Friday, July 25, 2008

Wide Excision


Recently, in the O.R.:

First assist, scrubbing in to help surgeon: Time to put Humpty back together again?
Surgeon: Yup.
Anesthesiologist: Ugh. I hate that.
First assist: Hate what?
Anesthesiologist: That Humpty Dumpty rhyme.
First assist: Why?
Anesthesiologist: Because ALL the king's horses and ALL the king's men couldn't put Humpty back together again.
First assist: Of course not. He was an egg.
Anesthesiologist: SO? That's not the point.
Surgeon: She's just sore about the allocation of resources.
Anesthesiologist: No, no, not exactly. I'm sore that with all those resources allocated, they STILL couldn't do anything to help. I mean, doesn't that BOTHER you?
First assist: You need help. It's just an egg, for heaven's sake. A fictional one.
Anesthesiologist: But the egg is HUMPTY. The egg has a name. And someone loved Humpty enough to round up not just any horses, but the king's horses and the king's men.
Surgeon: DeBakeys, please. And I'll take a 2-0 Vicryl.


***

On another day, in a neighboring O.R.:

The atmosphere in the O.R. is relaxed. With the exception of the scrub tech, the surgical team - surgeon, anesthesiologist, and circulating nurse - consists entirely of women. The anesthetic is in maintenance mode, totally smooth, and periodic checks of all systems, physiologic and technologic, every one to three minutes, consistently show stable signs. We women chat amiably between requests for instruments, adjustments to I.V. fluid, the pushing of medications, pauses for surgically intricate stages of the surgery.

The surgeon hands a mass of tissue to the circulating nurse. "Tell pathology long sutures are medial, short ones are on the axillary side." The mass goes to the lab for analysis.

We continue our conversations, with the scrub tech ribbing us good-naturedly about our chosen topics: the latest reruns of Star Trek Voyager; comparative Klingon and Vulcan cardiac anatomy; the surgeon's recipe for cocoa cookies; the nurse's for peanut butter balls; soap opera story lines from our college days; a horror movie about a telepathic, man-eating plant.

"See, that's exactly why I don't like movies," says my friend Caroline, the surgeon. "What kind of story is that?"

"I love movies!" I counter. "But I'm an easy sell."

"Well, the ones that have a good story are fine. But how many really good stories do you get nowadays? It's all explosions and gore."

"The black-and-white ones have good story. Even my kids can get into those. So what happened after the plant ate the guy's legs?" I ask.

Just then the phone rings.

"It's pathology," the circulating nurse says. She puts the phone on speaker.

"Dr. Walsh? Yes, hi, about that specimen you sent..."

The news is not good. There's not just one cancerous lesion; there are two.

"The second one's invasive," the pathologist says, giving exact details about the type of tumor.

There's a pause. The energy in the room changes almost visibly, as if the lights are being dimmed, while the news sinks in. Our gazes drop, shift.

"Okay," says Caroline. "We'll do nodes, then."

We're quiet for most of the rest of the operation. When we do talk, it's about the diagnosis. That's the nature of diagnosis, after all; it seeps into every thread of life, like a dye.

"That sucks," the scrub tech says.

"Yup. It does," said Caroline.

We do feel it in the O.R., even after years in practice. A sad diagnosis cuts a wide swathe. Even with the patient anesthetized on the table, totally unaware of our presence and our sympathy, we express our pain and our care, in awkward murmurs and pregnant pauses. The dye seeps into our stories as well; the fringes touch and mingle. We are changed.

The circulating nurse wonders how old the patient's children are. I ask Caroline more about the patient's history, why the patient hadn't been referred or hadn't sought her care sooner. Our questions are intermittent, halting - blips of sound in the silence of Caroline's cutting and sewing.  Even though we've seen it before, it still jars us: the patient's life has turned just like that and will never be the same. Though of course, our lives rarely turn on a dime; if medicine suggests anything, it's that tomorrow's story is already being written today, and today's probably began long ago. It's our realizations that come upon us so suddenly, our understanding of what's happening to us as our stories spin beyond our control. The worst part, when you're not actually in the vertiginous center of that spin, is having to tell someone what's going to happen next when you know it's something terrible. And that there's very little you can do about it.

"Okay. Done," Caroline says, sewing in the final stitch.

I've already shut the anesthetic off. It's time for awakening, awareness. Emergence, we call it. And I actively prepare our patient for emergence, working to make it a safe one, a smooth one, for her. Then I watch, and wait, and stay by her side, until she opens her eyes, until her hand can grasp mine.

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Photo credit: Egg image originally posted to Flickr by rockymountainhigh and licensed on Wikimedia.

8 comments:

Beach Bum said...

Beautifully written!

T. said...

Thanks, Beach Bum. Love your blog, by the way! (http://anatomyonthebeach.blogspot.com/)

katy (aka funny girl) said...

I have always said the hardest cases we did were the ones where the family sent their child to the OR with hope...hope that it wasn't cancer...and the child came out with a malignancy. It's a watershed moment. Their little lives won't ever be the same. I hated that.

Love your description of that day...exactly as I remember it during those hard cases.

BTW, not that this is important, but it never says that Humpty is an egg. I'm just saying...

T. said...

Katy - you're absolutely right, and would you believe I am geeky enough actually to have looked it up?!

According to Wikipedia (I know, I know - such the authority, right? - NOT!), "The fact that Humpty Dumpty is an egg is not actually stated in the rhyme. In its first printed form, in 1810, it is a riddle..." A 1902 edition with illustration does give the answer ("an egg") in parentheses at the end of the rhyme but "The rhyme is no longer posed as a riddle, since the answer is now so well known."

Poor little Humpty, just sitting on his wall and all...ugh, I get upset just thinking about it. I think the First Assist had a point. I get emotionally involved way too easily! :)

rlbates said...

T, you write so well! Another fine tale

cliff said...

Thanks, This blog here is charming.


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Wide Circles

Crayons said...

What a good writer you are. I rarely meet a person who is so enthusiastic of her profession. It feels good to know that there is a good conscience and a good heart in the hospital.

PS: Thanks for your nice note on my blog. I hope you did, in fact, break out your crayons.

william said...

All the comments are good and interesting.Thanks.
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john

Wide Circles