by Cap Lesesne
“Pump on,” said Shumway.
The bypass pump whirred on. The bleeding stopped.
A machine was now pumping blood to the outer vessels of the patient’s heart, although the amount needed to replace what had been lost was staggering.
Plus, the heart was still damaged. If it wasn’t repaired soon, the patient would never leave the OR table alive.
Dr. Shumway called for a 4–0 prolene suture. The scrub tech had already slapped the right suture into the doctor’s palm. Dr. Shumway, the smoothest surgeon I have ever seen, deftly began to repair the torn heart with the two prolene sutures. His fingers were moving fast, back and forth, back and forth, gently, sewing, tying off perforators. The concentration and skill were incredible. Alex and I stood motionless. Dr. Shumway’s fingers kept moving.
Finally, they stopped. Shumway barked, “Vein.”
Dr. Shumway took the vein he was handed, cut it for the right length, and performed a three-vessel bypass.
Once he completed this job, it was time to get the patient off the bypass machine and restart his heart. The doctor called for potassium and medication and now the paddles, and he was telling us all to stand clear so we didn’t get electrocuted. He placed the paddles directly onto the patient’s heart.
Boom!
Buh-bum. Buh-bum. Buh-bum.
The banker’s heart was going again.
Dr. Shumway had no change in expression.
“Next case,” he mumbled, and left the room.
Alex unfroze. He would go on to become one of the great heart surgeons in the Deep South.
One week later, the doors to Stanford University Hospital whooshed open and a banker – a leg vein now running from his proximal coronary artery to the base of his heart – walked out into the California sunshine.
My very first operation as a resident.
What’s important in life?
To help people not die. That’s one. But you see people die all the time. Old people, young people. Teenagers, pregnant women. There’s no justice to it, no value system, no right, no wrong. They just die. Bad genes, bad luck. You don’t know what to make of it. You’ve seen it happen like this before, in bulk, and then it involved children, lots of them. Do you get used to it? Does anyone? You were raised Anglican, went to Sunday school; throughout boarding school and college you attended church. You’re not sure what you believe. You’ve read the Bible, the Torah, the Koran, the Bhagavad Gita.
People keep dying.
When you see death day after day, you have to do something positive with it. You help people, yes. Well, that’s good. Keep them from dying too soon. Keep them from living with sickness, from living too unhappily. Good.
But what about for yourself? How do you keep from losing it? How do you keep despondency at bay?
You cultivate a healthy appreciation that every day is special. You appreciate that every day may also be your last.
Welcome to the life of a medical resident, cardiac rotation.
Tory, my girlfriend of five years and in her first year of law school at New York University, said she wanted to get married.
I told her I wasn’t ready.
We broke up.
A year later, she would marry someone else.
Nasty Surgeons, Not Enough Sleep, and Other Myths
At Stanford, as at all surgical residency programs, my plastic surgery rotation consisted almost entirely of work and training in reconstructive, not cosmetic, surgery – hand surgery, head and neck reconstruction, postorthopedic-surgery reconstruction to cover exposed implants. Later, I would need to learn the nuances of cosmetic surgery, of course; I couldn’t expect to really understand spatial dimensions, 3-D relationships, skin thicknesses, and anatomical planes until I’d done more face-lifts than I could count.
But I was in my surgical residency, first and last, to learn what it takes simply to be a good surgeon.
Watching and working with great surgeons, I was learning what their common traits were. They were decisive. (Outside the OR, surgeons are often reflective and even filled with self-doubt; in the OR, they’re decisive.) When a problem arose, there was no dithering. Before you blinked, they were already working toward a solution, or taking a different approach. Their hands were always moving. They knew the ins and outs of the procedures and they were technically skilled, of course, but, of equal importance, they had a suppleness and resourcefulness of mind to take a different course. Like great chess players, the most skilled ones had plotted their actions several moves in advance. Over the years, watching them at Michigan, Duke, Stanford, and several New York hospitals (among others), I have always marveled at and appreciated the great ones.
You could say they’re hyperconfident and sure of themselves. Cocky and arrogant, even. You almost can’t help being that way. First, surgery tends to attract the most alpha, testosterone-fueled of an already alpha group, doctors. (Of the twenty-four plastic surgical residents in my six-year program at Stanford, three were women. I don’t know how much of the scarcity of female surgeons is systemic bias, how much is self-selection, how much is other factors. ) Second, what we do is pretty mind-blowing, if you think about it. Every once in a while, while operating, I’ll catch myself thinking about how odd, how unnatural, it is to do what I do: I’m taking a knife to someone, she’s bleeding, there’s her fat, there’s her muscle…In my first weeks during my plastic or otolaryngology surgery rotations at Stanford, when I might be operating on patients with cancers, my momentary, out-of-body ruminations were even more sobering: His life is in my hands.… If I screw up, he could be seriously injured … or I could kill him.…It’s a weird, unique, complicated, ultimate thing we surgeons do.
Confidence entered me sometime after I’d done a thousand of a given procedure. To me, confidence simply means an awareness that I’ve put in the work, that I know my abilities and limitations, that I appreciate medicine is both a science and an art, that I’ve done all I reasonably can to protect the patient and myself against the unpredictable.
I have also watched surgeons who shouldn’t be surgeons. They delay. They are unprepared. Often, they’re the cockiest of all. (Unlike the rest of us, they’re not constantly terrified that something might go wrong.) When you think you know everything, you don’t train as hard. Or you get sloppy. I know of a self-righteous, quick-to-pontificate chief of surgery who felt he didn’t need to be in the OR in the moments before performing a hernia repair – a common, generally uncomplicated operation. Instead he was drinking coffee in his office while his thirteen-year-old patient was being anesthetized. The anesthesiologist, alone in the OR, lost control of the patient’s airway. While inserting the endotracheal tube (for breathing), the anesthesiologist couldn’t quite see where it was going. A laryngeal spasm ensued and the patient’s oxygen level dropped, initiating a disastrous sequence that culminated in the boy’s cardiac arrest and death. Had the surgeon been in the OR, he could have performed an emergency tracheotomy, something all licensed surgeons learn our first year as interns.
The thoughtful doctor, on the other hand, the one who knows the stuff cold but also realizes his or her limitations, tends to train harder, tries continually to learn, and is willing to entertain a wider range of treatment possibilities (and is more likely to treat you, not the symptoms). Because the thoughtful doctor prepares better, he’s more likely to pick up mistakes before they manifest themselves, thus avoiding them. In what amounts to an irony, then, the more modest doctor, the one who can imagine his own fallibility, will probably end up being regarded as more infalliable by grateful patients and staff than are doctors who ooze self-assurance.
There were several surgical and medical myths whose truth (or not) I was beginning to sift through. For example:
Surgeons are emotionally detached, even nasty.
Largely false – except for surgeons who specialize in cancers and are notoriously cold, not because they’re innately misanthropic but because they see so many people die. It’s a well-circulated o
pinion among surgeons that urological surgeons are easily the nicest among surgeons, and cardiac the most intense. Plastic surgeons are often called the “fairy surgeons” – mostly because our surgery is more aesthetic and largely elective, and non-life-threatening. We’re more artistic. And there tend to be, by my observation, more gay surgeons in plastic surgery than in other surgical disciplines.
Surgeons, particularly plastic surgeons, are in it for the money.
Some are, of course; most are not. It’s simply too brutal a life to do it primarily for the money. Dan Baker, a well-known New York plastic surgeon, told me he works harder now, in his mid-sixties, than he’s ever had to work before. We see each other walking to the local Starbucks at 6:30 A.M. on a Sunday – and that’s after we’ve seen our patients.
A nice office suggests a successful practice and a good doctor.
Plastic surgeons in particular are guilty of turning their offices and waiting rooms into palaces (gorgeous fish tanks, flower collections), often because they feel that their wealthy clientele expect it. Dr. Joseph Murray, a brilliant surgeon and the only physician ever to win the Nobel Prize for Medicine, had benches in a hall outside his modest office.
If a surgeon does lots of operations a day, he must be good.
Volume is not indicative of quality. There’s a balance between being quick and facile, on one hand, and really understanding the operation, on the other. When surgeons routinely take longer than usual to complete standard operations, it probably means they’re not as sure and prepared as they should be. I’ve heard women boast about how their plastic surgeon took seven and a half painstaking hours to do a face-lift, suggesting that he was especially careful. To me it suggests he’s probably not very good. The best plastic surgeons are neither too fast nor too slow.
The number of papers published or prestigious titles (e.g., department chair, medical society president) suggests a good doctor.
Not necessarily. In fact, there may be an inverse relationship. I have met several surgeons who published papers so often, they scarcely performed surgery anymore. That might not be a doctor you should go to.
Good doctors know a lot.
No – and yes. That is, we do know a lot – but about very, very little, and that area of expertise narrows over time, for two reasons: One, doctors get older and more experienced; two, the field of medicine becomes ever more specialized. I have come to know a great deal about the face, millimeter by millimeter, but less and less about hand surgery, a specialty that I, as all plastic surgeons, was trained in.
Residents (and interns and medical students) are so sleep-deprived it compromises their ability and particularly their judgment.
Myth – not that they’re sleep-deprived, but that they can’t function on little sleep. People make too much of this one. Yes, you can be exhausted and your thought processes change, but you compensate. When you work in a hospital, you cope. I’ve never failed in a case because I was tired, and God knows, as a resident I operated tired. You teach yourself to recognize when you’re too depleted. Hospital training is excellent for teaching residents that at the slightest sign of uncertainty, they should always seek backup. Or delay the procedure. Because this idea was beaten into my brain for years, now, in private practice, if I’ve been operating all day, and I don’t feel well or alert, and another operation awaits, I know to reschedule. Patients understand. As for being on your feet operating and concentrating sometimes for five, seven, ten, even sixteen hours at a time: It’s not a problem. You’re so focused on the patient and what you need to do, the body and mind transcend fatigue.
These are just a few lessons I’ve learned in medicine.
The invasive cancer had wrapped around the patient’s left carotid artery, threatening to slowly reduce the blood flow to the brain – in essence, to strangle it. (The left and right carotids are the two main arteries to the brain.) If I was one millimeter off, I would puncture the carotid, which would cause massive, rapid, gushing bleeding, and I would wipe out half his brain, paralyzing or killing him.
To get control of the cancer, I worked around the normal tissue to get at the abnormal tissue. I removed the left maxilla – the cheekbone – only to find that the tumor had invaded the back of that. I kept dissecting tissue, sending it to the pathology lab, and results kept returning with the phrase positive margins – that is, the cancer was continuing to show up. Without getting a result of clear margins, the patient would die.
I had yet to find the end of the cancer’s incursion. I removed the patient’s whole left face (essentially) to see that the tumor had infiltrated all the way to the base of his brain. I started going deeper, millimeter by millimeter, using scissors to cut away soft tissue, a drill with a bur when I needed to shave bone.
You know, if I screw up at all I thought, this will be very, very bad. I will kill him.
Finally, I got a pathology result of clear margins.
I leaned back. This was much bigger than I had anticipated. Now I had to close the hole in his face.
How the hell was I going to do that?
My thoughts raced through what plastic surgeons call “the reconstructive ladder.” The first option is simply to close the skin. I couldn’t do that here because too much was missing.
The second option is to apply a skin graft, usually taken from the leg. I couldn’t do that either, because the skin graft wouldn’t take to bare bone, and he was missing too much tissue.
The third option is a flap – which means to rotate skin, fat, and usually muscle from somewhere else on the body. In his case, I decided on a delto-pectoral flap from the chest.
Eventually, a couple short years after feeling inept, after having no confidence as a surgeon, I’d found it. Over time and numerous procedures, especially more complicated surgeries, I’d found it. Mentors covered me less and less. The responsibility and complexity of what I was given to do kept growing. No longer was I doing an appendectomy or taking out a superficial lipoma. One day I realized simply that I was now the one with the high-speed drill in my hands, I was the one screwing plates on to close a fractured cheekbone, millimeters from the eye. One slip and I was the one who would puncture the eye and blind him.
With each pass of the drill, I moved faster, smoother, totally in control. I was no longer scared.
In the 1980s, the Bay Area was a hotbed for sex-change surgery, and I operated on transsexuals at Stanford. Only I didn’t know it. At least not the first time she – he – was under my care.
Mary Lou came to the Stanford Clinic with an infected breast implant. She was the first breast implant patient I’d ever seen. I looked at her in the examination room, with an attending resident present. Mary Lou described her problem. I prescribed antibiotics and told her we’d probably need to replace the implant.
As I walked down the hall afterward, a group of senior residents surrounded me, laughing.
“Clueless,” said one.
“What?” I said.
“What’d you think of Mary Lou?” one of them asked me.
“What do you mean?”
“Well,” said one of them, “would you ever date her?”
“Huh?”
“Would you date him?” said another.
“What are you talking about?” I asked.
“Cap,” said the first, “exactly how clueless are you?”
Very. Had they not chided me, I would never have known that she was in fact a he, probably in the final stages of sexual reassignment, prepenectomy.
The more senior residents would play a joke on interns. We’d all go to a Palo Alto bar popular among many groups, including postoperative transsexuals. The residents would buy a few beers for the intern, then elbow him to hit on one of these great-looking women – and some of them were truly great-looking. The poor intern was as clueless in that trannie bar as he was his first time in an OR.
In fairness to the residents, they always yanked the intern away before things went too far.
At least, that’
s what I was told.
Our parotid glands are just in front of and below our earlobes. They secrete saliva into our mouth. For the plastic surgeon, they are particularly important because they wrap around the nerves that move the muscles of the face.
The attending surgeon, nurse, patient, and I were in the Veterans Hospital in Palo Alto. Millimeter by millimeter, I was removing a superficial (closest to the skin surface) lobe of the parotid, a gland full of invasive cancer. All surgery requires concentration, of course, and can turn disastrous if one misses by the slightest amount – too deep, too far right, too far left. But this operation was more than usually treacherous. Total and permanent facial paralysis awaited just this side of a mistake.
The attending surgeon walked out for a moment, and it was left to me to dissect out the nerve away from the tumor. I was focusing as hard as I possibly could; still, I sensed something weird going on, though I hardly registered what.… Had the table just hopped? Was I trembling? Was I more exhausted than I thought? Physically, emotionally? No, I felt fine, or thought I did. Sure, I was tired, if I stopped to think about it, but fine. I was a twenty-six-year-old surgical resident, more adroit and getting smoother, at Stanford University Medical Center. I just needed the OR nurse to hand me the iris scissors for delicate dissection.
I continued to cut, concentrating on the nerves and the gland immediately before me. Things proceeded smoothly. I dissected the nerve free from the gland.
I took a breath and stepped back, rewarding myself a moment to recalibrate.