Sunday, October 22, 2006

A Few Passages From My Book

Ordinary thyroid surgery is very tidy. The thyroid is like the trinket in a surprise package; you open one layer after another, each prettier than the last. Once there, if you get your finger in exactly the right place, not a filament too deep or shallow, you can sweep in front and behind each lobe of the gland, popping it forward and partly out of the neck. Because there’s critical anatomy behind the gland, you have to contain your excitement. But the dissection is nevertheless a classic exercise in anatomy.
Except now. Besides being huge and stony, Gary’s gland was stuck to everything, even the skin over it. It became obvious there was no way it was coming out. All that was possible was a biopsy to find out what type of cancer it was and, because his trachea was already distorted by the tumor, a tracheostomy to prevent future airway obstruction (placing a breathing tube directly into the trachea). “Trach,” pronounced “trake,” is the abbreviated term.
Placing a trach tube is usually not difficult, especially with the neck wide open and absent a respiratory emergency. The normal thyroid drapes over the trachea but doesn’t obscure it. In this case, however, it was necessary to chisel through rock to get there, and having finally exposed the trachea, no available tube was long enough or shaped appropriately to pass through this huge gland and angle comfortably into the trachea. .......

It was a cheap horror movie, switching from black and white to color at the scariest moment. I opened the shower door to see Gary wilting, collapsing slowly like a leaking balloon, melting onto the floor as pint after pint of blood sprayed from his neck with each cough, the white tile walls by now splashed fatally red. Momentarily paralyzed, I felt as if blood were draining from me as well. Somehow, I acted, and as we dragged Gary across the hall to his bed, I called for an IV set-up and managed to get a needle into a big vein. The blood bank was two floors below. Using the handrails like parallel bars, I swung over several stairs at a time, knocked open the lab door, demanded ten units of O-negative
blood, STAT!!

** ** *** ***

San Francisco General Hospital, “the County,” was the essence of our surgical training, the crucible and the soul. More dignified and in some way predictable, the UCSF hospital—Moffit Hospital— was the medical center, the research hospital, where I’d started. The County was drama, fear, chaos, and excitement, the prism through which you saw yourself and your readiness to be a surgeon. A classic county hospital, decades old, it was made of solid brick, with incongruous fancy filigree—artsy details along the roof line, marble in the entryway—overlooked and no longer relevant to the seething survival-struggle that the place had come to embody. Slung low, with long hallways, too few and too slowelevators, SFGH housed patients in open wards, dank and underlit warehouses, except for the rare private room used for people with dangerous infections, or for the occasional muckamuck waiting to get well enough to transfer the hell out of there. The County was, in a word, alive.
It also had a dark side, buried deep. Connecting the main building to the psych ward across the alley were long and claustrophobic tunnels—dangerous at any time for a lone woman, eerie even for me when I made the rare trip over there. Not sated by its diet of damaged people, the County sometimes coughed up its own cud from down there; assaults on employees, though uncommon, were not rare. But from a physician in training, and most especially from a surgeon, San Francisco General Hospital demanded love and got it easily, unconditionally. It’s where I always wanted to be.

* * * *

Lester Weisman looked like Death. Bony, stooped, hook-nosed, and spider-fingered, he spoke in a voice that was chronically hoarse, a wheezing gust from Hades. He walked slowly, head down, peering above his glasses. Raising a hand toward you if he addressed you, he let the fingers droop and motioned vaguely, as if it were too much effort to point. When he smiled, it looked like he smelled something putrid. He should have carried a scythe, but it would have been unseemly for a former chairman of the department.
I liked him a lot. At this point in his career he had only a few patients, but he gave the occasional lecture. “The parathyroid . . . [grimace] . . . was first described . . . [sigh] . . . in the African water buffaloooh . . . [lengthy exhale]. . . .” Weisman even still did the occasional thyroid or parathyroid operation, and I wondered what his patients thought when they met him: hoarseness is the main complication of such operations, and he was the anthropomorphism of the word.

* * * *

We spent time on the wards and in the operating room, but the intensive care unit was the center of the vortex for the junior residents. If critical illness were heat, you’d melt in there. Jumping out a sixth-story window does things to a body. So does getting run over by a bus or taking a shotgun to the belly. Having five or six such victims at all times, along with a few lesser recoverees— couple of stab wounds, a bullet or two, ruptured appendix, perforated stomach or colon—produced a broad if wobbly workbench on which to learn to care for the sickest of humanity. Hearts and lungs, kidneys and livers failed alone or in concert, while we dialed in drugs, adjusted the ventilators, calculated fluid and caloric requirements, cleaned wounds, checked drains. With the help of surgical and anesthesia attendings, we became comfortable juggling disparate needs of multiple patients, street performers in white coats. Cirque du malaise......

Tending the wards, out of the ICU, was like being some sort of deviant gardener. Working our way up and down rows of beds lined along the edges of narrow, cavernous rooms, separated by curtains which hung like under-watered foliage— drooping, dirty, shredded—we cultivated patients who were in various states of mute acceptance or vocal defiance. “This pain medicine you’re givin’ me ain’t fer shit” was the most common salutation. (Until, after a day or two of complaining, they’d be pleasantly compliant on morning rounds, having made the connection; the night shift orderlies had a side business going. Drugs flowed when the lights went out.) The open wards, while highly efficient, by definition prevented intimacy, exacerbating an already precarious relationship. No one was happy to be there; most had fallen victim to their own or someone else’s stupidity or violence. Some were in withdrawal from alcohol or drugs; many weren’t anxious to return to their home life, while we were trying to get them well and out of there. Gratitude was not in the air. But I loved it. This was a real county hospital, the ferment of its wards connecting back to the earliest days of hospitals in this country, and across the seas to Europe. I felt it every time I entered.

** ** ** **

There aren’t a lot of kids with kidney failure. Katy Dawkins was beautiful, very sick, and very scared, admitted to a service that could be cold and hurried. When she arrived, I was smitten and never entertained for a moment maintaining professional distance from this speed-talking, pig-tailed ten-year-old, freckled like a crumpet. Having had some unusual problems with matching, she was getting a kidney from her dad—and even he was much less than an ideal match. Such “living related” transplants were uncommon then, and she and her dad were admitted a few days early for preparations. That meant I had time to get to know Katy and her family. Dad was a big guy and seemed perfectly comfortable with the plan; he’d apparently already donated a bunch of his freckles. I liked to visit Katy at night, when no one else was around, and when I could usually spare a few minutes.

* * * * *

When you’re still an embryo, your intestines are floating out in front of you, and your belly is wide open. As development proceeds, the intestines corkscrew their way inside, and the colon lays itself down around the inner periphery of your abdomen, in the shape of an inverted horseshoe. The right (“ascending”) colon is the first part, beginning where the small intestine joins it, in the lower right part of your belly. It heads up the right side to the liver, takes a left turn and crosses under your stomach (becoming the “transverse colon”), heads up toward the spleen (the “splenic flexure”), makes a hairpin turn down to the left side (the left, or “descending” colon), and finally takes an S-shaped (“sigmoid” colon) spin into the rectum. The blood vessels to the colon head outward from the middle of your belly, like hands on a clock. All of that derives from the embryological corkscrew, and it meansthat if you cut it loose from its outside attachments to the abdominal wall, you can deliver the colon up into your hands where you can work on it quite easily (unless it’s stuck and swollen from infection or a large tumor, or has perforated and retracted inward, or any of a number of other things that can make it anything but easy). Doing that—separating the colon from the sides of the abdominal wall—has always struck me as one of the neatest things a surgeon does. It’s like knowing one of the body’s deepest secrets: this big long fat bloody tube, which seems tightly stuck in there, can in fact, with the most delicate of maneuvers, be made to lift right out while still connected to its blood vessels. The trick is inserting your hand in just the right place laterally and doing a “c’mere” motion with your first two or three fingers, then cutting the thinned-out layer you’ve made. It’s nearly bloodless up the right side and down the left (it does get harder in between).

* * * * *

I believe I mentioned that Dr. Williams was a lunatic. He was a good operator but certifiably crazy in the OR, regularly losing control, yelling, berating people, throwing instruments. He might accuse someone of sabotage if something went wrong. That kind of crap was tolerated back then. Shaking his head like a bad imitation of Richard Nixon, he’d tighten his lips into a sort of cephalic anus and suck air in with a hiss at anything he didn’t like, which was nearly everything.

* * * * *

An artfully made bowel anastomosis is a thing of beauty. There’s an inner row of dissolving suture, in a running fashion, from the back side to the front, done in such a way as to make it all turn inward, and an outer row of individual (interrupted) stitches, requiring turning the tip of the needle holder in a perfectly circular motion, digging the exact depth to penetrate the outer surface and muscle, but not the inner layer (mucosa). As you watch the edges disappear inward, and see a row of evenly spaced sutures complete a perfect circle, no mucosa showing; as you observe the tiny nearby arteries dancing their proof that you haven’t disrupted the blood supply to the edges, you know you can safely drop it back inside, a secret gift to the patient.

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