmail.com.

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