So what if I were a manual laborer? Manual labor, whether it is simple
or complicated, can be done well or done badly. There are clever and
stupid ways of digging a hole, just as there are careful and neglectful
ways of putting a person to sleep. A hole digger may do mediocre or
excellent work; it depends upon his technique, his care of the shovel, his understanding of the soil, and the attention he gives to the weather. If he tries to make his work a little better than is required of him, he becomes an artist and is rewarded with more self-respect and personal enjoyment.
But unlike the manual laborer, the doctor-technician cannot really
improve on his work. An anesthesiologist, for example, is expected to put a patient to sleep and wake the patient up, safely. He can do worse—
catastrophically worse—but no better. A healthy, living patient is ex-
pected of him each time. Theoretically, an anesthesiologist should be as
proud of his success in making his operating room into a perfect little
world as a hole digger of his in digging a hole, or a diplomat of his in
organizing a country’s affairs. But the anesthesiologist has no real room to improve or embellish, and no reason to do any more than is necessary.
The hole-digger hand paints a beautiful flower on the walls of his hole,
without any relation to technique, and becomes a free artist, compared to the anesthesiologist, who never really passes beyond the boundary of
technique, and never has any reason to do so.
The doctor-technician is a proletarian and a manual laborer who can-
not even aspire to art, I concluded. Was this to be my calling in life? I rolled over onto my side and groaned.
I looked again at the Vermont picture. At the margin a man and wom-
an held hands and looked into each other’s eyes while standing in a field.
I imagined them speaking to each other, their voices quiet, offering up
declarations of love. Through the haze of my mind I pictured the glitter in the woman’s questing eyes as she spoke, and the man’s half-closed eyes
that gleamed when he listened. I tried to imagine their interior lives. It was an odd feeling—to be using my imagination in the hospital, that is. I realized I hadn’t been compelled to do so for most of my time in medicine. Every day on the wards I would memorize, reason, calculate, and
estimate. I would think with my hands and manipulate objects that had
weight and resistance. I would think with words and manipulate sounds
and symbols to communicate a point or to prompt another person to act.
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C H A P T E R 3
But none of this is the same as using one’s imagination, where one leaves the actual world and ruminates and meditates. This may surprise, as professional medicine calls the practice of medicine an art, and art demands imagination.
Herein lies professional medicine’s great mistake. Medicine is an art.
But professional medicine confuses artistry with craftsmanship and em-
phasizes the latter, while only the former requires a person to be able to imagine another person’s interior life.
The work of the artist is at once like and unlike that of the craftsman.
Both must possess a technical expertise that can be acquired only by
careful study, practice, and experience. Both the artist and the craftsman must achieve a precision of touch that enables him or her to perform a
task with rapidity and complete success. During my residency, for exam-
ple, I would often marvel at how fast some heart surgeons could sew in a
coronary artery bypass graft. They could do so within minutes because
they had been doing this all their lives. But the acquisition of technical expertise, which is essential to the craftsman (and to the monkey), is only a part of the work of the artist. The artist must pour something of himself, of his experiences, into his labor. A composer, for example, knows the
form of the symphony, but he also pours his soul into the symphony. In
other words, the artist, unlike the craftsman, must have lived.
So must the doctor. The doctor’s life includes the actual technical part, but it also includes an imaginative part that teaches him what people are like, as well as a meditative part in which he chews the cud of his past life in order to transform his knowledge of people into medical decisions.
This makes living, reading, and conversation as necessary for the doctor
as learning technology.
I flicked off the light switch and lay back down on my side. I gave
myself the freedom to imagine the girl in the picture. I wondered what
she was like. For a young heterosexual male doctor alone in an on-call
room, nothing is more desired in the middle of the night than a woman to
share his bed, to caress him, to rub his leg with the soles of her feet. I began to imagine a pretty woman I had known in college, her way of
fixing her hair, her smile. I felt a sudden yearning, and the effect of her memory on my body startled me. All these thoughts bombarding my
consciousness exhausted me. But now, rather than welcome sleep, I
fought it, eager to pore over old memories. Eventually, losing the strug-
gle, I dozed off, my wakeful dreaming merging into semi-conscious hal-
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lucinations. I imagined a pretty woman alone, standing amid Vermont’s
blindingly brilliant autumn foliage, surrounded by the murmurs of the
forest, the white, wind-driven clouds overhead. She was wearing a simple
cotton dress, her hair was long and flowing, strands pulled back on each
side in wings and held together by brown barrettes. My heart trembled
with gladness; I wanted to run to her, but my strength failed me, or
something restrained me, and the most I could do was move in little
spurts. Her image began to fade, and I wondered how I was going to live
in this forest alone. An invincible terror took possession of me. I strained harder; I prayed to whoever was holding me for mercy, groaning and
cursing.
Then my beeper stuttered insistently and angrily.
The real world was calling. Time to get up. . . .
I called the number on the screen. It was the emergency room. The
doctor on the other end of the line said that a patient was having difficulty breathing and might need to be intubated.
I went to evaluate her. The woman was in her twenties, thin, and
wearing a party dress. She had asked her friend to take her home because
she was feeling feverish and her throat hurt. While in the car she grew
short of breath, so her friend made a quick detour to the hospital. When I met her she was sitting bolt upright in a tripod position, her head leaning forward and her arms extended in front of her, her fists bracing against
the gurney. All her energy was focused on getting air into her lungs; even her saliva was ignored, as she let it drool down the sides of her mouth.
Her eyes were unmoved, unseeing, and inexpressive. When I introduced
myself a look of helpless bewilderment passed over her face in a sort of
anxious spasm, making her sentient for an instant, only to return again to that look of dumb amazement.
Her symptoms suggested acute epiglottitis, where the inflamed organ
sitting above the windpipe blocks air from passing into the lungs. This
confused me, as I thought epiglottitis was a disease of children. Nevertheless, an X-ray of her neck confirmed the diagnosis. The situation was
urgent. The woman needed to have an artificial airway established in the
operating room before the inflamed tissue c
losed off her windpipe alto-
gether.
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C H A P T E R 3
When I went upstairs and told Dr. C about the case, he turned pale and
looked at his watch. It was five o’clock in the morning. Perhaps the case might be delayed until seven, when the regular day would start and more
staff would be around, he wondered out loud. I rolled my eyes. Then he
pulled himself together and announced the plan:
Acute epiglottitis is usually a pediatric problem, he noted. Therefore
we would apply the strategy that pediatric anesthesiologists use in such
cases. We would breathe the woman down with anesthetic gas; when she
was deep enough, we would intubate her. To be safe, we would have an
ENT surgeon around, ready to open a hole in her neck in case the airway
closed off altogether before the tube could be inserted.
A modest plan, but in retrospect it was not realizable. Again, Dr. C’s
error was to copy pediatric anesthesiologists at all points and not dare to stray. Our patient exhibited stridor, meaning she made a vibrating noise
with each inhalation because her airway had narrowed. Because a child’s
airway is already narrow it takes only slight additional narrowing to cause stridor; hence the endotracheal tube size needed in a stridorous child may be only slightly less than that needed in a healthy child. Moreover, the
alternative to intubation—placing a hole in the windpipe directly through the neck, a procedure called tracheostomy—is fraught with post-operative complications in children. This is why pediatric anesthesiologists
prefer to intubate children suffering from acute epiglottitis. Stridor in an adult, however, indicates a high degree of narrowing. The normal adult
airway is fifteen to twenty millimeters in diameter, but an adult will not exhibit stridor until his or her airway is less than five millimeters in
diameter—a large drop in cross-sectional area. Only a tiny breathing tube relative to normal size can pass through a stridorous adult’s narrowed
airway, leaving the adult with the impossible task of breathing through a thin straw. Much safer to let a surgeon carefully and methodically place a wide-bore tracheostomy in an adult’s neck while the adult is still awake, especially since adults suffer fewer postoperative complications from
tracheostomies than children do.
But Dr. C wasn’t thinking that way. He was a pseudo-technician try-
ing to mimic a real technician. He was a monkey on the wrong stage.
Although he had a plan, Dr. C showed signs of uneasiness. Instead of
waiting calmly for the moment to strike, he did his utmost to avoid it, to put it off and to keep it at a distance from him. When the ward clerk asked him if she should send for the patient, Dr. C said he needed more time to
T H E T R A P O F O V E R S P E C I A L I Z A T I O N
4 7
set up the operating room. When the nurse finished sterilizing the instruments, he told her to run them through the autoclave again, to be safe. He was trying to run out the clock; he was trying to get to 7 AM. His instinct for self-preservation was strong. It is the same instinct that fills a man sentenced to death with hopes that are not destined not be fulfilled. Dr. C
kept looking anxiously at his watch, as if expecting it to save him. He
seemed to know that his expectations were in vain, but he waited all the
same.
The patient arrived. The ENT resident arrived a minute later. He was a
good-looking young man with that look of self-satisfaction and conceit
that senior residents are often more likely to exhibit than to deserve. He stood near the operating room table with a bored air. When Dr. C asked
him whether he was ready to place a tracheostomy quickly, he replied,
“Of course. No problem.” I detected something of the patronizing attitude of the expert standing above the rest of humanity in the tone of his reply, which was jarring, since he was a resident, as was I, but Dr. C either
failed to notice it or simply overlooked it.
It was Dr. C’s second mistake—again, the mistake of the craftsman,
not the artist. Dr. C was obsessed with technique and ignorant of what life experience should have been screaming to him about this young man:
how this young man had yet to lose the freewheeling habits of his student days; how he had retained the urge to brag, to feign omniscience, and to
conceal with casual aloofness any personal doubts about his abilities;
how this young man proudly felt he was not like other young men. I
recognized the personality from my college years: mental laziness com-
bined with a rapscallion’s hope that “something always turns up, not to
worry.” The young man could not be taken at his word! But Dr. C failed
to take his measure and wrongly put his trust in him.
We put the woman at a forty-five degree angle on the operating room
table. She made a long and melancholy cry with each inspiration. The
sound seemed to arise from the very depths of her being. As the nurse
prepped the neck, the woman fixed her eyes on the operating room light
overhead, as if thinking here was the center, the focus around which the
world gravitated. She was oblivious to the activities going on around her.
She seemed to know only that something strong and bright, but less bright than sunny warmth, swept her face, and that she needed more air.
I placed the mask on her face and turned up the gas. Gradually, the
anesthetic tugged at her consciousness, inducing forgetfulness, lassitude.
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C H A P T E R 3
Then came darkness, deep and impenetrable, weighing heavily on her
brain. I thought she would be resigned to the darkness, to be almost
grateful for it. But she was not resigned. There was some instinct in her that desperately craved freedom from the blackness. Although unconscious, she snapped her head from side to side. She reached for the mask
with an arm I had forgotten to tie down. She defiantly withheld her
breath.
Finally, she settled down. Then I looked inside her mouth with my
laryngoscope. I saw only red, angry-looking tissue. I could not find the
hole where I needed to insert my tube. I asked Dr. C to bang on the
woman’s chest to send a small air bubble out of her windpipe, to act as a beacon. I confidently placed my tube at what I thought was the exit point.
But my monitors quickly told me that my tube had gone into the esopha-
gus and not the trachea. Dr. C furiously pushed me aside. His eyes darted back and forth, disturbed and restless. He tried to intubate the patient but failed. He tried a second time and failed again. Three attempts at intubation had irritated the woman’s already inflamed epiglottis, further nar-
rowing the hole she had to breathe through. Nevertheless, air still
squeaked through.
This is when the catastrophe occurred—a catastrophe that followed
directly from Dr. C’s misunderstanding of what a doctor is. Professional
medicine says a doctor is a craftsman, a technical expert. Therefore, Dr. C
assumed, a good doctor must be a good craftsman who can perform a
craftsman’s technical tasks. It would be a failure of doctoring not to do so, he believed. It was on such thinking that one more attempt at intubation hinged. Dr. C could have ordered the ENT resident to start work on a tracheostomy now, while the woman was still breathing. That way the
resident could have taken his time. But Dr. C was tempted to try one more time to intubate, to prove to the whole world he was a doctor.
I have watched this mind-set operate in other venues. Anesthesiolo-
gists, for example, are keenly conscious of who is superior in the art of spinal and epidural anesthesia. When an anesthesiologist successfully
places a spinal needle in a patient after another anesthesiologist has
failed, the failed anesthesiologist feels like a man unable to consummate his marriage. He feels impotent, he can’t penetrate, he can’t get the thing in, and another man must do it for him. He endures a serious challenge to his manhood, and although he appreciates the other anesthesiologist’s
help, he also hates him for succeeding.
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This mind-set is especially dangerous when it involves intubations.
The egos of some anesthesiologists are tied up with being technical wiz-
ards. Because they associate being a doctor with performing a procedure,
they will jam a breathing tube inside a patient’s airway again and again, determined to get the tube in, causing so much throat swelling that the
patient suffocates. I am familiar with several such patient deaths around the country.
It was on this mind-set that our patient’s life hinged. Already shamed
by his lack of pediatric anesthesia expertise, Dr. C was determined to
salvage his reputation by accomplishing a more difficult trick: intubating a patient with acute epiglottitis. “There was a man!” he imagined the
crowd would roar. In fact, there was a monkey. He placed the breathing
tube in the woman’s throat a fourth time. When the monitors proved
again that the tube was in the wrong place, he quickly removed it and put the mask over the woman’s face to let her breathe oxygen and anesthetic
gas, but now she was completely obstructed. Instead of her chest rising
when she tried to breathe, it sank. Within seconds her color grew dusky.
All of us knew instinctively that death was close. Dr. C barked at the
ENT resident, “Do the trach!”
The resident’s face grew white as a sheet. “Okay, but you know, I
actually haven’t done this before . . .” he pleaded.
Slowly, as if trying to remember the illustrations in a textbook, the
resident cut the delicate throat with a scalpel. The more layers he pene-
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