LIKE A SURGEON

This is a working draft of longer story titled Like a Surgeon. I presented  excerpts from this story at Richard Selzer’s  Masterclass at the 3rd Annual Yale Writers’ Conference. I was relived to hear Selzer (a retired Yale surgeon who retired to pursue a career in writing and has published over a dozen books) say that the description of surgery based on my thirty-year-old memory of the event was “precisely accurate.” I haven’t witnessed a surgery since 1984, but the intensity of the experiences back then resulted in a level of heightened awareness that has seared many of the events of Medical School into my hippocampus. 

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Like a Surgeon

 
It’s 5 AM on a hot September morning in 1984. After two years of lectures, it’s time to finally 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 a neurological symptom called jamais vu. The opposite of deja vu, jamais vu is the eerie feeling of a well known place being experienced as if seen for the first time. Jamais vu can signal the onset of a migraine or seizure. I brace myself for the day.
It’s a mile-long walk to the MD Anderson Cancer Center where I am assigned to work with Dr. McBride. McBride 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 into medical school felt like the closing of a door. There was no going back, the passage ahead felt dark and confined. For solace, I dreamed of writing and fantasized crafting the next Andromeda Strain, or becoming the next Richard Selzer.

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 and growls,

“You’re late.”

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. McBride admonishes him for also arriving late, 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.

McBride  introduces us to Dr. Martin, a thin woman with blonde hair, no make-up, and tense, thin lips. McBride 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.”

As we go door to door around the perimeter of the wards, Dr. Martin recites a summary of each patient from memory including recent lab values and current vital signs. Since it’s our first day, John and I are off the hook. Tomorrow we will be expected to present the patients. McBride glances into each room as Martin talks, as if examining the patients from a distance. McBride scratches orders along the way and hands each chart to me to take to the nurses. I run back and forth, missing much of Martin’s presentations. McBride is silent throughout rounds. After we have run through all eighteen patients, he walks away without saying a word. Martin tells us to be scrubbed in for surgery by 7:00. She also walks away.

I head over to the nursing station with the last chart. There are several nurses milling around, oblivious to my presence. I have heard warnings about nurses –– nurses do not like medical students. Part of the training experience of a medical student involves being tossed into an unfamiliar environment every month with minimal instructions. We are expected to figure out things on our own. The shifting crowds of untrained medical students are an annoyance to the nurses. Students cannot write orders without having them co-signed by a resident or attending and we have no authority over the care of patients. The nurses have no obligation to interact with us. We are an unnecessary part of the team. Since some nurses are openly hostile to medical students, it is essential for survival to feel out which nurses can be approached for advice.

A young blonde woman wearing green scrubs and pink sneakers is already transcribing the orders on one of Killian’s charts. I approach cautiously and look at the orders. The writing is a mess of jumbled lines scratched onto the page. It looks like someone tossed a handful of toothpicks onto the page. She is looking back and forth from the orders to a nursing treatment plan where she is apparently transcribing Dr. Killian’s instructions.

“How can you read that?”

“They’re his standard pre-op orders. He writes the same thing every time,” she replies.

“But what if he wrote something different this time?”

She shrugs and says, “I’m sure he’ll let me know.”

John approaches and says, “Maybe we should go look for the OR. I don’t want to be late.”

We head back to the lobby then follow the signs to the surgical suite. We find our way to the doctors’ dressing room, pick out a pair of scrubs from a rack, and change out of our street clothes. It’s the first time I have worn scrubs –– it feels strange, like wearing nothing but pajamas and shoes in public. I shut my locker, pin the key to my scrub-pants, and make a note of the locker number. John hands me a pair of booties and reminds me to cover my shoes. We exit the back door marked Scrub Attire Only. It opens into a long hallway. I am startled by the brilliance of white walls and fluorescent lights. John stops a passing nurse and asks,

“Do you know which OR McBride is in today?”

With an ominous tone, she replies,

“You’re with McBride? OR 4. Good luck.”

Outside each operating room are rows of deep stainless steel sinks. They remind me of urinals at a football stadium.

John asks, “How do you turn these sinks on?”

I search the sink. There is no handle and no foot pedal. A nurse approaches and says,

“They’re automatic. Wave your hands under the faucet. But put on a mask and cap first.”

She points to a stack of surgical masks and paper caps on a shelf above the sink. She then heads to a neighboring sink, puts on a mask and cap, and begins to scrub. I imitate her actions –– first tying the mask around the neck with one set of strings, then pulling the mask up onto the face and tying a second set of strings behind the head above the ears. Then pull on the paper cap onto the head with its strings in back and tighten it into place. It’s a simple procedure, but I study her every move to make sure I don’t make a mistake.

The water starts out cold then gradually warms up to a nearly painful level of heat. I watch the nurse out of the corner of my eye as she is scrubbing and again follow her lead. I choose a brush from the shelf, tear open the wrapper, toss the wrapper into a receptacle in the wall, wet the spongy side of the brush, lather each hand and forearm, then turn over the brush to the side with rows of plastic bristles and scrub under the fingernails, around the sides of each finger, the front and back of each hand, around each wrist, and up each arm to the elbow.

I check the clock –– five minutes have passed. She shakes the water off her hands and holds her forearms up and away from her body. The water drips off her elbows as she heads into the operating room. I continue to scrub for another minute. I shake off my hands, hold my arms out and up in what feels like an awkward supplication, and look over at John. I shrug and follow the nurse. As I enter the room, another nurse greets me silently by presenting me with a beige glove which she is holding stretched open with both hands. The glove is unusually long. The fingers dangle at her knees. I hesitate as I try to figure out what to do.

“Right hand first,” She says. “This must be your first surgery rotation.”

“Yeah.”

“So you got McBride. Lucky you.”

She pulls the glove up to my elbow as I shove my hand down into the opening. As she lets go, the glove snaps around my elbow with a satisfying pop. She then holds out another glove for my left hand. This time my fingers catch in the glove. My fourth and fifth fingers have gone into one hole and the pinky finger of the glove is hanging flaccid.

“That’s okay,” she says as pulls the glove off and tosses it into a trash bin marked biohazard. She opens a second set of gloves, unfolds the sterile wrapping, and lays it out onto a stainless steel table with each glove lying side by side. There is and R and an L on the inside of the wrapper. As I watch, I absent-mindedly allow my gloved hand to fall to my side.

“Keep your hands up. Be careful not to touch anything.”

She chooses the left glove and holds it out for me. She smiles and says,

“You’ll get the hang of it.”

I focus on my hand and spread my fingers slightly as I enter the glove. I lean over to check my fingers as she pulls the second glove place.

“Now for the gown.”

She picks up a folded gown from a shelf marked sterile. She shakes it and it falls open as she holds it up in front of me.

“Right arm first.”

The opening to the sleeve is crumpled. I carefully probe to find the opening. She assists by pushing the gown towards my body. After we repeat the procedure with the left arm, she dances around my body while holding onto the back of the gown, pulls the gown snug, and ties three sets of strings: one at my neck, one at my shoulders, and another at my waist. I feel like royalty as she circles my body to double-check the fit of the gown.

“Now you can go enter the sterile field. Keep your hands above the table at all times. Don’t touch anything unless Killian tells you to. And don’t 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 gently tells the patient that it is time to go to sleep and places the mask gingerly onto the patient’s 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.

McBride enters the room. The float nurse is waiting for him, gloves and gown ready. McBride waves each arm into the air with a flourish as the gloves are pulled into place, then pirouettes into the gown, and ends up at the side of the table opposite from me next to the scrub nurse. He hold his right hand out to the side and places his left hand onto the bare skin of the lower abdomen. The nurse hands a scalpel to McBride.

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. McBride 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 McBride 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 McBride another retractor. McBride places the second retractor into the other side of the incision and looks up at me.

“Hold this.”

I grab the handle with my right hand and pull.

“Pull harder. And don’t let go.”

My hand twitches.

“I said don’t let go! Do not move. I want you to hold that retractor like a catatonic monkey.”

The incision stretches open into a gaping maw. McBride reaches in and feels around for several minutes. He looks up at me and says,

“Put your hand in here.”

I slowly move my left hand towards the wound. McBride grabs my wrist and shoves my hand deep into the pelvis.

“What’s your hand touching?”

“The uterus?”

“What’s above your hand?”

“The bladder?”

“And above that?”

“The pubic bone?”

“What else?”

“Skin?”

“What else?”

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 McBride, 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 McBride’s questions. I try to recall the nerves and arteries of this area but cannot remember anything. McBride 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. McBride begins to grin.

“Pubic hair!” he announces, as he pulls my hand out of the depths of the patient’s pelvis.

He reaches back into the abdomen. “What is this?” he asks while nodding towards a deep crevice that he’s holding open with his fingers.

“The ovary?”

“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. McBride lets go and the crevice closes.

“I can’t see it.”

McBride crosses his arms across his chest again, “OK then. What could it be?

“The kidney?”

“No.”

“The ureter?”

“C’mon, think.”

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?”

McBride shakes his head and returns to his work. I concentrate on holding the retractor and pray that McBride 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 McBride’s attention.

McBride 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. McBride rolls his eyes and says, “Forceps.”

The nurse chooses a long pair of forceps and hands them to McBride.

“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 McBride’s hand. McBride tosses the instrument over his shoulder and shouts, “Moynihans.”

The nurse scrutinizes the instruments and states, “They all look the same to me.”

McBride 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 and announces,

“These are all wrong.”

McBride 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. McBride 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 McBride. McBride takes the instrument and proceeds with the surgery as if nothing has happened.

McBride 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. McBride 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 and says, “McBride’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?”

“Marvelous.”

Dr. Martin arrives to assist McBride 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 McBride finishes his incision and exposes the organs of the belly, McBride begins to interrogate John. I cannot see into the abdomen and have no idea what McBride is pointing to as he pimps John into oblivion. John responds to McBride’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. McBride ramps up the intensity. John becomes a lightning rod, drawing McBride’s attention away from me. I am invisible to McBride 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. Patients need to be seen. That’s what doctors do.”

“How do we know which patients are on McBride’s service?”

“Look at the charts and figure it out.”

“Can we get something to eat first?”

“If you must, but make it quick.”
My first patient is a twenty-six year old mother of three who has advanced breast cancer. She’s scheduled for a radical mastectomy tomorrow morning. She is youthful and attractive, and buxom. 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 McBride. Her demeanor is dour and strident. I imagine that she has never smiled. I wonder if the severity of her personality is a reaction to macho bravado of her male peers. But I suspect she was like this before she ever picked up her first scalpel.

As we go over the new admissions, she critiques and corrects every detail of our case summaries. Late into the ordeal, John mentions that one of his patients is feeling nauseous.

“You mean nauseated,” Martin interjects, “The correct word is nauseated. Learn to speak English.”

The sun has set hours ago. Backed by the dark of night, the windows of the hospital reflect the fluorescent-lit interior. Everything feels raw and familial. Just as I begin to wonder if Dr. Martin will keep us here all night, she announces,

“You can leave, now. Morning rounds start at 5:30. See all your patients prior to rounds and be ready to report on diagnoses, symptoms, physical findings, labs, and vitals. Any questions?”

“Is there a call room for us to sleep in?”

“Nope, the call room is for residents and fellows, only. You get to sleep at home”

“Do we get weekends off?”

“No. But 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. As soon as I exit the lobby, I am embraced by the sauna of heat and humidity that persists late into the Houston-summer nights –– it’s suffocating, yet strangely comforting. 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.

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 push an 8-track into the stereo. The music starts up in the middle of the second movement of Brahms First. The arching line of a solo violin soars in unison with woodwinds. I look across the campus towards the science buildings and wonder: what if I had stayed at Rice to get a Ph.D. –– perhaps in Biochemistry. Or Literature. I imagine the life of a graduate student 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.