This is an excerpt of a working draft of a chapter from a book-in-progress titled “Swearing by Apollo.”
I presented this excerpt at Richard Selzer’s Masterclass at the 3rd Annual Yale Writers’ Conference. Anyone interested in the entire chapter can read it here: Like a Surgeon edit 619
Like a Surgeon
It’s 5 AM on a hot September morning in 1984. I’m sitting in my pale blue VW Beetle. The car is twelve years old and has a stiff clutch, a loose stick-shift, a broken speedometer, and no air-conditioning. But it has everything I need in a car: an eight-track player with three tapes –– Linda Ronstadt’s Heart Like a Wheel, Jethro Tull’s Thick as a Brick, and Bruno Walter conducting Brahms First Symphony with the Columbia Symphony Orchestra. My mind is racing in anticipation of my first clinical rotation as a medical student. After two years of lectures and labs, it is time to enter the hospital and work with actual patients.
I’m parked in the Rice University stadium lot. Although the medical center has it’s own lot and shuttle, I prefer to park at Rice where I attended college and jaywalk across Main Street to the Houston Medical Center each morning. I find the ritual of parking in the familiar lot of my alma mater comforting and the walk to the school gives me time to collect my thoughts and prepare for the day. I prefer not to endure the fifteen-minute shuttle-ride at sunrise with a crowd of over-caffeinated students. Medical students are prone to nervous chatter fueled by fear and doubt. Even worse than the typical anxious students are the ‘gunners’ (derived from the military slang ‘tail-gunner,’ –– referring to the crewman who sits in the rear turret of a B-52 and guns down enemy planes that approach from behind.) With a head full of memorized facts, a gunner acts without doubt or fear –– he’s already mastered medicine and is out to prove it.
I check my watch and hurry out of the car. I’m wearing a waist-length white lab-coat –– several feet shorter than the lab-coats of residents and attendings –– it clearly marks me as a student. I wade through the Houston humidity and dodge traffic to arrive at the edge of the medical center. In the pre-dawn dark, the buildings look strange and unfamiliar, reminding me of the neurological symptom called jamais vu. The opposite of deja vu, jamais vu is French for never seen. In neurology, it refers to the uncanny feeling that a well known place is being seen for the first time. Jamais vu can signal the onset of a migraine or seizure. I brace myself for the day.
The Houston Medical Center is a huge complex of hospitals, institutes, libraries, and research centers, including two medical schools: Baylor College of Medicine, and the awkwardly named University of Texas Health Science Center at Houston. I interviewed at both schools –– Baylor turned me down, UTHSCH did not. UTHSCH is adjacent to Hermann Hospital and across the street from the Hermann Park Zoo. The white-washed facade and terra-cotta tiled roof of Hermann Hospital exudes an aura of nobility, reflecting the pride and purpose of a past era. In contrast, the medical school, built in the 1970s, has a utilitarian sensibility, composed of brownish-orange bricks, straight lines, and plenty of glass.
Only halfway through the eighties, the decade already feels stale. The excitement of the sixties has long ago evaporated into a psychedelic haze. Bob Dylan, The Beatles, Joni Mitchell, and Pink Floyd have been replaced by Wham!, Foreigner, Chaka Kahn, and Dire Straits. Our culture has become boring and disappointing. But the medical school feels fresh and utopian. One step through the plate-glass doors and the atmosphere changes: a palpable energy is in the air. It feels something like hope, optimism, and, dare I say it, joy. A large sunken lounge –– known as the leather lounge –– dominates the lobby of the medical school. The musky scent of the couches portends success and fulfillment, way out there, in the future, somewhere on the other side of the hellish labyrinth of medical education.
For the first time since starting medical school, I walk past the doors to the leather lounge and head across the Houston Medical Center for the first of three month-long surgery rotations. It’s a mile-long walk to the MD Anderson Cancer Center where I am assigned to work with Dr. McQuillen. Dr. McQuillen is notorious for aggressively interrogating his students. This practice is referred to as ‘pimping’ –– it involves asking a series of escalating questions until the ignorance of the student is revealed. Only a true gunner can withstand the assault.
[The next several pages are internal reflections on the events that lead to my decision to go to medical school leading up to this:]
… I knew it would be a prolonged and challenging ordeal: four years of medical school, four years of residency, a minimum of two years to become board-certified, then a lifetime of practice. My acceptance in medical school was like the closing of a door. There was no going back, and the passage ahead felt dark and confined. For solace, I dreamed of becoming a physician-writer and fantasized crafting the next Andromeda Strain, or becoming the next Richard Selzer.
I put my dreams of being a writer aside as I arrive at the hospital. I enter the automatic doors and am hit by a peculiar smell –– a mixture of bleach, soap, and surgical steel, tinged with a hint of blood. I pass through the lobby and search my way through the halls and stairwells to the third floor surgical ward. As I approach the nursing station, a stout middle-aged man with shoulder-length grey hair wearing scrubs and white lab-coat looks up is writing in a chart. He looks up and glares at me.
The other student assigned to this rotation, John LaPrade, arrives a few minutes later. He is one many students in my class of 160 that I have never met. As Dr. McQuillen admonishes him for being tardy, John glances my way. I can tell by his expression that he is not a gunner. I will have a sympathetic companion during the arduous month that looms ahead.
McQuillen introduces us to Dr. Martin, a thin woman with blonde hair, no make-up, and tense, thin lips. McQuillen tells us that she has just started a two-year post-residency fellowship specializing in cancer surgery
“You will be working with Dr. Martin. Whatever she says, you do. Now let’s run through the patients.”
[After morning rounds, I scrub in for my next surgery. After gowning and gloving, the nurse tells me to take my place at the operating table.]
… “Now you can go enter the sterile field. Keep your hands above the table at all times. And do not move away from the table until the surgery is over.”
She steps back and nods towards the operating table. A woman is on the table, covered in green sheets with an opening exposing her bare belly. The skin is tinged orange from iodine antiseptic that another nurse is applying with a swab of gauze held by a pair of forceps. The scrub nurse is standing to the patient’s left near the head of the table, arranging instruments on a cloth-draped table on wheels. The anesthesiologist jots some numbers onto a flowsheet, looks up at the heart monitor, and reaches over and turns a valve to start the flow of oxygen and halothane. He injects something into the intravenous live then picks up a mask that is attached to the valve by a tube. The mask hisses as he leans over the patient. He whispers that it is time to go to sleep and places the mask gingerly onto the her face. Her breathing slows and her body relaxes. The anesthesiologist holds the mask in place and squeezes on a bladder attached to the mask to oxygenate the patient. After a few squeezes, he takes the mask off with his left hand and picks up a laryngoscope with his right hand. He inserts the long curved metal prong of the scope into her mouth and deep into her throat. He puts the mask down, and while still holding the laryngoscope in place, picks up an endotracheal tube that is glistening with KY jelly. He bends down and peers down her gullet as he and deftly slides the lubricated tube down her throat. He quickly injects air from a syringe attached to the near end of the tube to inflate a bladder that surrounds the other end of the tube. I know from a class that I took last month that the syringe inflates a bladder that expands around the outside diameter of tube in order to secure a seal in the trachea so that all the airflow to and from the lungs goes through the tube. I left the class after the instructor suggested we pair up and practice on each other. I later heard that several gunners actually stayed and took turns intubating each other. The anesthesiologist then attaches a tube from a ventilator onto the end of the endotracheal tube, and flips a switch. The breathing machine clicks on. A rubber bellow cranks up and down within a glass cylinder. The patient’s belly rises and falls, ebbing and flowing with each sigh of the ventilator.
McQuillen enters the room. The float nurse is waiting for him, gloves and gown ready. McQuillen pirouettes into the gown. He waves each arm into the air with a flourish as the gloves are pulled into place. He takes his place at the other side of the table next to the scrub nurse. He hold his right hand out to the side and places the fingertips of his left hand onto the bare skin of the lower abdomen. The nurse hands a scalpel to McQuillen.
With a grand sweep of his hand, he places the scalpel onto the abdomen and pulls across the skin from left to right. A slight break in the skin opens up in the wake of the scalpel –– a six inch cut from pubis to umbilicus. McQuillen teases the scalpel across the cut until the membrane that lines the inside wall of the abdomen is exposed. He delicately pinches the lining with a pair of tweezers and raises a small tent which he then nicks with the scalpel. The nurse exchanges the scalpel for a pair of scissors which McQuillen inserts into the opening. He cuts along the length of the incision. The scrub nurse places a retractor into one side, holds it in place with his left hand, and hands McQuillen another retractor. McQuillen places the second retractor into the other side of the incision and looks up at me.
I grab the handle with my right hand and pull.
“Pull harder. And don’t move.”
My hand twitches.
“I said don’t move! I want you to hold that retractor like a catatonic monkey.
The incision stretches open into a gaping maw. McQuillen reaches in and feels around for several minutes. He looks up at me.
“Put your hand in here.”
I slowly move my left hand towards the wound. McQuillen grabs my wrist and shoves my hand deep into the pelvis.
“What’s your hand touching?”
“What’s above your hand?”
“And above that?”
“The pubic bone?”
What is he getting at? My mind races as I try to imagine diagrams from anatomy class. The sound of the ventilator fills the silence in the room. The scrub nurse is averting his gaze. The anesthesiologist is attending to the settings on the machines, adjusting dials, and glancing at the clock. The float nurse is standing behind McQuillen, fiddling her thumbs. I notice the movement of the second hand of the clock. I’m distracted by my overwhelming awareness that a woman is lying on the table, riddled with cancer, undergoing a major surgery, and that her surgery is being delayed due to my inability to answer McQuillen’s questions. I try to recall the nerves and arteries of this area but cannot remember anything. McQuillen has stepped back from the table and is staring at me with his arms folded across his chest. He’s not to continue this surgery until I answer. I remind myself of the question: What is above the pubic bone other than skin?
“The surgical drape?”
“OK. Let me rephrase. What else would be above your hand in a woman who’s not getting chemo?”
Pubic hair? Is he trying to get me to say pubic hair? The scrub nurse glances up me. The anesthesiologist is staring at me. The float nurse is looking at me. McQuillen begins to grin.
“Pubic hair!” he announces, as he pulls my hand out of the depths of the patient’s pelvis.
McQuillen reaches back into the abdomen. He probes around for a while, the nods towards a deep crevice that he’s holding open with his fingers.
“No no no. Not that. What’s this, down here, at the tip of my finger?”
I lean in closer to get a line of sight into the hole. McQuillen lets go and the crevice collapses into a sea of blubbery pink bowels.
“I can’t see it.”
McQuillen crosses his arms across his chest again.
“OK then. What could it be?
My mind goes blank. My pulse is pounding in my neck. Sweat’s dripping down my back. This poor woman has no idea that her surgery is being delayed due to my lack of knowledge. I can’t recall anything. Jamais vu… Jamais vu… The textbook images that I am trying to visualize implode into a dark void.
“Jesus Christ, son! What the hell are they teaching in medical schools these days? Haven’t you learned anatomy?”
McQuillen shakes his head and returns to his work. I concentrate on holding the retractor and pray that McQuillen doesn’t ask any more questions. My hand is cramping from holding the retractor. I tense my arm to make sure that the retractor doesn’t move. I don’t want to do anything to attract McQuillen’s attention.
McQuillen holds out his right hand and waits for the scrub nurse to supply an instrument. The nurse glances back and forth between the surgical opening and the instrument table, his hand poised over the instruments. McQuillen rolls his eyes.
The nurse chooses a long pair of forceps and hands them to McQuillen.
“No. I want the Moynihans.”
The nurse looks over the rows of instruments. There are over a dozen forceps lined up on the side by side on the instrument table. He chooses another and places it into McQuillen’s hand. McQuillen tosses the instrument over his shoulder.
The nurse scrutinizes the instruments.
“They all look the same to me.”
McQuillen throws his head back, spins away from the table, goes around behind the scrub nurse and without pausing to look at the forceps, scoops them all up using both hands. He holds the bundle of forceps in front of the nurses face.
“These are all wrong.”
McQuillen flings the instruments across the room. They fly by my head, hit the wall, and clatter onto the floor. He then returns to the table and stands with his eyes closed.
The float nurse runs out of the room. McQuillen slowly opens his eyes and stares blankly into space, holding his hands clasped as if in prayer. The cycle of the ventilator marks time as everyone waits motionless. The nurse returns with a new set of instruments which she places on the table. She carefully unfolds the edges of the sterile cloth wrapping to lay the instruments bare. The scrub nurse sorts through the instruments and hands what appears to be an identical pair of forceps to McQuillen. McQuillen takes the instrument and proceeds with the surgery as if nothing has happened.
McQuillen remains silent for the next two hours until he announces, ”You can let go now.” I try to release my grip on the retractor –– my hand has cramped up, I can’t let go. McQuillen pulls the retractor out of my hand and chuckles. He closes the wound with sutures. Then without saying a word, turns away from the table, pulls his gloves off, and tosses them into the corner as he leaves the room.
There is a noticeable shift in the atmosphere of the room –– a release of tension –– as the nurses tidy up the remains of the surgery and the anesthesiologist turns off the halothane and waits for the patient to begin to wake up. The float nurse is picking up the interments that are scatter on the floor. The scrub nurse turns to me.
“McQuillen’s next surgery will be in OR 5.”
As I exit the door, I see John standing at the sink, scrubbing his hands. It dawns on me that John never made it into the OR.
“Have you been here the whole time?”
“Of course not! Dr. Martin showed up just as you went in and dragged me into OR 6 for an exploratory lap followed by a lymph node biopsy.”
“How’d it go?”
“Delightful. How about you?”
Dr. Martin arrives to assist McQuillen with the next surgery. Martin tells John scrubs in. There will not be enough room at the table for both of us, so I am to observe the surgery from behind. As soon as McQuillen finishes his incision and exposes the organs of the belly, McQuillen begins to interrogate John. I cannot see into the abdomen and have no idea what McQuillen is pointing to as he pimps John into oblivion. John responds to McQuillen’s questioning by becoming flip and sarcastic with answers such as I have no idea and How would I know that? It doesn’t go over well. McQuillen ramps up the intensity. John becomes a lightning rod, drawing McQuillen’s attention away from me. I am invisible to McQuillen for the duration of the surgery. I feel sympathy for John’s plight, but am relieved that it’s him and not me.
It’s after 5:00 by the time the last surgery is finished. Dr. Martin tells us to go write up the new admissions.
“You mean tonight?” asks John.
“Of course I mean tonight. We have patients. They need to be seen. That’s what doctors do.”
“How do we know which patients are on our service?”
“Look at the charts, and figure it out.”
My first patient is a twenty-six year old mother of three who has advanced breast cancer. She is scheduled for a radical mastectomy at 7:30 tomorrow morning. She is youthful, attractive, and buxom. Tomorrow she will wake up from surgery disfigured. Even with surgery, she is unlikely to live more than a few years. Her breasts, symbols of motherhood and feminine beauty, have become her mortal enemy.
I spend the next three hours seeing the rest of my patients in preparation for evening rounds. During rounds, Dr. Martin proves to be even more intimidating than McQuillen. Her demeanor is dour and stringent. I imagine that she has never smiled. I wonder if the severity of her personality is a reaction to being a woman in the male-dominated field of surgery –– a response to the macho bravado of her peers. But I suspect she was like this before she held her first scalpel.
With a tone of derision punctuated by signs of irritation, Dr. Martin critiques and corrects every detail of our case summaries. Late into the ordeal, John mentions that one of his patients is nauseous.
“Saying your patient is nauseous means he made you feel sick,” Dr. Martin interjects, “ the correct word is nauseated. Learn to speak English.”
The sun set hours ago. Backed by the dark of night, the windows of the hospital reflect the fluorescent-lit interior. Everything feels intimate and raw. Just as I begin to wonder if Dr. Martin will keep us here all night, she announces,
“You can leave, now. I suggest you get her by 4:00 tomorrow. See all your patients prior to rounds and be prepared to present. Rounds start at 5:30. Plan to be here late every night –– no one leaves until I leave. Any questions?”
“Is there a call room for us to sleep in?”
“No, the call room is only for residents and fellows. You get to sleep at home”
“Do we get weekends off?”
“No. If you’re lucky, I might let you have Sunday afternoons off.”
It’s nearly midnight when I leave the hospital to return to my car. I am hit by a wall of heat and humidity as I leave the lobby. It’s a comforting feeling, being enveloped by the sauna of August that persists into the night. I jog across the medical center and cross the sparse traffic on Main Street in a hurry to get home for a few hours of sleep before rounds. I realize that the circadian flow of the next two years will be disrupted. One day will bleed into the next without a break.
Back in my Beetle, I relax into the torn vinyl seat and breathe in the familiar scent of mold, oil, and gas. I start the car and look across the campus towards the science buildings. I wonder about being a graduate student at the university. What if I had stayed at Rice to get a Ph.D. –– perhaps in Biochemistry, or Literature. I imagine that life as serene and idyllic. I think of the camaraderie of the academic environment, the challenge of the research laboratory, and the satisfaction of teaching undergraduates. I find myself feeling nostalgia for the life I did not pursue.
As I pull the stick-shift into first and release the clutch, the Beetle grinds into gear and lurches forward. I push an 8-track tape into the car stereo. The music starts up in the middle of the second movement of Brahms First. It is recording that I have listened to since high school. The arching line of a solo violin soars in unison with the woodwinds: yearning, pleading, hopeful.