Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: wonder

Waking up slowly

When I first saw her in the trauma ICU, she was posturing.

B was a college student who had been on a skiing vacation with her family when she lost control and broke her leg.  She was taken to a hospital closer to the mountain, where her fracture was repaired.  Unfortunately, she’d suffered from fat embolism during the operation.  Fatty marrow from inside the bone had entered her bloodstream, eventually becoming lodged in her brain.  When she wouldn’t wake up, her family asked for her to be transferred to our specialist trauma center.

For the first few days she was with us, B showed very few signs of improvement.  Her parents were at her side every day, and during our rounds, they would insist that she was progressing.  I didn’t see it though.  When we examined her, she would grimace and extend her arms – decerebrate posturing, a sign that her brain was massively damaged.  Patients with this type of response to stimulation typically don’t do well.

But our attending, Dr. D, remained optimistic.  He said it was too soon to tell.  Patients with fat embolism tended to do very well in the long-term, he insisted to a skeptical crowd of residents.  He sent us articles to back up his claims, but I still couldn’t believe that B would ever wake up, let alone return to any kind of normal life.

After about a week of this, B was physically well enough to be sent to a regular hospital ward.  She was still quite unresponsive, but Dr. D was unflappable – “Give her a little more time – you’ll see.”

Some weeks and many patients later, I was getting ready to move on to my next rotation.  I was chatting with G, one of the trauma coordinators.  She knows me quite well, so she knows which patients bother me the most.

“So, girlwithaknife, remember B?  She’s going home soon!”

“Really?  To rehab?”  I assumed she’d be sent somewhere for traumatic brain injury.

“Nope, she woke up, she’s done her rehab, and she’ll be going home-home.”

“No way!”  Just a few weeks ago, I was convinced that she’d remain in a permanent vegetative state.

Later that afternoon, I found some time to duck out of the ICU.  I walked over to the rehab unit and found B’s room.  I knocked and heard her voice for the first time, weeks after first meeting her.

“Come in.”

The girl who I thought would never return to independent life was sitting up in a chair with her healing leg propped up.  She was awake, alert and oriented – and serenely buttering a slice of toast.

I introduced myself and sat down.  She apologized for not remembering me.  I could only shake my head and chuckle at her words.  I still couldn’t believe she was awake.  We had a brief conversation before I had to leave her room and return to work.

I left feeling oddly settled.  I was wrong, Dr. D was right.  And I couldn’t have been happier about that.

The Art of Surgery

Much has been written about the art of medicine and how important the humanities are to our work.  Abraham Varghese has a TED talk in which he explores the art of the doctor-patient relationship far more eloquently than I could.  I’d encourage everyone to watch if they can.  I’ll stick to what I know instead – surgery.

Much of the vernacular of surgery seems dramatic in origin.  It’s no accident that operating rooms were originally called “theaters”.  In Thomas Eakins’ oil painting The Agnew Clinic, the good surgeon and his entourage occupy center stage with their patient.  They are surrounded by rows of seated observers, an audience of medical students whose expressions range from curious to horrified to bored.  Dr. Agnew, dressed in his surgical whites rather than street clothes, has just performed a mastectomy.  He’s no doubt pontificating to the students while his assistants finish the case.

Perhaps we surgeons are just performance artists?  Well, we no longer operate in theaters, though observation opportunities do still exist.  Let’s consider a hypothetical case.

The patient has been prepared in the peri-operative area – he has signed the consent, changed from his own clothes into a hospital issued gown, and an IV line has been placed.  He’s subject and audience of this play – he’s bought his ticket, changed into his costume, and been through the prosthetics department.  Now he’s about to leave the wings.

He’s wheeled into the operating theatre  room and positioned in the center of the OR, under a canopy of dimmed lights.  The anesthesiologist guides him to the twilight zone, where he will remain unconscious, paralyzed, amnesic.  The surgeon and her assistants then position him – an arm tucked here, legs propped up there,  a pillow under the head, as though he is a sculptor’s flaccid model.

Their subject positioned, the surgeons leave temporarily to complete their scrubbing, allowing the nurse to clean the patient’s skin.  The nurse and tech cover him  in blue drapes, marking out the sterile zone, exposing only what is necessary.  The lights are turned on and focused onto the operative field.  The patient is no longer visible, he’s been reduced to a slab of exposed abdomen.

By now, the surgeons have marched back into the room.  They form a line, with the attending surgeon first, followed by a senior resident, then a lowly intern.  Once their hands are dry, the scrub tech helps dress the lead surgeon for her performance, first one arm, then the other, finally tossing the rest of the gown over her shoulders.  The resident surgeons are left to gown themselves.  As the nurse ties their gowns from behind, the scrub tech helps each surgeon with their gloves.   “Shall we dance?” asks the attending, before pirouetting with the nurse to complete the wrapping of her gown.

The surgeons approach the patient, a troop of masked players, anonymous except for their eyes.  They adjust the lights while the scrub tech brings his table full of props closer.  There’s a brief pause to review the plan, spelling out the program for the day.

“Knife please.”  And with a flourish of the scalpel, the performance finally begins.

OK, perhaps I’m being overly dramatic.  We accept that for a successful, clean operation, patients need to be anesthetized, positioned, cleaned, and draped before an operation, while their surgeons must scrub, gown, and glove.  But do these rituals serve a need beyond their technical purposes?  While a well-established routine certainly helps us to remember all these steps, I would argue that it also prepares us for the bizarre acts that are to follow.

If you were to see a surgeon walking down the street, would you know?  After all, this is someone who enjoys using potentially lethal instruments to disassemble and reassemble other people’s bodies on a daily basis – the bodies of patients who have willingly agreed to allow strangers to drug and cut them.  What happens in an operating room everyday is far from normal.  In any setting outside healthcare, it might constitute assault and battery at best, torture at worst.  How could anyone willingly participate in this?

The ritual, being “on stage” and performing in costume, allows us to assume roles outside our ordinary selves, overcoming the limits of what we see as natural or normal.

The patient dresses for his part and becomes a willing subject.  He’s about to allow strangers to make him lose consciousness before they break his skin – but it’s OK, the rites of preparing for surgery have marked him as a patient rather than a victim.  In a hospital gown and with an IV in his arm, he’s here to be cured, not killed.

Once scrubbed, gowned and gloved, I’m no longer girlwithaknife,  I’m now Dr. girlwithaknife.  I’m no evil torturer, I’m the surgeon to whom this patient has entrusted his health and given his permission to operate.  I can allow myself to press a scalpel into another living person’s skin without fear, because he needs my skill.

So, we may not be performance artists – but for a surgery to succeed, every person in the room needs to fill a role that goes far beyond the ordinary.  And perhaps our funny costumes help us do that.