14 July 2013

Surgical exploration

Note: This post describes a surgery. It has content that some would find graphic. Please use discretion.

We were performing a major abdominal surgery on a large patient. The surgeons had made a "chevron incision," a particularly large incision through the abdominal wall that exposed many of the patient's organs.

Although I have dissected three cadavers, seeing the inside of a living person is different. For one thing, it's more dynamic. In front of my eyes, the patient's arteries were pulsating with each heartbeat. The small intestines were undergoing peristalsis: parts of it were curling like an earthworm, and other sections were tightening and loosening as though invisible hands were delicately massaging toothpaste out of a tube. The color scheme was different, too. The organs and tissue were much pinker and healthier-looking than a cadaver's.

Early on in the surgery, the lead surgeon took some time to point out (and quiz me on) the various anatomical structures. He pointed out the edge of the liver. "Have a feel!" he said, setting down his electrocautery pen.

I reached in my hand and poked the tiny patch of liver that was closest to me. It felt soft yet firm, different from the squishy, rubbery sensation of our formaldehyde-soaked cadavers. I quickly withdrew my hand so that they could continue with the surgery.

The surgeon looked at me expectantly. "No, you need to really reach your hand in there!"

I reached back in, sliding my hand a bit farther than before. I looked up at the surgeon, whose eyes were fixed on me. I dove in deeper. Now my wrist my submerged. All around my hand, it felt remarkably warm.

The surgeon motioned with his head for me to keep going.

I took a breath and then took the plunge. I reached along the edge of the liver until my fingertips tapped bone. I had made it to the patient's rib cage. I curled my arm along the underside of the liver, snaking my way up towards the sinewy diaphragm. Then I closed my eyes, and contorted my wrist towards the patient's stomach, trying to grasp the faint outline of the plastic gastric tube that had been threaded into the patient. I opened my eyes and looked down. My arm was in the patient! All the way up to my elbow!

I withdrew my arm. My glove and the sleeve of my gown were smeared with fat and blood.

I nodded at the surgeon, who was still looking at me expectantly. It seemed like he wanted me to say something.

"It felt a whole lot warmer inside than a cadaver," I said.

"I should hope so!" the surgeon quipped. "Otherwise, we'd have a major problem on our hands." Everyone laughed. The surgery resumed.

When the surgery finished, the anesthesiologist woke up the patient and we wheeled him to the recovery room. Some minutes later, I stopped by the patient's bed. "How are you feeling, sir?" I asked.

"It hurts pretty bad, but I'm OK," he said. "When will they let me drink some water?"

The man had no idea that I had just explored his viscera with my hands and had even participated in a very small portion of his surgery. I felt a bit sleazy. Yet I also felt connected to him. As I watched his mouth form words, I couldn't believe that just after this patient had undergone such a major surgery, he was talking! Casually discussing something as trivial as a drink of water! I was delighted to see that he was back to being an ordinary person.

"I had my arm in your abdomen!" I was bursting to say. "And now, you're talking to me!" It was like I had a secret that I needed to confess. Perhaps because I was so exhausted, I was flooded within emotion, emotion that I could barely make sense of.

Physicians often talk about the intimacy of the doctor-patient relationship, and the surgeon's relationship with his patient is an especial one. The surgeon crafts a part of the patient's body, leaving a distinct physical signature that the patient then carries for life. Within each patient, the surgeon leaves a part of himself. The bond the surgeon has with the patient is also one of immense responsibility, because for a few hours the patient's life truly is in the surgeon's hands. The act of operating on one's fellow man is incredibly intense, and I'll bet that is what draws a lot of surgeons to the profession.